Hightlights from this edition include:

The FSRH’s 20th anniversary

It is 20 years since the establishment of the Faculty of Sexual and Reproductive Healthcare (FSRH). In celebrating its anniversary there is much to be proud of, and indeed Community Sexual and Reproductive Health is now a specialty in its own right. Readers should find the story of the birth and rise of the specialty interesting and some will be reminded of ‘old times’, while looking ahead to a bright future. See page 78

Does HRT cause breast cancer? Part 5

Shapiro and colleagues conclude the interesting and enlightening series of articles looking at the evidence around hormone replacement therapy (HRT) and breast cancer risk (page 80). The final part examines the evidence for there being a declining trend in breast cancer incidence as HRT use reduced. Although the two are widely held to be related, they conclude that it is not possible to say either way. In the accompanying
Commentary (page 72), Nick Panay reviews the whole series of five articles and reminds us that optimising the lives of millions of women going through the menopause should be our priority. See pages 72 and 80

COCs and the risk of VTE, ATE and cardiovascular death

Syd Shapiro provides another of his incisive reviews of the latest database study of the combined pill and venous (VTE) and arterial (ATE) thromboembolism risk. Unsurprisingly, he finds many of the same problems as in the other studies, and asks the question why do these studies keep being done badly when the methodological flaws have been so well established? See page 89

“Anything for the weekend – and beyond, madam?” Community pharmacies increase OC uptake

Parsons et al.‘s evaluation of a community pharmacy delivered oral contraceptive (OC) service in South-East London is of particular interest, as it demonstrates the value of providing OCs via this service outlet, especially for women who would not otherwise access long-term contraception. Specially trained pharmacists provided OCs under a patient group direction (PGD), and subsequent evaluation showed that these pharmacists were clinically competent to provide OCs according to a PGD, and that the service was successful in attracting the population identified as most in need.  See page 97

There’s a tale in this sting – The policing of abortion services in England

What was the background to last year’s Care Quality Commission inspections of all English abortion services? Why were medical and nursing colleagues reported to their regulatory Councils and why is a Metropolitan Police investigation still ongoing? Sam Rowlands’ commentary provides a fascinating and detailed account of the regulatory framework of abortion services in England and the unexpected consequences of a national newspaper’s ‘sting’ operation on certain clinics in February 2012. It suggests that the regulation of abortion goes further than the Law requires and that this is now out of step with progress in abortion practice, leading to unnecessary restriction for women with unwanted pregnancies in accessing the support they need. See page 121

Role of ambulatory hysteroscopy in reproduction

The relatively recent introduction of outpatient operative hysteroscopy enables investigation and treatment previously carried out in the operating theatre to be performed in the clinic setting without the need for general anaesthesia. A ‘see and treat’ style of management is being adopted, which is changing how we configure our gynaecological services. This review aims to summarise the role for ambulatory hysteroscopy in the diagnosis of conditions contributing to reproductive failure and in sterilisation. See page 127

LAM: why ignore this useful option?

In this interesting personal view article, the authors explore and elaborate on the reasons why health care providers and the public are hesitant in recommending/adopting the lactational amenorrhoea method (LAM), a valuable short-term postnatal contraceptive option. These include ignorance about the LAM criteria for correct use, mistrust of the method’s effectiveness despite a strong evidence base, inconsistencies in the advice given to breastfeeding women in the UK by health practitioners and public bodies (e.g. the National Health Service, Royal College of Obstetricians and Gynaecologists), and lack of awareness about potential benefits. See page 136

Internet: good or bad?

2013 marks the 30th anniversary of the Internet. Our Consumer Correspondent looks at whether this technological miracle is a ‘good idea’ for the health profession. See page 139

Results from a new study published in the March issue of Obstetrics and Gynaecology demonstrate that the use of depot medroxyprogesterone acetate (DMPA) does not appear to increase fracture risk. Whilst the use of DMPA reduces serum oestrogen levels and is associated with significant loss of bone mineral density (BMD), this study shows that it does not appear to have an effect on fracture risk.  In addition although DMPA users had higher fracture risk than non-users, the risk did not increase after starting DMPA but was similar to before it was initiated.

The retrospective cohort study by Lanza et al¹ of 312,395 women, who had had 11,822 fractures, was designed to assess the extent to which DMPA increases fracture risk. Using data from the General Practice Research Database, the study compared fracture incidence in DMPA users with women using non-DMPA hormonal contraceptives. It also investigated fracture incidence before and after initiation of contraceptive use. The study reported that before contraceptive use started, DMPA users had a higher fracture risk than non-users (incidence rate ratio [IRR] 1.28; 95% confidence interval [CI] 1.07-1.73). After use began, crude fracture incidence was 9.1/1000 person-years for DMPA users and 7.3 for non-users (crude IRR 1.23; 95% CI 1.16-1.30). Fracture risk in DMPA users did not increase after starting DMPA  (IRR after/before 1.08; 95% CI 0.92-1.26). Fracture incidence was 9.4/1000 person years in low exposure DMPA users, and 7.8/1000 in high-exposure DMPA users. DMPA users had a higher fracture risk than non-users at the start of contraceptive use, with no discernable induction period.

Commenting on the results Professor Anna Glasier, Honorary Professor of the University of Edinburgh and the London School of Hygiene and Tropical Medicine, said “This study confirms what others have shown, that women who use Depo-Provera^® appear to have a modest increase in fracture risk compared with women using other contraceptive methods. Importantly however, in this UK population the increased risk of fracture preceded the start of Depo-Provera^®. The difference in fracture risk was mainly in fractures associated with trauma rather than those typical of osteoporosis. Further research is indicated to explore behavioural differences among populations of women choosing to use different contraceptive methods.”

1. Lanza L. et al. Use of depot medroxyprogesterone acetate contraception and incidence of bone fracture. Obs and Gynae. 2013; 121(3):593–600.

The following Online Firsts have been published

Does a full bladder assist insertion of intrauterine contraception?: a randomised trial (Cameron, Glasier, Cooper,  Johnstone)

Cameron and colleagues set out to answer a simple question: does a full bladder assist insertion of intrauterine contraception? In the world of assisted conception a full bladder had been shown to aid intrauterine catheter insertion for embryo transfer, but could this knowledge be transferred usefully to the world of contraception? This simple question was answered in a simple and elegant way with a properly constructed and conducted randomised trial, which showed that we needn’t ask our clients requesting IUD/IUS insertion to arrive bursting – a fact for which both they and clinic staff will be duly grateful.

Impact of UK Medical Eligibility Criteria implementation on prescribing of combined hormonal contraceptives (Briggs, Praet, Humphreys, Zhao)

Briggs et al. have assessed the effect of the UKMEC on prescribing of combined hormonal contraceptives (CHC). Sadly, although there has been a small decrease in the proportion of higher-risk women being prescribed CHCs, their results suggest that in 2010 7.3% of CHC users had Category 3 or 4 risk factors, particularly BMI ≥35. The authors point out that it is likely many of these women were being placed at an unnecessarily high risk of cardiovascular events, given the availability of lower risk alternatives.

Understanding barriers to sexual health service access among substance-misusing women on the South East coast of England (Edelman, Patel, Glasper, Bogen-Johnston)

This interesting article explores why substance-abusing women have problems accessing SRH services in Hastings, UK. Drug use, low self-esteem and previous traumatic experiences all combine prevent women accessing help. This is a qualitative interview study and provides important insights into the care of these women; there are no easy answers but the authors have provided some suggestions as to how practitioners may make the service more accessible.

Coping after recurrent miscarriage: uncertainty and bracing for the worst (Ockhuijsen, Boivin, van den Hoogen, Macklon)

Pregnancy loss is a significant trauma for women, the more so if repeated.  In their study, Ockhuijsen and her colleagues investigated the ways in which women coped in the time after single and recurrent miscarriages and in the difficult period soon after conception while waiting for ongoing pregnancy to be confirmed. They found that coping strategies differed between the two groups of women and they investigated the use of a simple psychological support tool, the Positive Reappraisal Coping Intervention, that may be of help, particularly to those with greater concern for the future following recurrent miscarriage.

The role of ambulatory hysteroscopy in reproduction (Robinson, Cooper, Clark)

The relatively recent introduction of outpatient operative hysteroscopy enables investigation and treatment previously carried out in the operating theatre to be performed in the clinic setting without the need for general anaesthesia. A ‘see and treat’ style of management is being adopted, which is changing how we configure our gynaecological services. This review summarises the role for ambulatory hysteroscopy in the diagnosis of conditions contributing to reproductive failure and in sterilisation.

The use of local anaesthesia for intrauterine device insertion by health professionals in the UK (Akintomide, Sewell, Stephenson)

What to do now? How women with breast cancer make fertility preservation decisions (Snyder, Tate)

A service-based approach to nurse training in sexual and reproductive health care (Shawe, Cox, Penny, White, Wilkinson)

Increasing male participation in the uptake of vasectomy services (Singh, Mishra, Alam, Pandey)

Correlates of unprotected sexual intercourse among women who inject drugs or who have sexual partners who inject drugs in St Petersburg, Russia
(Abdala, Hansen, Toussova, Krasnoselskikh, Verevochkin, Kozlov, Heimer)

Plus Organisation Factfiles on Tommys and the College of Sexual and Relationship Therapists (COSRT) by Susan Quilliam and a letter to the editor “Learning from Romanian women’s struggle to manage their fertility” by Ann Furedi following the article in the January Journal

Risk of Unwanted Pregnancies with Morning After Pill Conscience Clause

This article is published in the Journal of Medical Ethics today – “The Fox and the grapes: an Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription”

Conscience clauses, which allow pharmacists to opt out of providing the “morning after pill” without a prescription, risk unwanted pregnancies and undermine the principle of universal healthcare in the NHS, say pharmacists in the Journal of Medical Ethics.  These clauses should either be banned or enhanced so that pharmacists and patients know exactly where they stand, rather than the current “fudge”, which serves nobody well, the authors conclude. Emergency contraception without a prescription became available from UK pharmacies in 2001 and the Republic of Ireland in 2011.  Built-in conscience clauses allow pharmacists to opt-out of provision on moral or religious grounds, providing they refer patients to other providers willing to prescribe the product.

Cuts to services set to saddle UK with a £136.7 billion NHS and welfare burden by 2020

A new report from the UK’s leading sexual health charities, Brook and FPA, has revealed for the first time the economic and social impact of NHS cuts to contraception and other sexual health services. Cuts are resulting in these services been reduced or restricted and this can already be seen across the UK today. The report looks at what happens if these restrictions to services continue unabated. The key findings of the report reveal:

-          A significant rise in the number of NHS abortions and STI rates by 2020

-          An additional cost burden on the NHS of £612.8 million as a consequence of increasing numbers of unintended pregnancies and STIs

-          An increase in wider public spending of up to £124.7 billion – equivalent to 10% of all welfare spending – by 2020

Anne Connolly, GP in Bradford, and Chair of the Primary Care Women’s Health Forum, said; “There is a clear danger that imminent changes to commissioning could significantly undermine the good work that professionals are doing. Maintaining progress requires investment and if we are brave enough to invest money at a time when there is pressure to disinvest there are massive cost savings as well as quality of life savings to be made, as this report clearly illustrates.”

In response to reports of restrictions to contraception across the UK Brook and FPA joined forces earlier this year to launch XES – We Can’t Go Backwards, a major awareness campaign. Brook and FPA are calling on people in the UK to join the campaign and rate and share their experiences of contraception services, good and bad, through the UK’s only interactive online sexual health map www.wecantgobackwards.org.uk

WHO – 40 years of innovation in sexual and reproductive health

A comment piece in The Lancet by past and present directors of WHO’s Human Reproduction Programme (HRP) discusses the achievements of the Programme since it was established in 1972.

Online First – Evaluation of a community pharmacy delivered oral contraception service

“Anything for the weekend … and beyond, madam?” Community pharmacies increase oral contraceptive uptake

Parsons et al.’s evaluation of a community pharmacy delivered oral contraceptive (OC) service is of particular interest, as it demonstrates the value of providing OCs via this service outlet, especially for women who would not otherwise access long-term contraception. Between 2009 and 2011, seven specially trained pharmacists at five pharmacies in South-East London provided OCs under a Patient Group Direction (PGD) during 741 client consultations. The evaluation showed that trained pharmacists were clinically competent to provide OCs according to a PGD, and that the service was successful in attracting the population identified as most in need. Nearly half of all consultations occurred following emergency hormonal contraception supply, and nearly half of clients receiving an initial supply of OCs were first-time Pill users. Based on satisfaction questionnaires from a small sub-group, most clients valued this service, were happy about privacy, and would recommend it. Although the primary aim was to reduce teenage pregnancy , and nearly a quarter of clients were aged <20 years, the study shows that women aged 20+ years also require this service and should not be overlooked when formulating policies for service provision.
summary by Walli Bounds, Associate editor

Infertility: Survey shows nearly half of all GPs lack knowledge

Results of a comprehensive patient survey by the National Infertility Awareness Campaign (NIAC) shows that GPs need to be better informed about infertility treatment, including IVF, and the options available when the commissioning of IVF switches to local commissioning groups next year. The NIAC survey found that nearly 50% of GPs lacked the necessary knowledge of infertility and the treatment options available to provide an effective service. This could explain why some patients with fertility issues perceived their GPs as unsympathetic.

Calling All Baby Boomers: Get Your Hepatitis C Test

A report issued by the U.S. Centers for Disease Control and Prevention (CDC) recommended that all Americans born between 1945 and 1965 be tested for the hepatitis C virus (HCV). An estimated 2.7 million to 3.9 million people in the United States are infected with this liver-damaging—and sometimes lethal—virus, and many do not know they carry it. CDC calculates that roughly 75% of those infected are baby boomers: 3.25% of people born in that “birth cohort” test positive for HCV, which is five times higher than the rate in adults born before 1945 or after 1965. CDC has determined that universal testing of baby boomers is the most cost-effective strategy for detecting undiagnosed HCV infections.  As reported in Science

New lab for HIV research

The Indian Government has opened the new $12 million HIV Vaccine Translational Research Laboratory in New Delhi. The new Laboratory will aim to recruit around 30 scientists with the goal of creating a new vaccine against HIV, and will work in collaboration with the International AIDS Vaccine Initiative.  As reported in Science

The following papers have been published this month at http://jfprhc.bmj.com/content/early/recent

More than poverty: disruptive events among women having abortions in the USA (Jones)

We are all aware that poverty is associated with abortion but how many of us knew that bad (or disruptive) life events also play a major role? The research by Jones et al. demonstrates that more than half of the women seeking abortion had experienced a disruptive life event in the preceding 12 months. Women are making decisions about their abortion whilst in the midst of complex life events. The authors’ suggestions for changes in policy may not be directly relevant in the UK; however, the study findings are of wider significance. from Gillian Robinson,  Associate Editor

Psycho-social factors affect semen quality (Cao)

Semen quality appears to be declining and this cross-sectional study in China casts light upon some factors that may be associated with that decline. The research team analysed the semen of 1346 healthy 20-40-year-old Chinese men, capturing their psychological, social and behaviour profiles via questionnaire. It appears that stress, social class and underwear made from man-made fibres all play a significant part in declining semen quality. from Scott Wilkes,  Associate Editor

Young people and chlamydia – peer led strategies to increase the uptake of screening (Horner)

The major burden of Chlamydia trachomatis infection is borne in individuals under 25 years of age. Complications of untreated infection are manifold and encompass pelvic inflammatory disease, sub-fertility, epididymo-orchitis, urethritis, arthritis, conjunctivitis and proctitis. Despite high hopes, uptake of the English National Chlamydia Screening Programme has been lower than expected. As a result, the expected decline in chlamydia prevalence has not been observed. Paddy Horner’s group have investigated the use of a peer-led approach to increase screening and examine the feasibility and acceptability of this strategy in young people. Interestingly, although this is a relatively small proof of principle study, women peer-led screening was more successful than male in recruiting peers to participate in the programme. from Rachael Jones,  Associate Editor

Inequity in family planning provision in urban Nigeria: a providers’ perspective (Herbert)

In Nigeria contraceptive use is low: used by only 10% of married women and with 20% of women estimated to have an unmet need. Provision needs to improve, and understanding the roles and perspective of the mixed economy of contraceptive providers is a key step in designing better services. A qualitative study from the Nigerian Urban Reproductive Health Initiative explores the experiences and challenges faced by a range of providers in two urban Nigerian areas. Using structured in-depth interviews and checklists, researchers identified need for further training and support for all providers to empower them to provide a wider range of contraception. Few providers engaged in meaningful promotional activities for their products or services. Vulnerable groups, likely to have high needs for contraceptive advice and provision, were routinely excluded from family planning services: adolescents, married women and those seeking post-abortion care. Understanding the underlying reasons for this inequitable provision, and developing appropriate marketing strategies and materials will indeed be key to developing more sensitive service provision. from Imogen Stephens,  Associate Editor

New female condom, the ‘Woman’s Condom’ – will the Chinese go for it? (Coffey)

The need for products that simultaneously protect against unwanted pregnancy and STIs, including HIV, has prompted interest in the development of Multipurpose Prevention Technologies (MPTs), including new variants of the female condom. In this issue, Coffey and colleagues describe their survey of initial reactions to the ‘Woman’s Condom’ (which obtained marketing approval in China in 2010) by potential user groups in Shanghai. Their study demonstrates the importance of assessing the potential acceptability of new products in a range of populations, with differing expectations, needs and culture-specific influences. Their findings are of particular value to programme/service providers, in order to identify most likely adopters of this new type of female condom. from Walli Bounds,  Associate Editor

IVF twins: buy one get one free? (Mittal)  (published online 18 July)

The aim of IVF treatment should be to achieve a full-term singleton birth. This article explores the tensions that exist between IVF provision and the elective single embryo transfer (eSET) policy. The authors present a balanced contemporary review describing why twin pregnancies are undesirable yet may be a risk couples are willing to take. They go on to discuss the issues faced when considering strategies to reduce twin pregnancies and the tensions that exist with the eSET policy. Blanket eSET implementation appears not be a simple answer to avoid twin pregnancies. from Scott Wilkes, Associate Editor

1 in 7 couples in the UK have infertility problems

Most people growing up assume that, if and when they want children, they will be able to have them. They don’t expect to have problems with fertility, and assume that, if they do the wonders of modern fertility treatments, such as IVF and ICSI (intra-cytoplasmic sperm injection) will be able to solve them. However, in contrast to this, background figures point to 1 in 7 couples in the UK having fertility problems. This is according to new research published by the Health Experiences Research Group at the University of Oxford and available from healthtalkonline. The research team was founded by Ann McPherson (who sadly died in May 2011) and headed by Sue Ziebland and Louise Locock.

ESHRE 2012 Reports highlight fertility issues

UK still trails behind Europe in number of IVF cycles – yet it all started here.

As the number of babies worldwide born thanks to in vitro fertilisation (IVF) – breaks the 5 million barrier for the first time, figures show that the UK is still lagging behind many of its European neighbours in numbers of treatment cycles per year.  A report presented at ESHRE 2012 shows that the UK carries out 879 cycles/million inhabitants per year, which is significantly lower than many other countries including Denmark (2,726 cycles/million), Belgium (2,562 cycles/million) and Slovenia (1,840 cycles/million).

The pioneering treatment, which hit the headlines worldwide back in 1978 with the birth of Louise Brown in Oldham, has dramatically reduced the devastating burden of infertility, benefitting millions of couples both in the UK and worldwide.

However, for thousands of couples here, the dream of having a child of their own remains elusive: many are denied IVF because their Primary Care Trust or Health Board is reluctant to fund sufficient treatment. Around three quarters of all PCTs in England still don’t offer the 3 full cycles of IVF as recommended by the National Institute for Health and Clinical Excellence (NICE).

Leading national infertility charity supports new research on Single Embryo Transplant (SET)

Leading patient charity, Infertility Network UK (IN UK), has backed new research presented at the annual meeting of ESHRE, which shows that a policy of single embryo transfer reduces the risk of perinatal death in infants born after IVF and ICSI.

The report is based on analysis of more than 50,000 births recorded in the Australian and New Zealand Assisted Reproduction Technology Database from 2004-2008, where the introduction of  SET seems to have reduced overall perinatal mortality for IVF and ICSI babies.

Said Clare Lewis-Jones, Chief Executive of IN UK and Chair of Fertility Europe: “We welcome a move towards SET, and this report gives the medical profession more evidence to encourage patients to accept SET, which reduces the risks of multiple births to both mother and babies and gives the best possible outcome – one healthy baby.

“However, it must go hand in hand with full implementation of the NICE clinical guidelines which recommend up to three full cycles of treatment, including any frozen embryo transfers (FET). Other European countries which routinely offer five and six cycles of treatment have successfully implemented SET, and it is high time that patients in the UK are offered access to the level of treatment recommended by NICE nearly eight years ago!

“Many PCTs here still fall short of the recommendations and it is totally unacceptable and unethical for some PCTs to offer only one cycle of treatment and not to include FET for patients.”

Highlights from this issue include:

Norethisterone and VTE risk

Diana Mansour’s article previewed at online first and in the 15th June blog. See page 148

Helping women with hirsutism

Editor’s Choice article – Stephen Franks provides useful guidance for helping women with this common and often distressing condition. See page 182

US administration’s attitude to family planning

The winner of the 2010 Margaret Jackson Prize Essay for undergraduate medical students has looked at the differences between the Bush and Obama administrations’ attitudes to family planning and abortion. See page 187

Avoiding a shocking experience with intrauterine contraceptive procedures.

Aisling Baird et al. make a compelling case for adherence to the current Faculty and UK Resuscitation Council guidelines. The last time this issue was raised, in the January 2011 edition of the journal, a flood of letters followed. See page 191

Nurse Training in the UK

Shelley Mehigan & Janice Burnett describe and discuss the Berkshire training programme for nurses which mimics the DFSRH. See page 194

The SDM: a realistic option for longer-term use

A report on the experience of nearly 500 women who used the Standard Days Method for between 2 and 3 years. See page 150

CycleBeads: the latest in ‘contraceptive jewellery’!

Describes CycleBeads®, a colour-coded string of beads, that are a visual tool that helps women use the SDM correctly. See page 157

Ovarian and cervical cancer: better awareness, earlier recognition, improved outcome?

Simon and colleagues developed and validated reliable disease-specific Cancer Awareness Measurement tools for both forms of cancer, testing them in matched comparison groups. See page 167

Encouraging IUD uptake after medical TOP

Sharon Cameron and colleagues in Edinburgh created a fast-track referral service so that women who had undergone early medical abortion & wished to use intrauterine contraception afterwards could be seen promptly for fitting. See page 175

Psychosexual therapists speak out

Psychosexual therapy can seem like one of the dark arts, but in this issue Consumer Correspondent Susan Quilliam brings us the therapists’ own stories. See page 196

The Journal of Family Planning and Reproductive Health Care’s 2012 impact factor is 1.636, a massive 32% increase on last year. The IF reflects the number of citations a journal receives and is seen as a marker of its relative ‘importance’. It is calculated by dividing the number of times articles were cited in the previous 2 yrs by the number of citable items.

The table shows how this has changed over time and compared with others in the field.

Congratulations for their hard work are due to the Editor-in-Chief (Anne Szarewski), her team of editors and Editorial Manager (Janie Foote).

Effectiveness of Long-Acting Reversible Contraception

From the New England Journal of Medicine: A large (7486 paticipants) prospective cohort study, by researchers at Washington University School of Medicine in St. Louis, to evaluate contraceptive methods has found dramatic differences in their effectiveness. Women who used pills, the patch or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer-acting forms such as an intrauterine device (IUD) or implant.

And from the American Journal of Obstetrics & Gynecology

Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?

The purpose of this study in Colorado was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant insertion and showed excellent continuation 1 year after delivery; rapid repeat pregnancy was significantly decreased compared with control participants.

Predictors of long-acting reversible contraception use among unmarried young adults

The objective of the study from South Carolina was to improve the understanding of long-acting reversible contraception (LARC) use patterns among unmarried, young adults at risk of unintended pregnancy. LARC use was associated with older age, high IUD knowledge, and earlier onset of sexual activity and concluded that increasing knowledge of IUD among certain groups may improve LARC use among young, unmarried adults and in turn decrease unintended pregnancy.

Knowledge of contraceptive effectiveness

Another study from St Louis, Missouri looking at 4144 women’s knowledge of contraceptive effectiveness and, not surprisingly, showed many gaps.

Unintended pregnancy and contraception among active-duty servicewomen and veterans

The number of women of childbearing age who are active-duty service members or veterans of the US military is increasing. These women may seek reproductive health care at medical facilities operated by the military, in the civilian sector, or through the Department of Veterans Affairs. This article reviews the current data on unintended pregnancy and prevalence of and barriers to contraceptive use among active-duty and veteran women. Active-duty servicewomen have high rates of unintended pregnancy and low contraceptive use, which may be due to official prohibition of sexual activity in the military, logistic difficulties faced by deployed women, and limited patient and provider knowledge of available contraceptives. In comparison, little is known about rates of unintended pregnancy and contraceptive use among women veterans. Based on this review, research recommendations to address these issues are provided.

Antenatal sexually transmitted infection screening in private and indigent clinics in a community hospital system

The study aimed to determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics in North Carolina. They concluded that clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.