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This journal opens with three demanding subjects: patient partnership in medical research, women’s reproductive health in disaster areas, and the likely effects of the Trump presidency on sexual and reproductive health (SRH) in the US and worldwide.
New presidential policy threatens women’s sexual and reproductive health
In his inauguration speech, President Trump promised to govern on behalf of all Americans. But what does this mean for women’s sexual and reproductive health? A key US women’s health expert answers this in a critical editorial: enumerating deep discrepancies between the President’s stated policies and the reproductive health needs of women, its author highlights the many ways in which that policy will need to change, if the presidential promise is to be kept. See page 89
Women’s reproductive health in disaster zones is both compromised and overlooked
Women’s reproductive health continues to fall off priority lists across the world´s disaster zones, from war-torn Syria to earthquake-shattered Nepal. Commenting on two articles in this issue, an editorial itemises the neglect surrounding women’s health needs in these areas, as resources and attention are focused elsewhere. Already trapped by the global gender gap in wealth, education and political power, women in disaster regions face increased risk of unwanted pregnancy due to unavailability of contraceptives and reduced sexual bargaining power. And this, just when healthcare facilities are being destroyed around them. See page 92
In a step towards partnering with patients, JFPRHC introduces a new ‘patient involvement’ checklist for authors
At JFPRHC, meanwhile, we plan to involve patients more actively as partners in the material we publish, wherever possible. In order to build awareness about the presence or absence of patients in research, we are following the lead of The BMJ and others, by redesigning our editorial processes. From 1 April 2017, authors of all submitted original research articles will be asked to complete a form telling us how they have involved patients or service users in the conception, design and reporting of their research. We also aim to reflect patient voices in our content in other ways. See page 94
Syrian refugees face blocks to accessing family planning
Family planning (FP) services are often neglected in crisis response efforts. A qualitative study based on interviews with women in a Syrian refugee camp about their experiences of accessing FP found significant access barriers remained. These included poor awareness of services, poorly trained providers, overburdened services, and cultural pressures. A linked commentary highlights a particular gap in the literature on the 6.5 million people internally displaced within Syria, and the predominance of women and children among those living as refugees in Lebanon and Jordan. It also highlights the methodological challenges to studying the reproductive health needs of forcibly displaced people, and the need to develop and support research in conflict-affected countries. See pages 96 and 103
Family and partner violence compounds unmet need for contraception
The impact of family violence on contraception is under-researched. This study uses data from the domestic violence module of a nationally representative population and family health survey conducted in Jordan to examine this connexion, also taking account of child marriage, and of whether the perpetrator of violence was a natal or marital family member. It finds that family and partner violence has a significant compounding effect on unmet need for contraception among women married as minors, suggesting that screening for violent relationships in health services may help. See page 105
The etonogestrel implant seems safe for bones in the first 6 months of lactation
Lactation is a relatively hypo-estrogenic state, and concerns about increased bone metabolism in users of injectable contraceptives prompted the authors of a small Turkish cohort study to look at the subdermal contraceptive implant during early lactation. Prospectively comparing bone mineral markers in 25 healthy lactating women using a non-hormonal method of contraception (intrauterine device) with 25 women using the implant, the authors found no difference in bone mineral density at 6 months. A linked commentary applauds this rare study of the influence of hormonal contraception on the lactating woman herself, rather than just her infant, but cautions that its findings would need confirmation in larger, multicentre studies with longer follow-up. See pages 113 and 118
Experienced sexual health doctors acknowledge challenges in discussing sex, and contraception
As experienced sexual health practitioners trained in communication skills we may consider ourselves expert in discussing intimate issues, but a new qualitative, interview-based study from Australia might challenge our complacency. Fifteen doctors experienced in sexual health and contraception, when questioned, expressed discomfort in discussing sexual relationships. They also acknowledged that their own personal preference competed with the evidence when they were recommending contraceptives. A linked commentary warns that differences in patient and clinician goals can easily go unacknowledged in hurried consultations, leading to decision making which is not truly shared, and suboptimal outcomes for all. See pages 119 and 126
Australian women who have never used the subdermal contraceptive implant view it with ambivalence
Women’s attitudes towards contraception, key determinants of satisfaction and adherence, often receive less attention than clinician-centred views. An interview-based study of Australian women's attitudes towards the subdermal contraceptive implant in this issue identifies considerable uncertainty and ambivalence among never-users. Other women’s stories played a powerful role in shaping negative perceptions, underlining the need both for good contraceptive counselling, and for reflection on how we integrate professional perspectives with women’s own agendas. See page - 128
Self-collection of HPV samples appears acceptable in rural Malawi
Human papillomavirus (HPV) testing matters in Malawi, the country with the highest age-adjusted incidence of cervical cancer in the world, where only 3% of the population is screened, and 60% of those diagnosed will die of the disease. A study interviewing rural women in local languages examines their openness to self-collection of HPV samples. Most women appeared willing, especially given awareness of the cancer, a clinician’s recommendation, the perception that they were in control, and that others were doing likewise. See page 135
Couples do not always agree on what happens during sex
Sexual behaviour – intimate in nature and necessarily self-reported – is challenging to measure reliably. Using a questionnaire to HIV sero-divergent couples in Uganda, analysed using Kappa statistics, the degree of agreement between couples’ answers was studied. Some areas, such as whether a condom had been used the last time they had sex, showed good agreement, but couples were less likely to agree on frequency of intercourse and decisions relating to fertility. The greatest disagreement was found in the least objective measures – those influenced by gender bias and perceptions of control in relationships. See page 142
Intentional self-poisoning with the pill is a growing problem in young women in Sri Lanka
Self-poisoning using oral contraceptive pills (OCPs) is an unfamiliar problem to most readers, but this article identifies it for the first time as a new and growing problem in Sri Lanka, a country where self-poisoning is widespread and where OCP poisoning now represents 4% of incidents. Of 60 hospitals surveyed, 52 women and two men, in two separate hospital clusters, had taken an overdose of an OCP for intentional self-poisoning. Most were young, and over half, women in their first year of marriage. See page 147
The role of the expert witness is a demanding but rewarding one
Few SRH specialists in are qualified to act as expert witnesses in court cases, and the the pool of expertise is shrinking. One such expert summarises in this journal issue what the role requires. Apart from clinical experience, expert witnesses also need training in the tests of evidence that are applied, and awareness of the range of opinions that exists within the specialty and the standards of care considered appropriate at the time of a case. See page 151
Tailored patient group directions (PGDs) are improving access to contraception and STI treatment across London
No-one wants to reinvent the wheel when national standards have been painstakingly established; however, in England, health trusts have differing routes to the development and approval of guidelines and protocols, which often require local adaptation. This article describes how a group of experts in London drafted patient group directions (PGDs) to help non-medical prescribers issue hormonal contraception and treatments for sexually transmitted infection (STI). Revised after review by clinical leads in all the London trusts, final versions could then be further adapted for local use. See page 154
Reusable sanitary towels can help women in post-earthquake Nepal
Menstrual hygiene is the last thing on most people´s minds following a major disaster such as the 2015 Nepal earthquake – unless you are a girl or woman lacking sanitary protection. This personal view article describes how cultural attitudes to menstruation conspire with difficult access to sanitation and problems with waste disposal, to blight the lives of menstruating girls and women, with significant knock-on effects such as non-attendance at school. The authors describe a simple, reusable sanitary kit developed locally, which may help address these issues. See page 157
Norethisterone is not the only way to postpone menstruation, and not always the best
Clinicians in primary care and community services are frequently asked by women to prescribe "some tablets to delay a period" for women going on holiday or with a special weekend planned. The only option licensed in the UK, norethisterone, is associated with an increased risk of venous thromboembolism. An expert personal view explores the alternatives: medroxyprogesterone acetate may not be as effective as norethisterone, but commencing a combined hormonal contraceptive in good time means that bleeding can be avoided. Alternatively, taking a short course of progestogens to induce a bleed will defer the next bleed. See page 161
A move to ‘the dark side’ refreshes a tired GP
In her latest Person in Practice article, Abi Berger reflects on how she’s currently balancing her National Health Service duties with some private general practitioner (GP) work, with surprising and positive results. Specific benefits include longer appointment times in both sectors, and a varied and stimulating patient mix. A definite win–win situation for both patients and practitioner! See page 162
TheBMJ and JFPRHC mourn an inspirational patient champion
This issue closes with an obituary for Rosamond Snow, a highly regarded researcher and active and influential campaigner for patients’ involvement in healthcare who, until her recent untimely death, was The BMJ’s Patient Editor. In recent months Rosamund had been very supportive of JFPRHC’s ambition to increase patient involvement in 2017, an objective that the editorial team will be actively pursuing in the coming months. See page 170
Venus
This quarter Venus once again covers a broad spectrum of themes in her search for interesting and informative SRH articles. Topics that have caught her eye this time include sexual problems experienced (or not) by PCOS sufferers, pupillary dilation as a measure of sexual attraction, contraception counselling in China, falling FGM rates in Ethiopia, and improving contraceptive outcomes by listening to patients and respecting their autonomy. See page 172
Footnotes
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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