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Trial registered on ANZCTR
Registration number
ACTRN12617000509369p
Ethics application status
Submitted, not yet approved
Date submitted
29/03/2017
Date registered
7/04/2017
Date last updated
10/08/2018
Type of registration
Prospectively registered
Titles & IDs
Public title
Uptake of levonorgestrel releasing intrauterine system (LNG-IUS, Mirena 'Registered Trademark') at caesarean section
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Scientific title
A study of uptake rate of levonorgestrel releasing system intrauterine system (LNG-IUS) at elective caesarean section
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Secondary ID [1]
291529
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Nil known
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Universal Trial Number (UTN)
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Trial acronym
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Linked study record
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Health condition
Health condition(s) or problem(s) studied:
Fertility
302619
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caesarean section
302706
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Condition category
Condition code
Reproductive Health and Childbirth
302142
302142
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0
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Contraception
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Intervention/exposure
Study type
Interventional
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Description of intervention(s) / exposure
Levonorgestrel releasing intrauterine system (LNG-IUS, Mirena 'Registered Trademark") is an intrauterine device that provides contraception for up to five years. It releases levonorgestrel over 5 years, at an initial dose of 20ug over 24 hours. It is usually inserted at least six weeks after delivery. Recent Australian contraception guidelines support its insertion at the time of caesarean section. This study is to investigate how many women choose to have LNG-IUS inserted at caesarean section when it is offered, as well as looking at the reasons that women choose to have the device inserted.
Women who are planning to have an elective caesarean section will have one or more consultations with a doctor to arrange and consent to caesarean section. The treating doctor will discuss LNG-IUS insertion at the time of caesarean, and will provide the women with written information about this.
The women will be asked to consent to answer a few questions about their experience with and attitude to LNG-IUS regardless of whether they choose to have the LNG-IUS inserted at the time of caesarean section.
The device is designed to remain in place for five years, but can be removed earlier if the woman wishes.
Women who have LNG-IUS inserted at the time of caesarean section will be followed up six weeks and one year after delivery.
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Intervention code [1]
297598
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Treatment: Drugs
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Intervention code [2]
297689
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Treatment: Devices
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Comparator / control treatment
No control group
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Control group
Uncontrolled
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Outcomes
Primary outcome [1]
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The primary outcome is whether women choose to have the LNG-IUS inserted at the time of caesarean section.
The women state their choice directly to the doctor arranging the caesarean section, and recorded in the medical record
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Assessment method [1]
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Timepoint [1]
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Prior to caesarean section
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Secondary outcome [1]
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LNG-IUS expulsion
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Assessment method [1]
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Timepoint [1]
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Assessed by ultrasound at 6 weeks after delivery
Assessed by phone call to patient at 1 year after delivery
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Secondary outcome [2]
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Strings visible in vagina
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Assessment method [2]
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Timepoint [2]
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Assessed by speculum examination at 6 weeks postnatal checkup
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Secondary outcome [3]
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patient satisfaction
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Assessment method [3]
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Timepoint [3]
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Assessed on 5-point Likert Scale 6 weeks and 1 year after LNG-IUS inserted
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Secondary outcome [4]
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vaginal bleeding pattern using a simple questionnaire designed for this study
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Assessment method [4]
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Timepoint [4]
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Assessed by patient questionnaire 6 weeks and 1 year after LNG-IUS insertion
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Secondary outcome [5]
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continuing LNG-IUS use
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Assessment method [5]
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Timepoint [5]
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Assessed by phone call to woman 1 year after LNG-IUS insertion
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Eligibility
Key inclusion criteria
Women who are planning an elective caesarean section will be eligible for the study of the primary outcome, which is whether or not they choose to have immediate insertion of LNG-IUS at the time of surgery.
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Minimum age
No limit
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Maximum age
No limit
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Sex
Females
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Can healthy volunteers participate?
Yes
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Key exclusion criteria
Allergy to LNG-IUS
Prolonged rupture of membranes
Suspected chorioamnionitis or pelvic infection
Uterine anomaly (bicornuate or septate uterus)
Abnormal cervical cytology requiring follow-up
Planning to have another pregnancy within 12 months
Unable to give informed consent
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Study design
Purpose of the study
Treatment
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Allocation to intervention
Non-randomised trial
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Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
No allocation concealment
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Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Not relevant
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Masking / blinding
Open (masking not used)
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Who is / are masked / blinded?
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Intervention assignment
Single group
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Other design features
This study is examining women's choice of contraception, therefore there will be no allocation, blinding or assignment
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Phase
Phase 4
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Type of endpoint/s
Efficacy
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Statistical methods / analysis
Descriptive statistics will be used to analyse the uptake rate of LNG-IUS at caesarean as well as secondary outcomes. A multivariate model using binomial regression will be used to analyse factors predicting uptake of LNG-IUS at caesarean.
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Recruitment
Recruitment status
Withdrawn
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Reason for early stopping/withdrawal
Other reasons/comments
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Other reasons
HREC approval not received
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Date of first participant enrolment
Anticipated
1/06/2017
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Actual
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Date of last participant enrolment
Anticipated
31/05/2018
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Actual
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Date of last data collection
Anticipated
31/05/2019
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Actual
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Sample size
Target
100
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Accrual to date
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Final
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Recruitment in Australia
Recruitment state(s)
QLD
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Recruitment hospital [1]
7727
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Mackay Base Hospital - Mackay
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Recruitment hospital [2]
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Proserpine Hospital - Proserpine
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Recruitment postcode(s) [1]
15651
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4740 - Mackay
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Recruitment postcode(s) [2]
15652
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4800 - Proserpine
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Funding & Sponsors
Funding source category [1]
296016
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Other Collaborative groups
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Name [1]
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Mackay Institute of Research and Innovation
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Address [1]
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Mackay Base Hospital
Bridge Road
Mackay
Qld
4740
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Country [1]
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Australia
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Primary sponsor type
Hospital
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Name
Mackay Hospital and Health Service
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Address
Mackay Base Hospital
Bridge Road
Mackay
Qld
4740
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Country
Australia
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Secondary sponsor category [1]
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None
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Name [1]
294906
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Address [1]
294906
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Country [1]
294906
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Ethics approval
Ethics application status
Submitted, not yet approved
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Ethics committee name [1]
297278
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Townsville Human Research Ethics Committee
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Ethics committee address [1]
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Level 1 JCU Clinical School The Townsville Hospital 100 Angus Smith Drive Townsville QLD 4814
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Ethics committee country [1]
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Australia
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Date submitted for ethics approval [1]
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27/03/2017
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Approval date [1]
297278
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Ethics approval number [1]
297278
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Summary
Brief summary
Initiating long acting reversible contraception at the time of delivery has several advantages that include high patient motivation, convenience, access to trained professionals, no need for an outpatient insertion (which may be uncomfortable) and immediate contraception prior to the resumption of ovulation(1, 2) . Levonorgestrel releasing intrauterine system (LNGIUS, Mirena, Bayer Healthcare), is an intrauterine long acting reversible contraceptive that provides contraception for 5 years(3). In Australia its use almost always involves insertion through the vagina 6 weeks or more after childbirth (standard insertion). The 2016 Australian contraception guidelines rate immediate insertion of LNGIUS at delivery including caesarean section as category 1 (that is no restrictions placed on use) (4). Mwalwanda and Black (2013) note that, “No studies have specifically examined the uptake rate, long term continuation rates, acceptability or effectiveness” (of LNG-IUS in the immediate postpartum period) (2). Intrauterine device (IUD) insertion has low rates of adverse events such as pain and infection, regardless of timing or route of insertion(1, 5). Expulsion rates following device insertion at the time of caesarean may be higher than following standard insertion but more research is required to quantify the risk. Expulsion of IUDs including LNG-IUS following standard insertion is reported to occur in approximately 1 in 20 women(2). Three studies have been examined expulsion rates of LNG-IUS inserted at caesarean section. Expulsion rates were 0%(6, 7) and 20% (8). IUDs including LNGIUS have nylon strings attached. The strings are useful because they can be seen or felt to check that the device is still present, and they can be pulled to remove the device when this is desired. When devices are inserted through the vagina into the uterus the strings are always visible in the vagina initially, and the chance of strings not being visible in the cervix at follow up visits is 5%(9). When IUDs are inserted at caesarean section the chance of the strings not being in the vagina at followup is 8%(10). Patient satisfaction with LNG-IUS insertion at caesarean section has been found to be high, and not different to standard insertion(7). Continued use of LNGIUS inserted at caesarean for 12 months after delivery has been found to be higher than following standard insertion but this difference was not statistically significant (60.0% vs 40.9%, p=0.35)(8). LNG-IUS contains the hormone levonorgestrel, which is a progestogen. Studies of use of various types of progestogen containing contraceptives early in the neonatal period have not show a consistent adverse effect on breastfeeding initiation or continuation, or on neonatal outcomes such as growth and development(11). LNGIUS insertion at the time of caesarean section is associated with reduced postpartum bleeding compared with insertion of copper-containing IUD at caesarean section or no device insertion at caesarean section(12). There is some evidence that the theoretical advantages of LNGIUS insertion at caesarean encourage higher patient uptake. Two studies of immediate LNGIUS insertion at the time of caesarean section compared to standard insertion showed that more women had the procedure done in the immediate insertion group (19/20 vs 18/22)(8) and 25/25 vs 19/23(7) . This trial aims to offer LNGIUS insertion at elective caesarean section. Uptake rate is the primary endpoint. Device expulsion, string visibility, patient satisfaction, continuing use and bleeding pattern will also be recorded. REFERENCES 1. Lopez LM. Immediate postpartum insertion of intrauterine device for contraception. Cochrane Database of Systematic Reviews [Internet]. 2015; (6). Available from: http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=edschh&AN=edschh.CD003036&site=eds-live. 2. Mwalwanda C, Black K. Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use. The Australian & New Zealand Journal Of Obstetrics & Gynaecology. 2013;53(4):331-7. 3. Heinemann K, Reed S, Moehner S, Do Minh T. Original research article: Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices. Contraception. 2015;91:280-3. 4. Family Planning New South Wales FPV, True Relationships and Reproductive Health. Contraception: An Australian Clinical Practice Handbook. Fourth Edition ed. Australia: Family Planning NSW,Family Planning Victoria and True Relationships and Reproductive Health; 2016. 5. Kapp N, Curtis K. Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009;80(4):327-36. 6. Puzey M. Mirena at caesarean section. The European Journal Of Contraception & Reproductive Health Care: The Official Journal Of The European Society Of Contraception. 2005;10(3):164-7. 7. Braniff K, Gomez E, Muller R. A randomised clinical trial to assess satisfaction with the levonorgestrel- releasing intrauterine system inserted at caesarean section compared to postpartum placement. The Australian & New Zealand Journal Of Obstetrics & Gynaecology. 2015;55(3):279-83. 8. Whitaker AK, Endres LK, Mistretta SQ, Gilliam ML. Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial. Contraception. 2014;89(6):534-9. 9. Marchi N, Castro S, Hidalgo M, Hidalgo C, Monteiro-Dantas C, Villarroeal M, et al. Management of missing strings in users of intrauterine contraceptives. Contraception. 2012;86(4):354-8. 10. Bhutta S, Butt I, Bano K. Insertion of intrauterine contraceptive device at caesarean section. Journal Of The College Of Physicians And Surgeons Pakistan. 2011;21(9):527-30. 11. FSRH. Clinical Effectiveness Unit Guidance Intrauterine Contraception April 2015 2015 [updated October 2015]. Available from: https://www.fsrh.org/documents/ceuguidanceintrauterinecontraception/. 12. Elsedeek M. Puerperal and menstrual bleeding patterns with different types of contraceptive device fitted during elective cesarean delivery. International Journal Of Gynaecology And Obstetrics. 2012;116(1):31-4.
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Trial website
No trial website
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Trial related presentations / publications
Nil
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Public notes
Nil
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Contacts
Principal investigator
Name
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Dr Kathleen Braniff
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Address
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Department of Obstetrics and Gynaecology
Mackay Base Hospital
Bridge Road
Mackay
QLD
4740
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Country
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Australia
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Phone
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+61 748857216
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Fax
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+61 748857989
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Email
73558
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[email protected]
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Contact person for public queries
Name
73559
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Kathleen Braniff
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Address
73559
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Department of Obstetrics and Gynaecology
Mackay Base Hospital
Bridge Road
Mackay
QLD
4740
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Country
73559
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Australia
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Phone
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+61 748857216
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Fax
73559
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+61 748857989
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Email
73559
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[email protected]
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Contact person for scientific queries
Name
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Kathleen Braniff
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Address
73560
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Department of Obstetrics and Gynaecology
Mackay Base Hospital
Bridge Road
Mackay
QLD
4740
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Country
73560
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Australia
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Phone
73560
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+61 748857216
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Fax
73560
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+61 748857989
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Email
73560
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[email protected]
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No information has been provided regarding IPD availability
What supporting documents are/will be available?
No Supporting Document Provided
Results publications and other study-related documents
Documents added manually
No documents have been uploaded by study researchers.
Documents added automatically
No additional documents have been identified.
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