Iris Publishers- Open access Journal of Gynecology & Womens Health | Contraception Experience among Adolescents with Sickle Cell Disease

Authored by Nancy Sokkary*

Abstract

Purpose: Sickle cell disease has unique impacts on females in their reproductive years. This study evaluated contraception use and knowledge among adolescent female sickle cell disease patients at a hematology clinic. Patients on hydroxyurea were predicted to report higher rates of contraception use than those not using hydroxyurea.

Methods: Female sickle cell disease patients ages 14 to 25 were surveyed regarding their contraception counseling experiences and their contraception knowledge and use.

Results: Of 12 participants, three reported having used contraception. Four reported receiving no contraception counseling. Patients on hydroxyurea did not use contraception more frequently than those not on hydroxyurea.

Conclusions: This study revealed gaps in contraception knowledge and need for better contraception counseling among female sickle cell disease patients. Further research should explore ways to increase contraception use and explore secondary effects among these patients. Collaborative care for these patients may help address all aspects of their care.

Introduction

Adolescent females with sickle cell disease face unique challenges related to menstruation, contraception, and reproduction. Not only does pregnancy pose higher maternal morbidity and mortality risks in these patients [1], but hydroxyurea, a commonly used treatment for the disease is teratogenic [2]. Further, the frequency of vasoocclusive pain crises increases during pregnancy, which is thought to be due the associated immune modulation, hypercoagulability, and necessary suspension of hydroxyurea use [3]. Studies have indicated that women with sickle cell disease also experience greater degrees of dysmenorrhea and pains distinct from dysmenorrhea during menses [4,5]. Females with menstruationinduced vaso-occlusive crises often have heavier, longer menstrual periods [4]. Blood loss from menstruation can increase the risk of iron deficiency anemia, compounding the already existent sickle cell anemia.

Ideally, contraception should be explored with these patients to decrease their risk of unintended pregnancy, exposure to teratogenic agents in pregnancy, and heavy menstrual bleeding. It is recommended that patients on hydroxyurea use contraception, though the optimal contraceptive has not been defined. Due to the pain associated with menses and risks associated with unplanned pregnancies in sickle cell disease patients, the American College of Obstetricians and Gynecologists (ACOG) asserts that the benefits of combination oral contraceptives often outweigh their risk of thromboembolic events [6,7].

Adolescent female sickle cell disease patients should be educated on the impacts that contraception can have on overall health to allow them to make informed decisions about contraceptive use. In this small survey study, adolescent female sickle cell disease patients of a middle Georgia hematology clinic were surveyed to examine contraceptive use, depth of contraception knowledge, and experiences with contraception counseling among this population. It was hypothesized that patients on hydroxyurea would report higher rates of contraceptive use than those not on hydroxyurea.

Introduction

Prior to study initiation, the Navicent Health Institutional Review Board approved the study protocol. Patients who agreed to participate provided assent with written guardian informed consent.

Subjects

Participants were recruited during their annual visits to the Hematology Oncology Place of Excellence (HOPE) Clinic in Macon, Georgia. English-speaking female patients between the ages of 14 and 25 who were being treated for sickle cell disease met inclusion criteria. Patients with developmental delays or an inability to speak English were excluded.

Procedures

After obtaining consent, participants’ names and phone numbers were collected at the time of the visit. One of two investigators then administered a confidential 24-question survey regarding patient demographics, degree of contraception counseling, and experiences with contraception use. Diagnosis and hydroxyurea use were confirmed via chart review. Patients were compensated with $10 gift cards for participation.

Analysis

Descriptive statistics, including means, medians, and proportions, were evaluated. Utilizing Fisher’s exact test due to a small sample size of 12, findings did not approach the p < .05 level of statistical significance.

Results

12 adolescent female patients with sickle cell disease were recruited for and completed the study survey. All participants self-identified as African American and had a diagnosis of sickle cell disease. The age range was 14-19 years with a mean of 16.3 years (s = 1.50). Average age of menarche among participants was 12.7 years (s = 2.47). 81.8% reported regular monthly periods and 25% reported heavy periods, defined as more than seven days of bleeding or eight pads or tampons per day.

Three of 12 (25%) surveyed used birth control at some point; one used medroxyprogesterone acetate (“Depo injection”), one used medroxyprogesterone acetate and a progesterone only pill, and one used a combination oral contraceptive. One patient, who experienced heavy periods and reported progesterone only pill use, reported lighter periods with less cramping after starting contraception. None of the three patients who had used birth control reported changes vaso-occlusive pain episodes.

Of the seven patients who used hydroxyurea, one had also used birth control (Figure 1). Comparatively, two of the five patients who were never on hydroxyurea had used birth control (p = 0.523, Fisher’s exact test). 50% of participants said they did not think birth control would have an effect on their pain crises, but 41.7% said they would be interested in using birth control.

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Iris Publishers- Open access Journal of Gynecology & Womens Health | Value of Neutrophil Lymphocytic Ratio and Platelet Lymphocytic Ratio in Premature Rupture of Membranes for Detection of Subclinical Chorioamnoitis

Authored by Shereen B Elbohoty*

Abstract

Aim: To evaluate neutrophil lymphocytic ratio (N/L) and platelet lymphocytic (P/L) ratio in detection of subclinical Chorioamnoitis in pregnant females suffering from premature rupture of membranes and to compare them with CRP and TLC.

Design: Clinical randomized controlled study.

Methods: 100 pregnant patients were selected suffering from PROM , and prepared for termination of pregnancy either normal or cesarean , all had no clinical signs of chorioamnoitis , blood markers ( CRP, TL, N/L ratio and P/L ratio) were taken before termination , the results statistically analyzed according to the result of pathological examination of amniotic membrane for detection of early inflammatory signs for chorioamnoitis.

Results: There was significant relationship for the P/L ratio and the finding of early chorioamnoitis by pathological examination with P value 0.0004 , however other markers failed to show any significant relationship with early chorioamnoitis , But CRP was found to have a significant relationship with the presence of postpartum complications with P value 0.0003 and other markers had insignificant relationship, There was insignificant relationship with all the four markers with the method of delivery , CRP and TLC had lower specificity in detection of subclinical chorioamnoitis as compared by N/L ratio and P/L ratio , also P/L ratio had the higher sensitivity 85.71% , so by comparing the four markers P/L ratio is the most accurate 90% and N/L ratio had accuracy more than TLC and CRP ( 80%).

Conclusion: P/L ratio and N/L ratio are available cheap markers for detection of subclinical chorioamnoitis, and they show more specificity and accuracy than CRP and TLC in detection of subclinical chorioamnoitis, also P/L ration had higher sensitivity.

Keywords: Subclinical chorioamnoitis, PROM , N/L ratio , P/L ratio , CRP , TLC

Introduction

Amniotic membrane, which is considered as a closed envelope around the fetus, is the most important barrier for protecting fetus from exterior , and the contained amniotic fluid gives the fetus the space to move and a media for excretion and also nutrion [1], Amniotic sac should remain intact till near the end of second stage of labour , Any break in the sac before that should be considered as a premature rupture of membrane (PROM), if it occurred before 36 weeks gestation it will be considered as preterm premature rupture of membranes [2].

The second most common cause of preterm labour is preterm PROM , as rupture of membranes will lead to local release of inflammatory mediators which in turn lead to premature uterine contractions that may end to preterm labour with its all hazards to the fetus [3]. But the most dangerous and most important concern about preterm PROM is the occurrence of chorioamnoitis [4]. Chorioamnoitis is inflammation of fetal membranes and may proceed to underlying decidua, it may lead to maternal toxemia and even septic shock, with very bad fetal outcome [5].

Occurrence of chorioamnoitis should be excluded in every case suffering from PROM , as it has dangerous consequences , and also may affect the course of labour when decision of labour is taken, as the uterus may not respond efficiently to uterotonic drugs in case of vaginal delivery that lead to increase rate of cesarean section , which also may complicated with surgical infection with all its hazards , with increase susceptibility to atonic postpartum hemorrhage [6].

Diagnosis of subclinical infection in case of PROM is a medical challenge. The most important and widely used markers are CRP and TLC , both had accepted specificity but low sensitivity making its use alone had many disadvantages and many misdiagnosed cases [7].

Neutrophil lymphocytic ratio (N/L) and platelet lymphocytic ratio (P/L) had been suggested to be used as alternative markers [8].

Methods

Study design: Prospective cohort study

Setting: Tanta University Hospital

Number of cases: 100 patients.

Timing of the study: from jun. 1, 2018 to august,31, 2019.

Cases selection: The cases were selected from the pregnant females whom attending Tanta University Hospital,

They were selected according to the following criteria:

1. Pregnant females with gestational age above 20 weeks gestation

2. Suffering from premature rupture of membranes

3. All the patients selected at time of termination of pregnancy whatever indication is except for acute chorioamnoitis ( like lung maturity , preterm labor pain , PROM before 24 weeks gestation)

And they were excluded if:

1. Presence of any clinical sign of chorioamnoitis ( fever , offensive vaginal discharge , tender uterus and non-reassuring non stress test)

2. If vaginal termination of pregnancy took more than 24 hours.

3. Patient with multiple gestations

4. Any systemic disease may affect N/L ratio or P/L ratio like Hematological disorders ,Malignancy, Hepatic diseases, autoimmune disease and Chronic renal diseases

5. Gestational D.M and pre-eclampsia.

6. Acute or chronic infectious or inflammatory diseases.

7. Cigarette smoker

Sample size calculation: The sample size was calculated using Epi-Info 7 specific program.

Methods:

• Written consent was taken from all patients submitted to the study with clarification of the methods, value and hazards of the study.

• Detailed history taking from all patients

• All patients before pregnancy termination were evaluated for absence of signs of acute chorioamnoitis

• Then blood sample was taken from the patient at time of termination of pregnancy if termination was normal , and before induction of anesthesia if termination was cesarean section , the blood sample used for :

1. C-reactive protein done by latex agglutination test. We took 2 mg/dl as a cut off value

2. Another 2ml of venous blood was collected into an EDTA contained bottle for .CBC measuring using an automated blood counter(ERMA PCE-210N) to measure the following :

A. Total leucocytic count ( normal 4000-11000/ul)

B. Platelet count (PCT), lymphocyte count and neutrophilic count were recorded so P/L ratio will be calculated; we took 125 as a cut off value.

C. Neutrophil –lymphocyte ratio(NLR) was calculated as absolute neutrophil count is divided by absolute lymphocyte count. We took 2.5 as a cut off value.

• Then after successful delivery of the baby, multiple samples from amniotic membrane were taken and sent for pathological examination for confirmation or exclusion of presence of inflammatory reaction so diagnosis of subclinical chorioamnoitis may or may not excluded.

• Correlation of the blood test with the pathological findings of absence or prescience of subclinical chorioamnoitis was evaluated using suitable statistical methods.

• Also, evaluation of the uterus and female postpartum was assessed for any complication.

Outcome:

A. Primary:

• Value of N/L ration and P/L ratio for diagnosis of subclinical chorioamnoitis and compared with CRP and TLC

B. Secondary:

• Relation of N/L ration and P/L ratio with timing of termination of pregnancy and compared with CRP and TLC

• Relation of N/L ration and P/L ratio with method of termination of pregnancy and compared with CRP and TLC

• Relation of N/L ration and P/L ratio with postpartum condition of mother and the uterus and compared with CRP and TLC

Ethical approval: This study was approved by local ethical committee of Tanta University before the start of this study.

Results

100 patients were selected in the course of study, all were suffering from PROM , and prepared for termination of pregnancy either normal or cesarean , all had no clinical signs of chorioamnoitis , blood markers were taken before termination , and the results statistically analyzed according to the result of pathological examination of amniotic membrane for detection of early inflammatory signs for chorioamnoitis.

Studying of patients’ data were demonstrated in Table 1, the gestational age at which termination of pregnancy was decided in the cases recruited for the study were range from 22-39 weeks gestation with mean 33.8 weeks, and the period of rupture of membranes range from 1-14 days with mean 5.05 days, of course in some cases the period of rupture of membranes was less than 1 day, those patient the duration of rupture of membrane was approximated to be 1 day.

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Iris Publishers- Open access Journal of Current Trends in Clinical & Medical Sciences | Biological Fragmentation of Circulating Cell-free DNA Alters Genetic Representation

Authored by Chen Hsiung Yeh*

Short Communication

High-throughput sequencing of circulating cell-free DNA (cfDNA) as liquid biopsy has revolutionized tumor genome profiling by providing a more accurate, longitudinal, real-time and non-invasive mean for precision and personalized medicine. Current knowledge on cfDNA characteristics revealed that it exists mainly as double-stranded molecules, resulting from biological fragmentation into both short (<1 kb) and long segments (>10 kb) [1,2]. Short fractions are mostly derived from apoptosis via the activation of cellular endonucleases leading to the cleavage of chromatin DNA into inter-nucleosomal fragments [3], whereas necrosis generates relatively long fragments of DNA. It is now believed that circulating cfDNA pool of cancer patients is originated from a combination of apoptosis, necrosis, and active release [4]. Within the nucleosomal core, cfDNA is protected from blood nucleases by histones, whereas the linker is vulnerable to digestion. As a result, regions showing high or low frequency of fragmentation correspond to the sequences between or occupied by nucleosomes, respectively, with the majority of short-fragment length corresponds to single nucleosome size of 160-170 bp. These observations strongly support the notion that the patterns of cfDNA fragmentation are guided by chromatin structure particularly the interplay between nucleosome positioning, epigenetic regulation, and gene expression machinery [5,6].

Furthermore, cfDNA is highly heterogeneous since it represents numerous different tissues each of which has its own gene expression profiles. Indeed, biological fragmentation of nucleosome-bound DNA is never random leading to biased representation of cfDNA sequences and unbalanced read coverage and uniformity, especially near genomic regions of transcription start sites and exonic boundaries, where nucleosome positioning is highly phased [6,7]. Hence, it is believed that chromatin changes associated with loci overall expression level contribute to the cfDNA fragmentation pattern, i.e., cfDNA patterning reflects a general picture of gene expression [8]. Accordingly, gene expression directed patterns of cfDNA fragmentation could have important impacts for next-generation sequencing (NGS) analysis. The required level of resolution for a NGS assay is achieved by providing sufficient coverage, which generally refers to the average number of reads that align to each base within the targeted gene regions. Theoretically, the coverage uniformity among different loci/alleles should be high and even to make calls with confidence. However, not all genes are born equally in terms of functionality and chromosome location, i.e., biological representation bias exists.

Information about the nature and mechanism of cfDNA fragmentation in their chromatin context is essential to understand not only the genetic representation but also the complex interactions that are responsible for tumor chromatin architecture. Changes in gene expression can alter dynamic chromatin states: gene activity is usually low with condensed and higher order packaged chromatin, whereas active gene expression always leads to relaxed and open chromatin where DNA fragmentation readily occurs (Figure 1).

Therefore, cfDNA fragmentation is not a random process evenly spread across the entire genome. As a result, it is expected that some genes in fragmented cfDNA are over-represented and others are under-represented. Most importantly, the real picture of uneven genetic representation of cfDNA caused by non-random fragmentation is greatly hindered by current DNA extraction methodology that depleted nucleosomes and other DNA-protein complexes in order to reach high sequencing uniformity.

The disparity in genetic representation in cfDNA fragments has been well documented [9-12]. Studies have shown that repetitive sequences Alu and certain satellite markers were found to be overrepresented, while L1 and L2 repeats were under-represented in the cell-free apoptotic DNA. L1 elements are mainly located in the transcriptionally inactive heterochromatin and Alu repeats are associated with gene-rich euchromatin regions that have high frequency of gene expression.

Examination of the fragment lengths present in cfDNA following silica extraction, we corroborated the findings in literature that fragmentation is primarily between nucleosomes with subsequent intra-nucleosomal cleavage along the DNA helical turn [13]. The fragment sizes corresponding to mono-, di- and tri-nucleosomal subunits appear to be prevalent (Figure 1). Only around 10-20 % of the cfDNA population are 170 bp increments with a laddering pattern, which is related to DNA wrapped around multiple nucleosomes and protected from nuclease cleavage. The higher abundance of longer fragment cfDNA population (>1 kb) could be due to the regions being generally inaccessible by enzymes because of the dense packaging. In addition, utilizing NGS analysis with each purified fraction, we are able to show that longer fragments exhibited much higher coverage uniformity, on-target rate and mean depth than shorter fragments (Table 1).

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Iris Publishers- Open access Journal of Yoga, Physical Therapy and Rehabilitation | YOGA as a Potential Mind-Body Medicine for Circadian Rhythm Restoration for Cancer Patients

Authored by Yu Huei Liu*

Short Communication

Cancer patients receiving chemotherapy suffer from a variety of side effects, including insomnia [1], However, the underling mechanisms behind insomnia during and/or after chemotherapy are not yet fully understood. Both cancer and anticancer therapeutics alter the production of proinflammatory cytokines such as sleep inducers TNF-α, IL-1 β and IL-6, to change the immune responses depending on immune cells repertories, which subsequence function on the central nervous system and the sleep– wake rhythms, by which to alter sleep behavior [2,3].

Currently no specific treatment for chemotherapy-related insomnia, nonprescriptive and prescriptive sleep medicines are the only way to choose even though those medications have not been evaluated in cancer patients. On the other hand, although dysfunction in circadian rhythms is a common occurrence in older adults and is a symptom of neurodegeneration [4], studies also suggest that circadian rhythm disruptions might potentially risk for developing neurodegenerative diseases such as Alzheimer’s disease [5-7] and Parkinson’s disease [7,8]. Although the causalrelationship requires to be evaluated in larger and longitudinal studies [9,10], it points the importance to address chemotherapyrelated insomnia to improve patients’ potentials to complete treatment for cancer, the recovery rate, and their quality of life.

Yoga is the original mind-body medicine that keeps physical homeostasis as well as mental and spiritual harmony in human. Several evidence-based mind-body medicine, including yoga, have been successfully used for the management of insomnia and have demonstrated efficacy in cancer patients receiving chemotherapy [11,12]. Indeed, yoga has been shown to improve sleep quality of chemotherapy-related insomnia especially for breast cancer patients [13-17], however, the underlying mechanism require to be identified. In addition, whether it is potent enough to manage chemotherapy-related insomnia for other cancer patients require further investigation. More high-quality randomized control trials to support the scientific evidence are warranted. This is what we eager to work on.

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Iris Publishers- Open access Journal of Yoga, Physical Therapy and Rehabilitation | Literature Review: Trauma-Informed Yoga in Couples & Family Therapy

Authored by Mindy Tran*

Introduction

Couples and family therapists are trained to view the world from a systemic lens, meaning that they practice closely examining our clients’ interpersonal relationships in addition to the clients’ intrapersonal and intrapsychic view of themselves. Understanding our clients systemically means that the therapist pays attention to different aspects of their identities, such as their social location, their past experiences, their support systems, and their identities. Therapists notice how these multiple dominant systems are working simultaneously in order to provide the clients’ internal world with meaning. A primary source that helps therapists better understand the client is by taking in the information that the clients tell us using their own words. As a result, much of mainstream therapy is conducted in the form of a conversation. Unfortunately for many therapy clients who have experienced trauma in their lifetime, talking with a therapist may not be enough to help the client as a whole. In addition to a client maybe having a memory of the past traumatic experience(s) that they experienced, their bodies also went through that same traumatic experience as well. Our clients’ brains are organized in a way that helps us survive in stressful situations, but the outcome of survival may result in our brains prioritizing our past traumatic memories, and our bodies reacting as if those events are occurring again in the present moment Van der Kolk [1] Trauma-informed yoga, or yoga that is taught from a trauma-informed lens, is one solution to incorporating the body into the therapy process since it offers a way for the clients to explore their experiences within their bodies while giving them permission to move at their own pace. By integrating trauma-informed yoga into a client’s treatment plan, therapists are able to begin addressing the client as a whole, offering them the experience of embodied awareness which, over time, can help our clients minimize their post-traumatic symptoms and feel more comfortable with living fully in the present moment.

Theoretical Perspectives on Trauma-Informed Yoga

In a survey that was conducted by Yoga Alliance in 2016 gathered information on individuals across the country who have practiced any form of yoga within the past year, and found that about thirty six million Americans, or roughly ten percent of the country’s population, have practiced yoga at some point in their lives Macy D [2]. Although not everyone has practiced yoga at some point in their lives, yoga is still a household name and yoga resources are widely available to many individuals through local gyms, studios, community organizations, or on the internet. The physical yoga practice is a bottom-up approach that utilizes breathing and movement cues to invite practitioners to tune into the sensations that they are experiencing in their bodies, increasing their sense of interoception Danylchuk [3]. During yoga, the student is led by an instructor that provides various cues that invite the client to observe the ebb and flow of their own emotions while also observing the physical sensations and mental states that accompany them Forbes [4]. By introducing ways that the client can practice feeling into their bodies, they can start to develop embodied awareness where they begin to feel into their experiences in the present moment while also recognizing their own needs [5].

A trauma-informed yoga practice can be used as an intervention when working with clients who are experiencing post-traumatic symptoms because it can help address some of the somatic symptoms in the body the same way that talk therapy can address some of the cognitive issues Emerson and Hopper [6]. The principles of trauma-informed yoga are rooted in traumainformed care principles that were developed by the Center for Disease Control in partnership with the Substance Abuse and Mental Health Service Administration that was intended to help those who are in the service field, under the assumption that individuals more likely than not have experienced some kind of traumatic event throughout their lifetime, to be able to provide the most appropriate and responsive care possible to their clients [7]. Trauma-informed care includes five core concepts: safety, choice, collaboration, trustworthiness, and empowerment. Incorporating these principles into a yoga practice would include ensuring that the class is both physically and emotionally a safe space, utilizing invitational language that allows the client to explore different modifications and postures, working with the students to adapt the class or cues based on the student’s needs, building rapport with the students, and empowering the students to take effective action to meet their needs.

In order to understand how trauma-informed yoga an effective tool can be to use in conjunction with talk therapy, it is important to understand how trauma affects the body. When a person experiences something that is traumatic, meaning that we have experienced something that was unbearable and intolerable that has also taken away our power and control, our brains and bodies will organize itself in a way that will increase their likelihood of survival [1]. During trauma, the body’s natural ability to cope has been overwhelmed and as a result, the body’s sympathetic nervous system, or “fight-flight-or-freeze,” will kick in to prepare the body to react. Over time, if the trauma has not been properly processed by the brain’s prefrontal cortex, the past trauma may begin reappearing during times when the person is otherwise safe and out of harm’s way. The cluster of symptoms that are most common amongst those who have experienced trauma in the past have been categorized as Post-Traumatic Stress Disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders. PTSD symptoms include intrusive symptoms including nightmares or flashbacks; avoidance to people, places, or things that are associated with the trauma; cognitions and moods that are negatively altered due to the traumatic event; and changes in a person’s behaviors that begin after the traumatic event [8]. In addition to a traumatic event being a one-time occurrence, other forms of trauma include complex trauma that could happen over the course of a long period of time and perpetrated by someone who has a close interpersonal relationship to the person Pleines [9], or intergenerational trauma that can pass along some specific reactions or maladaptive behaviors attributed to past traumas [10]. Regardless of the means that the trauma happened, the aftermath of symptoms is often times felt in the body just as much, if not more, than it is felt in the mind.

From a therapeutic standpoint, it is also helpful to take into account attachment theory when discussing trauma and embodiment because attachment patterns can be reflective of the individual’s internal working model. An internal working model is developed through the interactions that the person has with their primary caretakers during infancy that becomes internalized. As the child grows up, they use their internal working model to help them navigate the world [11]. Having a secure attachment figure allows the child to explore their world more freely because they are aware that they have a place among their caretaker where they feel a sense of belonging [12]. This sense of belonging within securely attached children influences the child’s internal working model and communicates to the child that the world is a safe place to exist. If the child had grown up in an environment where their caretaker was inconsistent or was not available, the child’s internal working model may begin to expect that the world will be just as inconsistent or unavailable to them. The internal working model is also how the child learns how to react to the world, including how safe they feel to advocate for their needs, how they handle receiving from or giving to others, and also how they are able to feel their emotions. If a child did not have a sense of safety for them to feel into their emotions, then they may grow up unable to access those emotions anymore [12].

Clinical Implications of Trauma-Informed Yoga for Couples & Family Therapists Couples & Family Therapists

Trauma is an extremely complex topic that has many manifestations that vary from person to person, which means that the treatment for trauma must be equally complex. Unfortunately for therapists, the use of mindfulness tools such as yoga have not been as common in the therapy room Briere & Scott [13], but as more and more research is being done on the efficacy of these ancient practices, the more it may become integrated into treatment. When treating trauma, the therapist must view this from a systemic standpoint and consider different factors such as the person’s environment, their family, their support systems, and any other strengths or weaknesses that may impact their capacity to heal. As couples and family therapists, we are able to apply this systemic lens to the intrapersonal dynamic of the client and consider the ways that the client’s different parts are not working in harmony with one another. Trauma-informed yoga can be a very effective addition to the treatment plan for our clients who are working towards healing trauma because of yoga’s inherent focus on the embodied experience. Even if the clients are hesitant or unwilling at first to try any kind of yoga or embodiment practice, being able to have this as an opportunity available to them and to support them in the choice that they make can be a really healing experience in itself.

Reflection

As someone who has been practicing yoga for over a decade, I can attest to the fact that yoga provides a path for its students that can create a shift in the way that they relate to their bodies. Traumainformed yoga can be a powerful tool in trauma healing and can be a refreshing change of pace from the traditional talk therapy setting. Yoga by no means can replace the importance of talk therapy, but instead it can help to extend the therapeutic process from the mind into the body and from the therapy room into the real world. For some of the clients who I work with, it is difficult for them to discuss their past traumatic experiences in fear that they will be flooded with emotions when they “go there,” or some of my other clients may feel no connection to most of the physical sensations in their bodies due to their past traumatic experiences. When working with clients who have difficulty with speaking to their experience, I have found that being able to incorporate some movement that is influenced by trauma-informed yoga can be helpful in providing a sense of grounding and comfort for the client. I have also found it to be helpful to be aware of the trauma-informed yoga classes that are nearby, so that I can offer that resource to my clients.

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Iris Publishers- Open access Journal of Pediatrics & Neonatal Care | Family Planning in Sudan Training Course in Sexual and Reproductive Health Research 2014 WHO

Authored by Ahmed Bashir*

Background

The Penal Code of 1 August 1925 (section 262-267) governed Abortion in Sudan until 1983. Under this code Abortion was prohibited unless it is to save the life of the pregnant woman. A person performing abortion with the woman consent was subject to imprisonment for a period not exceeding 3 years or payment of a fine if the aborts reached the stage of “quickening”. In 1983 the code was changed to meet the legislation designed to meet the Islamic law, although the performance of abortion is still prohibited, , but the punishment was changed to payment of blood money. Persons performing abortions are subject to payment of compensation as well as imprisonment.

Abortion law was once more changed in 1991; with the major change was expansion of the circumstances under which the performance of an abortion was legal in the following: (a) the miscarriage is for the sake of the mother’s life. (b) The pregnancy was the result of rape less than 90 days ago. (c) It is proved that the fetus has died in the mother’s womb.1991 new legislations did not apply to non-Muslim population.

Family planning services was introduced in Sudan since Independence in 1956, The Government of the Sudan provides direct access to modern methods of family planning. In 1975 the Ministry of Health established the maternal and child health and the family planning project. The Fertility Control Association was created in 1976. Both provide family planning all over the country by their 389 service points, with 11 permanent clinics and 4 mobile units [1].

Contraceptive Methods

Generally, in developing countries as in Sudan millions of women in the reproductive age do not use proper contraceptive methods, they prefer to limit their birth; this usually reflects their failure to prevent and avoid unwanted pregnancies.

Sudan is a country of great need of frontline sexual and reproductive health (SRH) services; this was shown by statistics. Advocacy, and undertaking information, education and communication (IEC). It works with 62 associated operations, 60 private physicians, and over 90 agencies. With 158 communities - based distributors/community - based services (CBD/CBSs) provides the essential on ground support, this will meet with nearly 64% of the country’s current demand for contraceptive pills.

The census of 2011 of Sudan Family Planning Association (SFPA) delivery as follows:

-240,000 condoms

-576,000 sexual and reproductive health services.

-134,000 HIV-related services [2-4].

Unmet Need for Contraception and Children Spacing

Largely populated countries probably have high fertility rates. High fertility rates are associated with inadequate spacing between births. 99% of maternal deaths occurred in developing countries, the WHO estimated that 13% are due to unsafe abortions. 50 million of women report to induced abortion each year worldwide. Other causes of high maternal mortality deaths are, complications of pregnancy, and complications of childbirth. In Sudan maternal and infant mortality rates are among the highest in the region, 600 per 100,000 live birth, and 70% per 1,000 live births, for maternal and infant mortality rates respectively.

Countries with high fertility rates, has low contraceptive use. Unintended pregnancies have significant consequences especially in adolescents, low income, and minority groups. Oral contraceptives and condoms are the base for majority of family planning in Sudan in recent years, however earlier programs relayed on methods such as (IUD) that are less prominent now. Over time newer methods were used, ingestible, and implants also find their way for use by some. The main trend has been changed to permanent methods; sterilization although simpler has now more demand.

Before 1999, the total fertility was 6.2 births per woman. . This figure decreased to 4.9 in 2002.

The proportion of women using modern methods of contraception in North Sudan increased slightly from 4% in 1977- 1978 to around 6% in 1989 and 7% in 1992-1993 [5].

In 1978 a fertility survey was carried in the capital Khartoum, it showed that there was widespread knowledge of family planning in the city, the level of ever –use of birth control is significant. Pills are used universally in birth control users; IUD, Rhythm, and withdrawal are relatively popular. It was observed that there is great consistency between reports given by husbands and their wives indicating that the use is for birth spacing rather than a smaller number of children however the purpose of using birth control is yet to be explained [6].

Unmet need for family planning is defined by WHO, as the percentage of all fecund women who are married or lived in union, presumed to be sexually active but are not using any method of contraception. Either does not want to have more children, want to postpone their next birth, or they do not know when to have another child [7].

The Sudan household survey in 2010 showed that, 9% of women 45-49 years used a contraceptive method. The unmet need for contraception is 29%, with the total fertility of 5.6 children per woman. The maternal mortality rate in the same study was 600 per 100,000 live births. This will readily reflect the concept of unmet family planning leading to the high maternal mortality rate in the country [8].

In one study at the Eastern part of the Sudan, Abdulazem A. Ali and Amira Akud found a high maternal mortality rate 713 per 100,000 live births, low use of contraception (44%), they commented that in spite of the tremendous effort for family planning done by both the Government and the Sudan Family Planning Association, there is no improvement in the use of contraception, the availability and/or accessibility still vary between urban and rural areas [9].

As there are scarce studies about the contraception use in the whole country, the separation of South Sudan from Sudan, I think more studies are needed to elaborate the problem and guide decision makers to start an effect programs guided by WHO guide lines and carried with the help of Sudan Family Planning teams.

Conclusion

In Sudan particularly in rural areas, other problems exist opposing family plans and contraception use, female genital mutilation, tribal believes of large families, and some wrongly translated religious believes also contribute to the low implementation of effective use of various contraceptive method.

The most commonly used contraceptive is oral contraception, followed by IUD in Cities and urban areas. Although there is very few studies for the rural areas but the mostly used method is breast feeding, as the majority will breast feed up to 2 years of age, this practice has dual effect as it is useful for spacing between children, it also prevent some common infectious diseases(pneumonias, gastroenteritis and others). This practice could be used effectively if utilized in an effective way by drawing an effective plan in the media and/or through (SFPA) Emergency contraception was of limited use, as well as withdrawal and other lines of contraception.

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