Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women.

BackgroundMeta-analyses of postpartum blood loss and the effect of uterotonics are biased by visually estimated blood loss.ObjectivesTo conduct a systematic review of measured postpartum blood loss with and without prophylactic uterotonics for prevention of postpartum haemorrhage (PPH).Search strategyWe searched Medline and PubMed terms (labour stage, third) AND (ergonovine, ergonovine tartrate, methylergonovine, oxytocin, oxytocics or misoprostol) AND (postpartum haemorrhage or haemorrhage) and Cochrane reviews without any language restriction.Selection criteriaRefereed publications in the period 1988–2007 reporting mean postpartum blood loss, PPH (≥500 ml) or severe PPH (≥1000 ml) following vaginal births.Data collection and analysisRaw data were abstracted into Excel by one author and then reviewed by a co-author. Data were transferred to SPSS 17.0, and copied into RevMan 5.0 to perform random effects meta-analysis.Main resultsThe distribution of average blood loss (29 studies) is similar with any prophylactic uterotonic, and is lower than without prophylaxis. Compared with no uterotonic, oxytocin and misoprostol have lower PPH (OR 0.43, 95% CI 0.23–0.81; OR 0.73, 95% CI 0.50–1.08, respectively) and severe PPH rates (OR 0.61, 95% CI 0.29–1.29; OR 0.74, 95% CI 0.52–1.04, respectively). Oxytocin has lower PPH (OR 0.65, 95% CI 0.60–0.70) and severe PPH (OR 0.71, 95% CI 0.56–0.91) rates than misoprostol, but not in developing countries.ConclusionOxytocin is superior to misoprostol in hospitals. Misoprostol substantially lowers PPH and severe PPH. A sound assessment of the relative merits of the two drugs is needed in rural areas of developing countries, where most PPH deaths occur.

Objective: To assess Mexican physicians' knowledge about the human papillomavirus (HPV) and cervical cancer and their opinions and practices related to screening, managing, and counselling women on these topics. Methodology: In August 2002 we surveyed 1206 general practitioners (GPs) and obstetriciansgynaecologists (Ob-Gyns) working in a nationally representative sample of public and private facilities in urban Mexico. Eligible physicians completed a self administered questionnaire. We conducted a weighted analysis and used x 2 tests to compare GPs and Ob-Gyns on outcome variables. Results: 76% of recruited physicians responded to the survey. 43% of Ob-Gyns had performed a hysterectomy in the last year to treat a case of CIN I or II. With respect to HPV, while 80% of respondents identified the virus as the principal cause of cervical cancer, many lacked detailed knowledge about this association. Ob-Gyns were more likely than GPs to have heard about specific oncogenic strains of HPV (p,0.001). Nearly all respondents thought that women should be informed that HPV causes cervical cancer; nevertheless, physicians believed that positioning cervical cancer as a sexually transmitted infection (STI) could cause problems in partner relationships (60%), confusion (40%), and unnecessary anxiety among women (32%). Conclusions: Mexican physicians support patient education on the HPV-cervical cancer link. However, findings suggest the need to present clear messages to women (emphasising, for example, that only certain types of HPV are oncogenic), to consider the conflicts such information might create for couples, and to further educate physicians about this topic and about overall cervical cancer screening and treatment protocols. C ervical cancer is the second most common cancer in women, with an estimated 500 000 new cases and 231 000 deaths annually worldwide.1 2 Latin America has among the highest incidence rates in the world, and unlike the United States and Canada, most of the region has seen little improvement in the past 30 years. In Mexico, cervical cancer remains a leading cause of death among women of reproductive age with a stable mortality rate of around 17/100 000 despite a national screening programme since 1974.3 Several factors contribute to cervical cancer rates in Mexico, including low coverage of Papanicolaou (Pap) smears especially among high risk women such as those in rural areas with limited contact with the health system, poor quality of cytology services, and lack of follow up for women with abnormal Pap results. One study found that only 64% of women aged 15-49 in Mexico City and 30% in the state of Oaxaca had ever had a Pap test in their lifetime. 4 Since the mid-1990s, clinical evidence has established the human papillomavirus (HPV) as a necessary cause of cervical cancer.5 Knowledge of this association has spurred research on HPV based strategies for cervical cancer prevention, including primary prevention of HPV, HPV vaccines, and the use of HPV testing for follow up of women with abnormal Pap ...

Clinical and operational research is needed to answer remaining questions about misoprostol, the anti-shock garment, and umbilical vein injection of oxytocin for retained placenta. Efforts are needed to ensure the availability of technologies with proven value, such as oxytocin in Uniject prefilled injection devices. Equally important, technologies and techniques with proven efficacy--such as active management of third-stage labor and aortic compression--must be translated into general use by disseminating the evidence for them, incorporating them into national guidelines and training curricula, and ensuring the availability of supportive supplies and equipment.

Objective The objective of this study was to compare efficacy for four medical abortion regimens used in one clinic setting: (1) misoprostol alone, (2) oral methotrexate + buccal misoprostol, (3) oral methotrexate + vaginal misoprostol, and (4) intramuscular methotrexate + vaginal misoprostol.Design Retrospective analysis of data from clinical records.Setting An anonymous women's health centre in Latin America, providing medical abortion services since 2001 in a highly restrictive setting. Methods Chi-square test was performed to compare patient characteristics by abortion outcome (success/failure). The impact of selected variables on method success was explored through logistic regression. A second regression analysis was conducted with a subsample (n = 4022), for which data on parity and previous abortion(s) were available.Main outcome measure Abortion outcome (success/failure) at 2-week follow up.Results Success rates for the three methotrexate regimens ranged from 81.7 to 83.5% and did not differ significantly; misoprostolalone regimen had a success rate of 76.8%. Efficacy was significantly higher for the three combined methotrexate regimens compared with misoprostol alone and remained so in the multivariate model (OR = 1.35). In the final regression, lower gestational age, being nulliparous, and having no previous abortions were positively correlated with method success.Conclusions In this real-use setting, methotrexate appears to confer a significant advantage over misoprostol alone for early medical abortion. This finding is important for settings where mifepristone remains unavailable. Additional factors such as gestational age limits and patient preference should be considered in regimen selection.Keywords Medical abortion, methotrexate, misoprostol.Please cite this paper as: Aldrich T, Winikoff B. Does methotrexate confer a significant advantage over misoprostol alone for early medical abortion? A retrospective analysis of 8678 women. BJOG 2007;114:555-562.