Technical Report Interim Report on Women’s Health Programming (Data through May 2013) May 9, 2013 Wuqu’ Kawoq

2 Calle 5-43 Zona 1, Santiago Sacatepéquez, Guatemala peter@wuqukawoq.org Peter Rohloff

Background Following initial baseline evaluations in several of our partner communities in 2011 and 2012, which showed large knowledge deficits among women about family planning and sexual health, as well as significant access barriers to women’s health care services, Wuqu’ Kawoq began a systematic expansion of its women’s health care programs in Fall 2012. These services include: 1. 2. 3. 4. Family planning services (oral contraceptive pills, condoms, Depo-Provera) Cervical cancer screening (pap smears) Syndromic detection and treatment of STIs Small group educational sessions covering domestic violence, family planning, STIs, HIV, breast cancer, cervical cancer, and menopause. 5. Clinical needs assessments Results of Data Analysis Demographics This report incorporates data from 178 participants from 4 beneficiary indigenous communities. One community is located in the department of Suchitepéquez, two in the department of Chimaltenango, and one in the department of Sololá. The average age of participants was 37.9 ± 12.1 years. 74% of participants were of childbearing age (15-44 years). Obstetrical and Sexual History Among the participants of childbearing age (n-131), only 1% were currently pregnant. Table 1: Obstetrical/Gynecological History of Participants Childbearing Number of Pregnancies Term Deliveries Premature Deliveries Miscarriages Living Children Cesarean (#) Cesarean (%) Age at First Pregnancy Older P 0.00 0.00 0.97 0.0001 0.00 0.02 0.02 0.005 Between Communities (P) 0.31 0.08 0.26 0.19 0.23 0.19 0.25 0.59

5.1 ± 3.1 3.6 ± 2.2 0.13 ± 0.05 0.37 ± 0.06 3.5 ± 0.2 0.37 ± 0.07 24.4 19.1 ± 0.36

8.0 ± 0.41 7.0 ± 2.9 0.13 ± 0.03 0.94 ± 017 6.3 ± 0.4 0.09 ± 0.04 8.9 21.7 ± 1.14

Age at Menarche Postmenopausal (%) Contraceptive Use (%)

13.48 ± 0.12 0 Condoms: 2 Depo: 39 Implant: 3 IUD: 1 Rhythm: 3 OCP: 2 Tubal: 12 No SA: 7 None: 34

13.57 ± 0.21 72 n/a

0.69 0.00

0.05 0.52 0.001

There was considerable heterogeneity between communities on types of contraceptive method used. For example Depo usage in Suchitepéquez was as high as 36%, but ranged from 17-29% in the Altiplano communities. Rates of no contraceptive usage ranged from 27-60%. Table 2: Sexual History of Participants Childbearing Age at Sexual Debut Number of Lifetime Partners History of Prior STI (%) Older P 0.01 0.52 0.16 Between Communities (P) 0.14 0.22 0.09

18.16 ± 0.36 1.11 ± 0.03 Yes: 13 No: 66 Unsure: 20

20.4 ± 1.06 1.06 ± 0.04 Yes: 6 No: 77 Unsure: 15

Cervical Cancer Screening/STI Table 3: Prior Cervical Cancer Screening History of Participants Childbearing Has Had Screening in Past (%) Years since Last Screening Results of Last Screening (%) 67 2.95 ± 0.37 Normal: 43 Abnormal cytology: 2 Infection: 28 Unknown: 26 Older 74 6.86 ± 1.22 Normal: 49 Abnormal cytology: 3 Infection: 23 Unknown: 26 P 0.41 0.0001 0.85 Between Communities (P) 0.00 0.0002 0.009

History of Prior STI (%)

Yes: 13 No: 66 Unsure: 20

Yes: 6 No: 77 Unsure: 15

0.16

0.09

Between-communities differences in prior cervical cancer screening rates were controlled largely by the relatively low rates of prior screening in the Suchitepéquez community (56%) as compared to the other Altiplano communities (75-88%). Between communities differences in date of last screening were also similarly explained, with mean years since last screening in Suchitepéquez of 6.5 ± 6.4 years (range for Altiplano communities of 1.7-3.7 years). On the other hand, the difference in distribution of reported results could not be easily explained by a difference between the Suchitepéquez and Altiplano communities, as the four communities all showed considerably heterogeneity on this response item. Of note, most of the respondents who answered “unknown” did so either because they never received a copy of their screening results or because they were lost to follow-up. Table 4: Current GU Symptoms among Participants Childbearing Bothersome Vaginal Discharge (%) Vaginal Pruritus (%) Dysuria (%) Dyspareunia (%) 36 27 24 30 Older 19 19 11 15 P 0.03 0.29 0.05 0.07 Between Communities (P) 0.49 0.00 0.33 0.17

Table 5: Results of Clinical Encounters/Pap Smears Childbearing Older P Between Communities (P) 0.58

Pap Smear Cytology (%) Normal Abnormal Bacterial Vaginosis Presumed STI Syndromic Rx (%) STI PID Bacterial Vaginosis

0.001 87 0 2 11 59 0 0 41 0.002 10 1 1 38 3 0

0.47

Initial Programming Conclusions 1. This is a convenience sample of participants presenting to our programs, therefore the results may not be representative of wider trends in the participating communities 2. The representation of pregnant women in the sample is very low. More efforts should be made to make participating communities aware that services are available to pregnant women 3. Rates of no contraceptive use among women of childbearing age could be improved. Since prior needs analysis has shown that women of childbearing age often site lack of access to contraceptive methods as a major barrier, more efforts should be made to educate women regarding the availability of these methods through our programs 4. Age at sexual debut and first child were surprisingly lower among younger participants. This highlights the need for more outreach to adolescents and young women. 5. Historical access to cervical cancer screening in the Suchitepéquez community was surprisingly low; therefore this program is providing a much needed service there. 6. Fully 25% of women reported prior cervical cancer screening but did not know the results. On further questioning, most of these instances were cases in which they did not return to a provider to receive their results. Importantly, our program staff are making considerable efforts to have follow-up encounters with each women to review results personally; these efforts should be continued. 7. There is considerable unmet need in the diagnosis of STIs among older women. In this group only 6% reported a prior diagnosis, but 41% were diagnosed syndromically and/or by cytology here. 8. Self reporting of GU symptoms were an unreliable indicator of clinical exam and cytology results. Women of childbearing age tended to over report GU symptoms, whereas older women underreported.