mortality associated with iatrogenic RTIs is to eliminate the need for unsafe abortion procedures. This goal is likely to be promoted by improving the supply of contraceptive services to those who desire them, widely promoting the use of emergency contraception, and decriminalizing abortion services (Alan Guttmacher Institute, 1994; Ellertson et al., 1995). Chapter 4 discusses some of the training and quality assurance efforts that could lead to lower rates of iatrogenic infection from abortion procedures. Given that a large number of septic procedures still occur in some areas, even where abortion has been legalized, successful intervention will also require ensuring an adequate number of trained abortion providers and, ultimately, the availability of safe alternatives to surgical abortion in the form of medical abortifacients that do not require transcervical procedures. Better training of providers to ensure the optimal treatment of abortion complications before infection develops will also be necessary.

Reducing the number of infections associated with other transcervical procedures, such as IUD insertion, will require more attention to adherence with infection control guidelines, improved provider technical competence, strengthening client counseling to help guide optimal contraceptive choice and proper use, and enhancing the overall management of service delivery programs. Given that some number of procedure-related infections occur even with optimal technique, the utility of antibiotic prophylaxis administered at the time of these procedures has also been investigated (Ladipo et al., 1991; Sinei et al., 1990). These results have been mixed, largely because of the unexpectedly low incidence of PID observed even among those IUD users who have received placebo regimens. Further studies, particularly studies involving new single-dose therapeutic regimens, may be necessary to fully understand the benefits and costs of use of antibiotics.

Secondary Prevention

Secondary prevention—the identification and treatment of established infections of the reproductive tract—is also an important element of a comprehensive intervention strategy; see Table 3-5. Appropriate treatment relieves symptomatic morbidity, prevents the more serious complications of infection that result in additional morbidity and occasional mortality, and serves to limit the duration of infectiousness—a critical determinant in the sustained spread of sexually transmitted infection. Unfortunately, a large proportion of RTIs are asymptomatic, especially in women. This characteristic of RTIs limits the utility of approaches that only treat symptomatic infection. Thus, while clinical management of symptomatic infections is essential, it is not adequate in itself. There

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