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Volume 4, Number 5
2 February 2004

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GUEST EDITORIAL

How Effective are the Newest and the Older-type Progestogen-only Pills?

by John Guillebaud, MA, FRCSEd, FRCOG, MFFP

j.guillebaud@lineone.net

Progestogen-only pills (POPs) during breastfeeding are in the same ballpark for efficacy as combined oral contraceptives (COCs). Otherwise, their failure-rate is at least 1 per 100 woman-years in compliant users under 40, rising to 3.1 even in well-motivated women aged 25-29 (1), and the requirement to use added contraceptive precautions for two days after just 3 hours delay in pill-taking (2) adds to their unpopularity for many users and providers.

Cerazette® (Organon) is a new product containing 75 µg desogestrel. It has the potential to "rewrite the text-books" about POPs, primarily because, in addition to having the mucus contraceptive effect of all POPs, a possibly fertile ovulation (defined by progesterone level and follicle rupture on scan) occurred in only one of 29 women, or in 1.7% of 59 cycles studied (3). An exceptionally low failure rate of 0.17 per 100 woman-years was also reported (4). So where available, may it be offered to young women as a more effective alternative than the other marketed POPs?

A recent widely-cited article (5) in Drug and Therapeutics Bulletin (DTB) is a good review, with all the important references, but in my opinion marred by surprisingly negative conclusions. What do we do when the evidence from clinical trials and epidemiology is not (yet) as complete as we would all like, but we have clients sitting in front of us wanting our help in choosing from available options? It is then not sufficient just to provide the 'evidence' from an ivory tower. A decision has to be made. Pending more data, evidence-based medicine (EBM) must be subjected to informed judgement, based on ALL available evidence (including the reported pharmacology of the product) and clinical commonsense.

The DTB says "there is insufficient evidence on whether it [Cerazette®] is a more effective contraceptive than other POPs…" (5). In truth, in the levonorgestrel POP comparator arm, the pre-marketing bleeding and efficacy trial (4) was indubitably under-powered for clinical efficacy. However, among the more than 600 consistent users aged 18-40, not breastfeeding, in the other (desogestrel) arm, the Pearl failure rate was 0.17 (confidence intervals CI 0.004-0.928) per 100 woman-years. In any clinical study of a POP, such a low rate (with an upper bound of the CI less than 1) is historically unprecedented (2). So it would have been equally valid to have concluded: "there is insufficient evidence that Cerazette® is not a more effective contraceptive than other POPs…." Indeed, taken with the strong evidence of greater inhibition of ovulation and—something overlooked by the reviewers—the fact that Cerazette® does not have that inbuilt contraceptive weakness of the combined pill (ie, the pill-free interval [6]), I would estimate the chances of it not being ultimately proved significantly more effective than other POPs to be close to zero!

This product is a useful new addition to the range of contraceptives, particularly for a young, non-breastfeeding woman wanting a pill method but recommended to or wishing to avoid the COC. It is highly likely (though again not yet fully established) to be more forgiving of late pill-taking than other POPs, though pending more data recommending the "3-hour" time window for compliance is probably wise. But users will, as usual for all POPs—indeed, all progestogen-only methods—need forewarning about irregular bleeding. And I see no special reason to use it where the combination with a cheaper old-type POP is already virtually 100%, such as in lactation at any age, or in older women, especially those above age 45.

Professor Guillebaud is Emeritus Professor of Family Planning and Reproductive Health, University College, London, UK, and the author, most recently, of the books Contraception: Your Questions Answered (4th Edition) and Contraception Today: A Pocketbook for General Practitioners (5th Edition).

References:

1. Vessey MP, Lawless M, Yeates D, McPherson K. Progestogen-only oral contraception. Findings in a large prospective study with special reference to effectiveness. Br J Fam Plann 1985; 10:117-121.

2. McCann MF, Potter LS. Progestin-only oral contraception: a comprehensive review. Contraception 1994;50(Suppl):S1-195.

3. Rice CF, Killick SR, Dieben T, Coelingh Bennink H. A comparison of the inhibition of ovulation achieved by desogestrel 75 µg and levonorgestrel 30 µg daily. Hum Reprod 1999;14:982-5.

4. Collaborative Study Group. A double-blind study comparing the contraceptive efficacy, acceptability and safety of two progestogen-only pills containing desogestrel 75 µg/day and levonorgestrel 30 µg/day. Eur J Contracept Reprod Health Care 1998;3:169-178.

5. Anon. Is Cerazette the minipill of choice? Drug Ther Bull 2003;41:68-69.

6. Korver T, Goorissen E, Guillebaud J. The combined oral contraceptive pill: what advice should we give when tablets are missed? Br J Obstet Gynaecol 1995;102: 601-7.

FAMILY PLANNING/REPRODUCTIVE HEALTH RESEARCH

Condom Effectiveness for Reducing Transmission of Gonorrhea and Chlamydia: The Importance of Assessing Partner Infection Status (research abstract)
This analysis examined the importance of differential exposure to infected partners in epidemiologic studies of latex condom effectiveness for prevention of STIs. Enrollment visit data were analyzed from Project RESPECT, a trial of counseling interventions conducted at five publicly funded US STD clinics between 1993 and 1997. Among 429 participants with known gonorrhea and chlamydia (Gc/Ct) exposure, consistent condom use was associated with a significant reduction in prevalent gonorrhea and chlamydia (30% vs. 43%). Among 4,314 participants with unknown Gc/Ct exposure, consistent condom use was associated with a lower reduction in prevalent gonorrhea and chlamydia (24% vs. 25%). The number of unprotected sex acts was significantly associated with infection when exposure was known but not when exposure was unknown.

Progestogen-only Pills and High Blood Pressure: Is There an Association? A Literature Review (research abstract)
In order to offer the progestogen-only pill (POP) as a safe, alternative contraception to women who develop hypertension on combined oral contraception (COC) or those who are at increased cardiovascular risk, it is important to take into account evidence of no association of high blood pressure with POP use. The author of this review article performed a search of published medical literature (PUBMED and Cochrane database) with this objective. A total of four articles were selected for final review after application of inclusion and exclusion criteria. Three of these were prospective control trials and one a cross-sectional survey. There was no randomized study to answer this question. The results of these studies consistently reported no significant association of high blood pressure with use of POPs for up to 2–3 years of follow-up.

Is Previous Use of Hormonal Contraception Associated with a Detrimental Effect on Subsequent Fecundity? (research abstract)
Related news article: Longer Fertility Wait for Pill Users
This study determined the effects of contraception on subsequent fecundity. A total of 2,841 consecutive pregnant women in the UK completed questionnaires inquiring about time to pregnancy (TTP), contraceptive use, pregnancy planning, previous pregnancies, age, and lifestyle characteristics of each partner. Outcome measures were mean TTP, conception probability, and odds of subfecundity after discontinuing each contraceptive method. TTP following long-term combined oral contraceptive (COC), short-term intrauterine device (IUD) or any duration of injectable use were 2-, 1.6-, 3-fold longer than TTP after condom use, respectively. Within 6 months of discontinuing COC or injectable use, conception probabilities were 0.86 and 0.34, respectively. All levonorgestrel intrauterine system users conceived within 1 month. Relative to condoms, odds of subfecundity after COC, injectable and short-term IUD use were 1.9, 5.5, 2.9, respectively. The effect of COC and injectables was stronger with long-term use, in older, obese or oligomenorrhoeic women. The authors conlcude that a significant reduction in fecundity occurs after COC, IUD, or injectables, which is dependent on the duration of use.

The Mirena® Levonorgestrel System (research abstract)
This article reviews the levonorgestrel intrauterine system, regarded as a safe, efficacious, long-term contraceptive device.

Combination Estrogen–Progestin Contraceptives and Body Weight: Systematic Review of Randomized Controlled Trials (research abstract)
Related news article: Study: Birth Control Pill Doesn't Cause Weight Gain
Contrary to popular belief, the birth control pill does not cause most women to gain weight, according to US and Dutch researchers.

Counseling about Contraception among Repeated Aborters in Ho Chi Minh City, Vietnam (research abstract)
Researchers conducted qualitative interviews with 30 repeated abortion clients in Ho Chi Minh City, Vietnam. Only 5 women were practicing contraception regularly. A common reason for the nonusage of contraceptives was adverse health effects. Half of the women were not counseled during the previous abortions, and contraceptives were given without explanation. Women pointed out that the current service was not enough or in-depth and was not meeting their needs. The type of counseling they wanted was a face-to-face discussion with a physician at a hospital using leaflets and pictures.

Congenital Syphilis in Russia: The Value of Counting Epidemiologic Cases and Clinical Cases (research abstract)
This multi-site study in Russia found that maternal risk factors and perinatal consequences for unreported epidemiologic cases (infants of inadequately treated mothers) of congenital syphilis resembled those of reported clinical cases.

A Conceptual Model for Empowerment of the Female Community Health Volunteers in Nepal (research abstract)
This article proposes a conceptual model that relies on Freire's theory of empowerment education and the participatory action research methodology to empower the female community health volunteers to increase their consciousness, competence and confidence in performing their job responsibilities.

Effect of Prolonged Use of Injectable Hormonal Contraceptives on Blood Pressure and Body Weight (PubMed abstract)
This study, from the Mymensingh Medical College, Mymensingh, Bangladesh, was undertaken to determine the effect of prolonged use of injectable hormonal contraceptive on blood pressure and body weight in young women. Two hundred volunteers were selected; 140 were taking injectable hormonal contraceptive, DMPA for 3 to 5 years, and 40 subjects served as controls (no contraceptive steroid). The authors report finding insignificant elevations of systolic and diastolic blood pressure from DMPA use. But body weight of the subjects taking the hormonal contraceptive was significantly increased compared with controls.

Gender Inequality, Family Planning, and Maternal and Child Care in a Rural Chinese County (research abstract)
This study examines the determinants of prenatal and obstetric care utilization within the context of recent social and economic changes in contemporary rural China. The aim of this study is to test the general hypothesis that gender inequality (women's status and son preference) and the state's family planning policy have a significant influence on maternal and childcare utilization. The findings lend support to this hypothesis. For example, the extent to which the husband shares housework and childcare, as an important marker of rural Chinese women's position within the family, is positively associated with the likelihood that a woman receives prenatal examinations, stops heavy physical work before birth, and gives birth under aseptic conditions. The author writes that the study provides further evidence that the family planning policy has a negative impact on women and their families, whose fertility and son preferences conflict with the birth control policy.

FAMILY PLANNING/REPRODUCTIVE HEALTH NEWS

US Poll: Parents Favor Abstinence Education (news article)
An overwhelming majority of US parents says a "pro-abstinence messages" is an acceptable, even preferred way, to teach family planning to teens. A new Zogby International survey of 1,004 parents found that 96% identified "abstinence" as being best for America's teens. Another 91% expressed the view that teens should be taught that it is best for sexual activity to be linked to love, intimacy, and commitment.

Sex Education in America (feature article)
This feature article from National Public Radio contends that the debate over whether to have sex education in American schools is over, citing a new poll that shows that only 7% of Americans say sex education should not be taught in schools. The debate now is about what type of sex education should be taught.

New STI Clinic Opens in Afghanistan (news article)
The first Centre for Education and Management of Sexually Transmitted Infections is opening this month in Herat. This will be the first clinic dedicated to STIs in all of western Afghanistan.

UAE: Fertility Clinic Fully Booked Till 2006 as Demand Grows (news article)
The only state-run fertility clinic in the United Arab Emirates has a waiting period until 2006. Doctors see around 40 couples per day, and about 700 fertility procedures were performed last year.

FAMILY PLANNING/REPRODUCTIVE HEALTH LAW AND POLICY

Mexican Church Attacks Pill Use (news article)
Mexico's Catholic Church leaders have criticised a government decision to allow the so-called morning-after pill. Use of the emergency contraceptive was approved last week in an amendment to family-planning guidelines. But some Church figures have said that the Church cannot remain silent on the issue, saying use of the contraceptive pill is comparable to murder.

Reproductive Health Without Rights in Peru (commentary)
This article from The Lancet provides an overview of the state of reproductive health rights in Peru.

Migration has Moved to Forefront of Population Policy Discussion, UN Official Says (news article)
The large flow of illegal migrants, the sometimes difficult conditions they face in host countries, and the "lucrative but troubling" human trafficking market have brought migration policies to the forefront of population discussions, a United Nations expert has said.

Antiretroviral Therapy in Africa (commentary)
Cheap and widely available antiretroviral therapy for treating HIV and AIDS may seem like the solution to Africa's AIDS epidemic. But if not carefully planned and carried out, the authors of this article say, any programs to administer the drugs could be disastrous. Warren Stevens, Steve Kaye, and Tumani Corrah of the Medical Research Council Laboratories in Banjul, Gambia, argue that consistent prescription and close monitoring of the drugs are essential to prevent widespread drug resistance. Patchy or poor adherence to a drug regimen is a sure recipe for viral replication, mutation, and resistance. To ensure the therapy is properly delivered, African countries will need adequate healthcare infrastructures. Without that, the developed world could help fuel an even worse AIDS epidemic.

AIDS Quick-fix Won't Save Africa (commentary)
On 1 December, World AIDS Day, the WHO announced a new program. It aims to treat 3 million people suffering from HIV or AIDS with billions of dollars' worth of antiretroviral drugs by 2005. But is this the best way to combat Africa's AIDS crisis? In this article, John Kilama, president of the Global Bioscience Development Institute in Wilmington, Delaware, argues that it is Africa's poor healthcare infrastructure that needs a boost, not its stock of drugs. Effective treatments are cheap and available — but if clinics and hospitals are unable to deliver them properly, it is all a waste, he says. HIV/AIDS prevention was once WHO's central priority. And rightly so, says Kilama: along with viable healthcare, education is still the only real way to control the epidemic.

South Africa: Proposed HIV Law Shot Down (news article)
This article reports that a number of the country's brightest legal brains have already shot down a proposal that the transmission of HIV should be made a crime.

Greying Asian Countries Growing Desperate for Babies (news article)
Some desperate East Asian countries are offering cash and other incentives to convince couples to have more children and help reverse the rapid greying of their societies. But government campaigns encouraging people to go forth and multiply are running into serious obstacles, partly as a result of their own past success in promoting birth control, gender equality, and economic empowerment. Working women, in particular, are opting to marry later and have fewer babies, resulting in the sharp drop in fertility rates below the minimum needed to naturally replenish the population.

The Philippines: Gov't Hands Tied by Conservatives (feature article)
This feature article relates how Filipinos are becoming sexually active at a younger age, but the Philippine government feels its hands are tied by conservative groups, including the Catholic Church, that resist more active state involvement in population programs and the use of artificial means of birth control.

Nigeria: FEC Endorses New Population Policy (news article)
The federal government of Nigeria last week approved a new population policy, which is expected to align the growth rate of the population to that of the economy. This new policy seeks to reduce the current population growth of 3% to a size that can be sustained by economic growth. The Minister of Health was quoted as saying the new population policy would leave open the choice of the size of the family, rather than the stipulated four children per household enshrined in the old policy.

Bush Scaling Back Dollars for Third World (news article)
President Bush plans to scale back requests for money to fight AIDS and poverty in the third world, putting off for several years the fulfillment of his pledges to eventually spend more than $20 billion on these programs. Hardest hit would be the United Nations-supported Global Fund to Fight AIDS, Tuberculosis and Malaria, whose contribution from the United States would drop to $200 million in fiscal year 2005 from $550 million, according to Congressional officials who have been briefed on the president's budget proposal. Over all, however, Mr. Bush's programs to combat AIDS and poverty to the world's poorest nations still represent a big leap from those of the Clinton administration.

Asylum Backed on China's Birth-control Policy: US Appeals Court Rules for Woman who Fled after Threats (news article)
A US appeals court has decided in a 10-1 ruling to grant asylum to Chinese nationals Xu Ming Li and Xin Kui Yu who fled that country in 1998 after warrants were released for their arrest. The couple, who were denied a marriage licence in China because they were not yet of legal age, were threatened with forced sterilization and abortion.

Spain Sentences Imam for Book Offering Advice on Wife-Beating (news article)
A Muslim spiritual leader who wrote a book telling Muslim men how to beat their wives was sentenced to 15 months in prison for encouraging violence against women, a court in Barcelona announced. In his 120-page book, "Women in Islam," Mohamed Kamal Mustafa, imam of the southern Spanish town of Fuengirola, urged husbands not to hit their wives on sensitive parts of the body or with force but, rather, "on hands and feet, using a light rod so that the blows don't leave scars or bruises," according to the sentencing document.

Sweden: Genital Surgery Banned? (news article)
Sweden may make illegal an increasingly popular form of plastic surgery in which women want to change their genitals. The country has banned genital mutilation, which is performed on 2 million women every year worldwide, often against their will, for cultural reasons. Cosmetic surgery is not mentioned in the law, but the country's National Board of Health believes the voluntary operations should be outlawed as well.

Kenya: FGM: Rights Group, Parents Clash Over Missing Girls (news article)
Parents of 40 girls who fled from their homes in Marakwet District to escape FGM are locked in a dispute with a human rights organisation. Now the Centre for Human Rights and Democracy is strongly protesting against the alleged harassment of its staff by the girls’ parents, who are demanding their daughters back.

HIV/AIDS RESEARCH

Business and HIV/AIDS: Who Me? A Global Review of the Business Response to HIV 2003-2004 (report)
This report, published be the World Economic Forum’s Global Health Initiative, provides the first global survey of business leaders on their perceptions regarding the impact of HIV/AIDS and their responses to the pandemic. The report provides business leaders, NGOs and policy makers with a tool to benchmark country-level business leader opinions as well as data-driven recommendations to guide future action. The results are also relevant for national business coalitions tackling HIV/AIDS. The report is available in PDF formats in full and abriged versions.

Changes in the Transmission Dynamics of the HIV Epidemic After the Wide-Scale Use of Antiretroviral Therapy Could Explain Increases in Sexually Transmitted Infections: Results From Mathematical Models (research abstract)
This mathematical modelling study of HIV/AIDS suggests that bacterial STI may increase following the wide-scale use of ART because it alters the natural course of the HIV epidemic and favors the renewal of the high-risk population.

Dhandha, Dharma and Disease: Traditional Sex Work and HIV/AIDS in Rural India (research abstract)
This paper discusses the results of two ethnographic studies with female sex workers in rural areas of Karnataka and Rajasthan, India.

Risks, Stigma and Honduran Garífuna Conceptions of HIV/AIDS (research abstract)
This article explores Garífuna community ideas about HIV/AIDS, focusing on issues of risk perception and stigma.

How Otherwise Dedicated AIDS Prevention Workers Come to Support State-sponsored Shortage of Clean Syringes in Vancouver, Canada (research abstract)
Vancouver continues to experience an ongoing HIV outbreak among injection drug users despite the presence of North America's largest needle exchange programme. The present study utilizes ethnographic interviews and observations conducted with fixed site and mobile van 'exchange agents' to examine access to sterile syringes by IDUs in Vancouver between May 2000 and March 2001. Point-for-point exchange continues to be the dominant policy. Ethnographic evidence suggests that there is a large demand for sterile syringes ('rigs') when users do not have any to return, indicating policy/practice discrepancies. Despite policy, an intricate rig loaning system has evolved out of agreements made between needle exchange agents and their clients. Restrictive syringe exchange policies lead to considerable unmet needs among injection drug users. The authors write policy makers must change their policies to better address issues of syringe access and in consultation with user groups, develop alternative models of needle distribution, and recovery that do not necessarily include exchange.

AIDS in Portugal: Endemic Versus Epidemic Forecasting Scenarios for Mortality (research abstract)
This article presents a multistage model to study AIDS in which the stage of infected patients precedes the stage of death by AIDS. The STATIS methodology (Structuration des Tableaux à Trois Indices de la Statistique) is used to condensate the information for these two stages. The results for the stage of infection enabled the choice of time-dependent control variables for prediction of the number of deaths and the assessment of the effectiveness of anti-retrovirus treatments. The authors write that these predictions point towards endemic scenarios and to anti-retrovirus treatments effectiveness lower than in other European countries. Moreover, when both series are jointly considered, the results obtained point to a lag of 2 to 3 years between infection by AIDS and death by connected causes. The multistage approach is more centered on actual data than other approaches (eg, back-projection).

HIV/AIDS NEWS

South Africa AIDS Group Asks Government to Roll Out Treatment (news article)
Related news article: Half of SA Patients HIV+
A South African AIDS pressure group on Sunday called on the government to urgently roll out a planned anti-retroviral program, amid reports that 46% of patients in state hospitals were HIV positive.

Global Coalition on Women and AIDS Launched (news article)
Actress Emma Thompson joined health experts and equal rights campaigners to launch a coalition to improve prevention and treatment for young women and girls with HIV/AIDS.

Over 264,000 HIV-infected Registered in Russia by Jan 1, 2004 (news article)
More than 264,000 HIV-infected people were registered in Russia by January 1, 2004, according to official sources.

South Korea: Rate of HIV Infections Rapidly Increasing, Experts Say (news article)
The Korea Center for Disease Control and Prevention announced Monday that the number of HIV carriers has sharply increased since 2000, with 2,540 Koreans infected with the virus as of the end of 2003. Even worse, the number of cases between 2000 and 2003 grew by an average of 35.1 percent a year.

Croatia's Catholic Church Protests AIDS Prevention Programs Showing How to Use Condoms (news article)
An AIDS prevention program that teaches Croatian high school students how to use condoms has come under attack from bishops in Croatia, a predominantly Roman Catholic country; they argue that it contravenes Christian morals.

India: Free AIDS Drugs, Government Set to Begin from April (news article)
A few months after announcing free Anti Retroviral Treatment for those affected with HIV/AIDS, the Government has decided to start the first phase of the project from April 1, 2004.

Ethiopia: First Free Treatment Programme for AIDS Patients Launched (news article)
The international medical relief organization Médecins Sans Frontières and the Tigray Regional Health Bureau this week launched the first programme of free anti-retrovirals for the treatment of HIV/AIDS patients in Ethiopia, according to a press statement issued by MSF last week.

Vatican: Profiteering from AIDS Crisis 'Genocidal' (news article)
The Vatican has condemned pharmaceutical companies for making huge profits from AIDS drugs even though millions of people in Africa are dying of the disease because they can't afford the medications.

India: HIV Sweep in Southern Tract (news article)
More than 6% in a population vulnerable to HIV/AIDS in South 24-Parganas have tested positive for the virus since October 2003. The Child in Need Institute, which has been given permission to counsel and test for HIV in the rural areas, has counselled 123 people, mainly families of migrant laborers, of whom 111 were tested. Seven tested positive.

MATERNAL AND CHILD HEALTH RESEARCH

Pregnancy-related Risk Factors for Breast Cancer (report)
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Related news article: Breast Cancer 'Not Linked to Abortion'
Having an abortion does not increase the risk of a women suffering from breast cancer, a new study claims. Many researchers have suggested a link between abortion and breast cancer, but this has been refuted by other scientists who say their is no conclusive evidence to back up the claim. Now a review of records from 4,000 maternity centers by Swedish researchers has failed to find any relationship between having a pregnancy terminated and the disease.

The Familial Technique for Linking Maternal Death with Poverty (research abstract)
Related news article: 'Poverty Raises Risk of Maternal Death'
Using a new study technique, UK researchers have confirmed that poverty increases a woman's chances of dying during or soon after pregnancy. Previous reports, based on population statistics, have yielded conflicting results regarding a link between the two. The new method is known as the familial technique.

Cost Utility of Prenatal Diagnosis and the Risk-based Threshold (research abstract)
The purpose of this study was to assess the economic validity of thresholds of prenatal testing based on age or risk for offering invasive prenatal diagnosis. The authors did a cost-utility analysis of chorionic villus sampling and amniocentesis versus no invasive testing using data from randomised trials, case registries, and a utility assessment of 534 diverse pregnant women aged 16–47 years in the US. Compared with no diagnostic testing, amniocentesis costs less than US$15,000 per quality-adjusted life year gained for women of all ages and risk levels. The results do not depend on maternal age or risk of Down's syndrome-affected birth. The authors write that current guidelines should be changed to offer testing to all pregnant women, not just those whose risk of carrying an affected fetus exceeds a specified threshold.

Urinary-Based Ovulation and Pregnancy: Point-of-Care Testing (PubMed abstract)
This paper reviewed the literature concerning ovulation prediction devices and pregnancy detection tests for home use. The authors did exhaustive reviews of MEDLINE, EMBASE, and International Pharmaceutical Abstracts. Additional references were located through review of the bibliographies of the articles found in the literature search. The authors found that luteinizing hormone-based ovulation tests demonstrated accurate and superior ovulation detection when compared to basal body temperature charting, calendar calculation, salivary ferning, or observation of vaginal or cervical discharge changes. Systems using LH and estrone-3-glucuronide also demonstrated accurate detection of the fertile period. The authors conclude that the literature evaluating home use of pregnancy tests demonstrated accurate use by lay persons.

MATERNAL AND CHILD HEALTH NEWS

Australia: Women Giving Birth Later: State Study (news article)
More Victorian women are having children later in life, with the average age of women giving birth now over 30. Victorian Health Minister Bronwyn Pike said birth statistics for 2001 and 2002 showed the average age of mothers giving birth had risen from 27.6 years in 1986 to 30.2. Ms. Pike said the proportion of women aged 35 and over giving birth had now reached 20.5%, almost double that of 10 years ago.

MEN'S HEALTH RESEARCH

Vasectomy: A "Seminal" Analysis (research abstract)
This study reviews the evolution of vasectomy as a contraceptive procedure and summarizes current literature addressing its unresolved issues.

POPULATION RESEARCH

Living Happily Ever After: The Economic Implications of Aging Societies (executive summary)
Related news article: A Global Demographic Time Bomb
Related resource material: Fact Sheet: Living Happily Ever After: The Economic Implications of Aging Societies
(You need Adobe Acrobat Reader to access this document)
This new report released at the World Economic Forum in January lays out how aging and falling populations could slam world growth. The report warns that a smaller workforce and larger population of seniors threatens the ability of governments to maintain social programs, reduces economic productivity, and lowers the standard of living. The data "raises profound questions around labour participation and productivity, the cross-border flow of capital, the globalization of labour markets, the financial viability of social insurance programs, and how economic output is shared between working-age and retiree populations," according to the report.

The Politics of Demography: A Study of Inter-community Fertility Differences in India (research abstract)
This paper examines differences in fertility between Hindu and Muslim women in India with a view to shedding light on an issue that both polarises and inflames academic and political opinion in India: how much of the higher fertility rate of Muslim women is due to differences between the communities in their responses towards fertility-influencing factors and how much is due to differences between them in their endowments of such factors? After comparing the high-fertility central, and the low-fertility southern, regions of India, the results suggest that slightly over half of the observed births surplus of Muslims over Hindus was due to differences between Muslims and Hindus in their responses toward fertility-influencing factors.

POPULATION NEWS

India's Population Expected to Stabilize by 2055 (news article)
India's population is expected to stablize only around 2055, about 10-15 years later than what is envisaged in the National Population Policy, a global expert said in New Dehli last week. "If the current trend continues, an Indian couple would have only about two children by 2020. In other words, India would reach replacement level fertility, [at which a couple has only two children] by 2020, ten years later than the goal envisaged in the National Population Policy," said Robert Clay, director of population, health and nutrition of the US Agency for International Development.

Russia: Catholic Charity Addresses Birthrate Problems (news article)
A Catholic charity has started providing a counseling and support service in St. Petersburg for pregnant women who are thinking of having an abortion. The German-funded charity Caritas says it is worried about the country's demographic decline. Its Life Protection project provides women with psychological and material help if they decide to proceed with the pregnancy. "Our main concern is the birthrate and the great number of abortions in Russia," said Olga Kochatkova, head of the project, who has been working with Caritas for four years. Abortion is a common, relatively cheap form of birth control, with about 13 abortions for every 10 Russian children born. In 2001, the WHO identified Russia as having one of the highest abortion rates in the world. Abortions are offered free to women 18 or under and cost only about 1,500 rubles ($53) for older women. Little in the way of sex education is offered in schools and women seeking abortions are not required to undergo counseling.

Singapore Records Lowest Birth Rate with Only 37,633 Babies Born in 2003 (news article)
Singapore's birth rate has hit an all-time low since independence. Only some 37,600 babies were born last year.

Azerbaijan: Birth Rate Increases (news article)
Birth rates in Azerbaijan have increased over the past 3 years. The chairman of the State Statistics Committee reported that 112,900 births were registered in 2003. The figure was 110,400 in 2001 and 110,700 in 2002.

WOMEN'S HEALTH RESEARCH

Factors Affecting Utilization of Cervical Cancer Prevention Services in Low-resource Settings (research article)
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This article summarizes the experiences of research projects in Bolivia, Peru, Kenya, South Africa, and Mexico and provides examples of strategies that programs are using to encourage women’s participation in cervical cancer prevention services.

Incidence and Mortality of Cervical Cancer in Latin America (research article)
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This paper presents cervical cancer incidence and mortality estimates for 2000 for the 21 Latin American countries, using estimates from the statistical package GLOBOCAN 2000. Additional data on time-trends are also presented, using the WHO mortality database.

Cervical Cancer, a Disease of Poverty: Mortality Differences between Urban and Rural Areas in Mexico (research article)
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Researchers examined cervical cancer (CC) mortality rates in Mexican urban and rural communities and their association with poverty-related factors during 1990-2000. A total of 48,761 CC deaths were reported in Mexico (1990=4,280 deaths/year; 2000=4,620 deaths/year). On average, 12 women died every 24 hours, with 0.76% yearly annual growth in CC deaths. Women living in rural areas had 3.07 higher CC mortality risks compared to women with urban residence. Comparison of state CC mortality rates (reference=Mexico City) found higher risk in states with lower socio-economic development. Predominantly rural states had higher CC mortality rates compared to Mexico City.

Prevalence of Menstrual Pain in Relation to the Reproductive Life History of Women from the Mayan Rural Community (research abstract)
The aim of this study was to determine the prevalence of dysmenorrhoea and the factors related to menstrual pains in women with natural fertility (ie, without hormonal forms of contraception). Subjects were 177 non-smoking women between 18 and 45 years of age living in one Mayan village (Yaxcaba, Yucatan, Mexico). The general prevalence of menstrual pains was 28%. There was only one variable influencing dysmenorrhoea, namely, the age at which women give birth to their first children. Those mothers who gave birth to their first child at an earlier age (at mean age of 19.4 vs 21.1 years) had a lower prevalence of dysmenorrhoea. The authors hypothesize that an earlier start to reproductive life in some way decreases the sensitivity of the uterus to prostaglandins.

YOUTH HEALTH RESEARCH

The Association between Depot Medroxyprogesterone Acetate Contraception and Bone Mineral Density in Adolescent Women (research abstract)
Researchers conducted a cross-sectional evaluation of the association between DMPA use and bone mineral density in girls aged 14–18 years. Of 174 study participants, 81 were DMPA users and 93 were not. Mean bone density at all anatomic sites (hip, spine, and whole body) was lower for DMPA users than nonusers, but differences were not statistically significant. Duration of DMPA use showed a trend toward lower spine bone density. But the authors write that their findings did not reveal a strong association between DMPA use and bone density.

Adolescent Vaccination in the Developing World: Time for Serious Consideration? (research abstract)
This paper examines the rationale for adolescent vaccination, looks at the success of other adolescent-targeted health care interventions, and considers the challenges associated with future adolescent vaccination programmes in developing countries.

Abstinence and Delayed Sexual Initiation (research review)
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This research brief from Family Health International summarizes findings from recent studies that show that, while promoting abstinence is an important strategy that can help delay sexual activity, complementary messages are needed for those who are sexually active.

Information and Communications Technology (research review)
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This research brief from Family Health International reviews recent studies that show that technology resources increasingly link professionals working with reproductive health and HIV prevention programs in developing countries. These same resources (e-mail, CD-ROMs, listservs, the Internet, radio, and television) hold great promise for reaching youth as well.

Breaking New Ground: Are Changes in Immunization Services Needed for the Introduction of Future HIV/AIDS Vaccines and Other New Vaccines Targeted at Adolescents? (research abstract)
In this article, the authors argue that pre- and early-adolescents will be one of the main target groups for future HIV vaccines, that is, before the age of exposure to the virus. They predict that even the poorest countries will be looking to developing integrated, sustainable strategies for reaching pre-adolescents and adolescents with vaccines in the coming decade.

Continuous Identification of Research Evidence (CIRE) Related to Family Planning Guidance

do Lago RF, Simoes JA, Bahamondes L, Camargo RP, and Perrotti M. Follow-up of users of intrauterine device with and without bacterial vaginosis and other cervicovaginal infections. Contraception. 2003 Aug;68(2):105-109. (CIRE)
Findings in this article have been found relevant to WHO Method: Copper IUD and Condition: Sexually transmitted disease (STDs)

Pakarinen P, Toivonen J, and Luukkainen T. Randomized comparison of levonorgestrel- and copper-releasing intrauterine systems immediately after abortion, with 5 years' follow-up. Contraception. 2003 Jul;68(1):31-34. (CIRE)
Findings in this article have been found relevant to WHO Method: Levonorgestrel IUDs and Condition: Postabortion

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Johns Hopkins Bloomberg School of Public Health: The INFO Project

Volume 4, Number 5 2 February 2004