Volume 5, Number 14
4 April 2005

Guest Editorials (free with every subscription)

Obstetric Fistula and the Ethics of Care: Listening for the Answers

Author: Mary Nell Wegner

MWegner@engenderhealth.org

Obstetric fistula—a devastating medical condition consisting of an abnormal opening between the vagina and the bladder or rectum—results from unrelieved obstructed labor. The physical consequences of a fistula, including the continuous leaking of urine, feces, or both, usually make a normal life difficult, if not impossible, for the woman. Many fistula patients are shunned, abandoned, or divorced (1).

Due to the efforts of many, the condition of obstetric fistula is garnering more attention on the international reproductive health agenda. A number of large and small organizations have added their energy and resources to the fight against obstetric fistula. Some focus on prevention and some on treatment, but all are united in contributing to the work that transpires day after day in resource-strapped areas where fistula is often a great problem. It is in these locations where committed health care providers have been toiling for years. And it is because of them, and the women with fistula they see, that we know the language from ICPD about the “right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth” does not yet universally apply (2).

For the epidemiologists among us, obstetric fistula causes countless frustrations. On a macro level, it hardly makes sense to try to apply a public health framework; true prevalence figures are elusive. If resources were available to do accurate counting, it would be more ethical to apply those resources to fistula prevention or repair efforts than simply to count a figure that is arguably far too large, yet certainly not as large as the number of women with HIV, for example, let alone the number of women with malaria. If prevalence figures are the basis for resource allocations, women with fistula lose (again).

Where obstetric fistula resides—in health care service delivery systems, in philosophical terms, in health ministers’ portfolios, indeed in women’s lives—is often confusing. Obstetric fistula dwells in the nexus between cultural beliefs about childbirth, notions of gender equity, the value of children in a given society, who holds the power to control another’s access to health care, and what health care might, indeed, be available to those who can ultimately reach it. It is often tucked away in maternal child health policy statements, in places where even the most dedicated bureaucrats might not be able to find it.

As we search for a public health rationale that allows us or even guides us to make allocations for a condition such as fistula, it is worth heeding the advice of those who have wrestled with profound injustices, balancing health and equity across multiple dimensions.

Aristotle would help us to see the value in the list of attributes that makes a life “good” (3), arguably a list that would include any number of variables that would steer women away from increased risk for fistula. Amartya Sen would help us to apply “the capability approach” (4) to ensure that women with fistula have the capability to improve their lot and their agency. Martha Nussbaum would urge us to apply that set of capabilities to the real life conditions that women in the developing world face in the quest for a just society (5). These philosophers build important frameworks that outline why we must act on fistula.

It is the women, themselves, however, who can tell us how. Individual women who have experienced obstetric fistula are the repositories of a wealth of information. In their stories lie the many definitions of how the maternal health system failed. Listening to their journeys, we will learn the details of why, in any given place, adequate maternal health care eluded them. It is in their experiences that we will find answers. What we need now is a commitment to listen and to use what we hear to make sustained change.

Mary Nell Wegner is Senior Manager, Maternity and Postabortion Care Program, at EngenderHealth.

References:

1. Hinrichsen, D. Obstetric Fistula: Ending the Silence, Easing the Suffering. INFO Reports, No. 2. Baltimore, Johns Hopkins Bloomberg School of Public Health, The INFO Project, Sept. 2004. Available at: http://www.infoforhealth.org/inforeports/fistula/index.shtml. Accessed March 16, 2005.
2. UNFPA, ICPD Programme of Action, 7.2, page 30, 1994. Available at:
http://www.unfpa.org/icpd/icpd_poa.htm#ch7. Accessed March 15, 2005.
3. Lord, C. translator. Aristotle. The Politics. Chicago, IL: University of Chicago Press, 1984.
4. Sen, AK. Development as Freedom. New York: Knopf, 1999.
5. Nussbaum, M.. Women and Human Development: The Capabilities Approach. Cambridge: Cambridge University Press, 2000.

FAMILY PLANNING/REPRODUCTIVE HEALTH RESEARCH

Effects of Making Emergency Contraception Available Without a Physician's Prescription: A Population-based Study
(Research Article)
In this population-cohort study conducted in British Columbia, Canada, the authors sought to determine whether granting prescriptive authority to pharmacists would result in women obtaining emergency contraceptives (ECs) from pharmacists instead of their physicians and whether the number of overall EC prescriptions would increase. Researchers found that the policy change that granted pharmacists authority to provide ECs to women without a physician's prescription did not simply expand EC availability but was associated with an overall increase in EC use in the province.

Application of the Case-crossover Design to Reduce Unmeasured Confounding in Studies of Condom Effectiveness
(Abstract)
This analysis examined how unmeasured confounding affects estimates of the effectiveness of condoms in preventing STIs.

Factors Influencing Discontinuation of Intrauterine Contraceptive Devices: An Assessment in the Indian Context
(Abstract)
This paper tries to distinctly outline the determinants of discontinuation of the intrauterine contraceptive device (IUCD), especially in the Indian context. The review of the literature is directed towards giving a new direction to assessment of family planning programs, especially in India where population control is largely dependent upon permanent methods.

The Coraliance Study: Non-compliant Behavior: Results after a 6-month Follow-up of Patients on Oral Contraceptives
(Abstract)
This follow-up study was planned to establish the frequency with which women miss their contraceptive pill and to observe their behavior when they forget it.

India: Family Planning? No, Thank You
(News Article)
In what may ring alarm bells in the Union Health Ministry, family planning program performance has dipped across the country in the first 8 months of the financial year 2004-2005. The number of users of different family planning methods between April to November 2004 has fallen by 2.1% as compared to the figures for the corresponding period in 2003.

Come Gather Around Together: An Examination of Radio Listening Groups in Fulbari, Nepal
(Research Article)
(You need Adobe Acrobat Reader to access this document)
This article examines the association between exposure to a family planning-related radio initiative, membership in radio listening groups, and family planning outcomes (knowledge, attitudes, and practice). Multivariate logistic regression models show a significant relationship between radio listenership and knowledge and behavior variables above and beyond the positive association with the radio program itself. Results affirm the importance of a partnership between program organizers, community leaders, NGO partners and the audience community, in order to at least sustain positive family planning outcomes.

The Re-Emergence of Syphilis in the United Kingdom: The New Epidemic Phases
(Abstract)
Since 1997, syphilis has re-emerged in the United Kingdom in response to behavior change in the era of highly active antiretroviral therapy. The epidemic has been associated with a number of outbreaks that have been focused in gay social and sexual networks across the United Kingdom.

"We Don't Really Have Cause to Discuss These Things": A Collaborative Model for Developing Culturally Appropriate Sexual Health Services with the Bangladeshi Community of Tower Hamlets
(Abstract)
This study identified barriers to accessing sexual health care among the Bangladeshi community of east London and to developed a model of community participation in service development.

FAMILY PLANNING/REPRODUCTIVE HEALTH NEWS

Mobile Reproductive Health Clinics Make Motherhood Safer in Remote Lao Villages
(News Article)
Six-member teams of doctors, nurse/midwives, and health educators reach 107 villages in the poorest parts of three south-eastern provinces.

US: Groups Protest Government Sex-ed Site
(News Article)
Related News Article: Leavitt Defends Agency Web Site on Sexual Abstinence for Teens
An array of advocacy groups are calling on the U.S. government to take down one of its new Web sites, saying it presents biased and inaccurate advice to parents on how to talk to their children about sex. The site (4parents.gov) stresses the promotion of abstinence.

FAMILY PLANNING/REPRODUCTIVE HEALTH LAW AND POLICY

UK: HIV Man Who Infected Devoted Lover is Jailed
(News Article)
A man with HIV, who infected his devoted lover after persuading her to have unprotected sex with him, has been jailed for four-and-a-half years.

Chile's Pols Battle Over Emergency Contraception
(News Article)
In Chile, where two women lead the presidential race, emergency contraception has become an incendiary campaign issue after a health official said the government was planning free distribution of the "morning-after pill" and was fired within hours.

Putting the 'Three Ones' to Work: National AIDS Commissions
(Policy Brief)
(You need Adobe Acrobat Reader to access this document)
This brief, from the Futures Group, considers the political, technical, and managerial matters of the formation of National AIDS Commission (NACs) in developing countries.

Making the Choice: the Translation of Global HIV and Infant Feeding Policy to Local Practice among Mothers in Pune, India
(Abstract)
In this article the authors propose the development of a decision-making algorithm that includes factors affecting mother-to-infant transmission, including site-specific data on health risks to the mother and the child. They argue that such an algorithm would allow identification of the healthiest feeding choice and would minimize the pitfalls of promoting homogeneous practices lacking site-specific evidence-based evaluation.

It Is Time to Implement Routine, Not Risk-Based, HIV Testing
(News Article)
Related News Article: HIV Testing Advised for All Sexually Active People
Now is the time to implement routine, not risk-based, HIV testing, according to an editorial published in the medical journal Clinical Infectious Diseases.

HIV/AIDS RESEARCH

Studies of Vitamins and Minerals and HIV Transmission and Disease Progression
(Abstract)
This study, from the Harvard School of Public Health and the Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania, reviews studies of the use of vitamins and minerals used to reduce HIV disease progression.

How Equitable Is the Scaling Up of HIV Service Provision in South Africa?
(Abstract)
The authors of this study argue that the process of scaling up of HIV services seems to be accentuating inequalities. The urban site in their study was better able to utilize extra resources while the poorer sites have thus far been unable to scale-up the response to HIV even with the availability of extra resources. They state that unless policy makers pay more attention to equity, efficacious interventions may prove to be of limited effectiveness.

Discriminatory Attitudes Towards People Living with HIV/AIDS and Associated Factors: A Population Based Study in the Chinese General Population
(Abstract)
This population-based cross-sectional telephone survey conducted with 808 Hong Kong Chinese found that 42% of the respondents exhibited discriminatory attitudes in at least 5 of 20 relevant items. For example, 35% believed that all infected medical staff should be dismissed, and 47% would agree with enacting a law to prohibit persons living with HIV/AIDS from visiting Hong Kong.

Attitudes to HIV and HIV Testing in High Prevalence Areas of China: Informing the Introduction of Voluntary Counselling and Testing Programmes
(Abstract)
Researchers assessed knowledge and attitudes towards HIV and its testing among pregnant women and health professionals in Yunnan Province, south west China, to inform the introduction of voluntary counselling and testing programs.

Unrecognized HIV Infection, Risk Behaviors, and Perceptions of Risk Among Young Men Who Have Sex With Men: Opportunities for Advancing HIV Prevention in the Third Decade of HIV/AIDS
(Abstract)
This study evaluated the magnitude and distribution of unrecognized HIV infection among young men who have sex with men and of those with unrecognized infection, the prevalence and correlates of unprotected anal intercourse, perceived low risk for infection, and delayed HIV testing.

The Less They Know, the Better: Abstinence-Only HIV/AIDS Programs in Uganda
(News Article)
Related News Article: Uganda: 'Abstinence-Only' Programs Hijack AIDS Success Story
Related News Article: Uganda 'Not Dropping' AIDS Condom
U.S.-funded "abstinence-only" programs are jeopardizing Uganda’s successful fight against HIV/AIDS, according to a new report by Human Rights Watch. Abstinence-only programs deny young people information about any method of HIV prevention other than sexual abstinence until marriage. But Uganda has strongly denied charges that it no longer promotes condoms as part of its fight against AIDS - seen as one of the most successful in the world.

HIV/AIDS NEWS

Guinea: Government Study Shows HIV Infections Rising
(News Article)
A new sentinel survey of pregnant women who underwent voluntary AIDS testing in maternity clincs, indicates that 4.3 percent of Guinea's adult population is infected with HIV. That represents a big jump from the figure of 2.8 percent suggested by the previous sentinel survey carried out in 2001.

South Africa: Interview with Dr Nomonde Xundu, Head of Govt's HIV/AIDS Unit
(Interview)
In this interview, Dr. Nomonde Xundu, chief director of the department of health's HIV/AIDS and TB unit, talks about the challenges of rolling out South Africa's much-anticipated HIV/AIDS treatment program.

South Africa: HIV/AIDS Rife in Education Sector
(News Article)
Every day 11 teachers in South Africa die from AIDS-related illnesses, a study commissioned by the Education Labour Relations Council has found.

Kazakhstan: Greater HIV Awareness amongst Youth Needed
(News Article)
Despite efforts to raise the level of HIV/AIDS awareness in Kazakhstan, young people remain inhibited about speaking openly about the issue and how it may impact their lives.

Soweto Sex Survey Shows AIDS Challenge
(News Article)
South Africa may have the world's largest number of HIV infections, but more than one in seven township dwellers say they rarely or never use a condom when having sex.

Cameroon: Infant Mortality - AIDS As Major Source
(News Article)
Statistics indicate that HIV is responsible for a substantial proportion of under-five deaths in Cameroon.

HIV/AIDS and Human Resources
(Editorial)
This article, from the Bulletin of the World Health Organization, addresses the impact of HIV/AIDS on human resources and public health expenditures.

Uganda Leads Way in Innovative HIV/AIDS Treatment
(News Article)
Public health officials and doctors in sub-Saharan Africa say innovative approaches to treating AIDS in poor settings have so far been successful on a small scale. Can these efforts be expanded to provide antiretroviral therapy (ART) on a massive scale? Uganda is one of the sub-Saharan countries that has led the way in the treatment scale-up. But while the country is expected to reach the 50% treatment target, scaling up to provide ART treatment for every Ugandan who needs it will be a major challenge.

Russia: AIDS a National Security Threat
(News Article)
The growing AIDS epidemic represents a threat to Russia's security, senior Russian officials said recently, as they pledged to reduce the cost of HIV/AIDS drugs sevenfold.

Nigeria: Trial of Tenofovir as a Prophylactic against HIV Suspended
(News Article)
Nigeria has become the third country to halt clinical trials of the antiretroviral drug tenofovir as a prophylactic against HIV after the US-based supervisor of the trials found that proper standards were not being observed.

Muslim Senegal Example for AIDS Control
(Feature Article)
This feature article from a Malaysia newspaper describes how one Muslim country, Senegal, is approaching AIDS control.

Viet Nam's HIV/AIDS Strategy Dubbed Best in Asia
(Interview)
Dr. Dominique Ricard, a French national working for the WHO office in Viet Nam for 5 years supporting the country's HIV/AIDS prevention program, is interviewed here.

MATERNAL AND CHILD HEALTH RESEARCH

Perceptions of the Role of Maternal Nutrition in HIV-Positive Breast-Feeding Women in Malawi
(Abstract)
The purpose of this study was to conduct formative research to better understand breast-feeding practices and perceptions, and to inform the Breastfeeding, Antiretroviral, and Nutrition (BAN) Study, a clinical trial to evaluate antiretroviral and nutrition interventions to reduce mother-to-child transmission of HIV during breast-feeding in Lilongwe, Malawi.

An Education and Counseling Program for Preventing Breast-Feeding–Associated HIV Transmission in Zimbabwe: Design and Impact on Maternal Knowledge and Behavior
(Abstract)
This paper reports on the design, implementation, and evaluation of an education and counseling program for new mothers in Harare, Zimbabwe.

Infant Feeding Dilemmas Created by HIV: South African Experiences
(Abstract)
This paper highlights the dilemma created by the risks and the benefits of breast-feeding and will discuss the implementation in South Africa, of the Safer Breastfeeding Programme, to reduce some of the known risk factors associated with HIV transmission.

Fertility, Maternal Mortality and Survival of the Children in the Medical District of Kolda (Senegal)
(Abstract)
This article (English abstract, French text) reports the results of a preliminary investigation of a community based reproductive project. This cross-sectional study was carried out in a sample of 1,287 women. An "aggregative" fertility index of 6.59 was found in the "intervention" area compared to 5.53 in the control area. The maternal death rate was estimated at 1,285 per 100,000 alive births. The infant mortality rate was 83 per 1,000.

MEN'S HEALTH RESEARCH

Sex Behaviour of Men Who Have Sex with Men and Risk of HIV in Andhra Pradesh, India
(Abstract)
The homosexual and bisexual behavior of 6,661 men who have sex with men (MSM) at 62 urban-rural locations of various sizes in the Indian state of Andhra Pradesh was assessed through detailed interview. The authors found that the average number of different male sex partners in the past 4 weeks was six. Almost 26% had anal sex without a condom with men and also vaginal/anal sex without a condom with women. This was prevalent across urban-rural locations and its strongest association was with currently married (MSM). The authors state that this high rate of unprotected penetrative sex by MSM with both men and women suggests that HIV prevention efforts in India should include a focus on MSM as well as their wives across many urban-rural locations and not only in large cities.

Surplus Men, Sex Work, and the Spread of HIV in China
(Abstract)
The authors argue from a sociological perspective that surplus men and sex workers will have a profound effect on the future of HIV spread in China and on the success or failure of future interventions.

POPULATION RESEARCH

Quadratic Spline Fits by Nonlinear Least Squares
(Tool)
This web program fits a Quadratic Spline model, as described in Schmertmann (2003; Demographic Research Volume 9, Article 5), to any empirical fertility schedule supplied by the user. The fit minimizes the sum of squared differences between the empirical nfx values and the nfx values from the QS model schedule. Output includes parameter estimates, a graphical depiction of the fitted schedule, and several text reports. Users do not need specialized statistical software or a particular operating system to run the program; the only requirement is a web browser.

POPULATION NEWS

Australia: Birth Rate Up after Cash Offer
(News Article)
Australia's birth rate had risen for the first time in 20 years following the offer of money for new mothers in last year's federal budget.

WOMEN'S HEALTH RESEARCH

Mexican Physicians' Knowledge and Attitudes about the Human Papillomavirus and Cervical Cancer: A National Survey
(Abstract)
Researchers surveyed 1,206 general practitioners and obstetricians-gynaecologists working in a nationally representative sample of public and private facilities in urban Mexico to assess their knowledge about the human papillomavirus (HPV) and cervical cancer and their opinions and practices related to screening, managing, and counselling women on these topics. Nearly all respondents thought that women should be informed that HPV causes cervical cancer; nevertheless, physicians believed that positioning cervical cancer as an STI could cause problems in partner relationships (60%), confusion (40%), and unnecessary anxiety among women (32%).

Results of a Randomised Trial of Male Condom Promotion among Madagascar Sex Workers
(Abstract)
Researchers found that the impact of male condom promotion on behavior can be heightened through more concentrated counselling on risk reduction. Persistently high STI prevalence despite increases in reported condom use by sex workers supports the need for multidimensional control programs.

Rural Women's Knowledge of AIDS in the Higher Prevalence States of India: Reproductive Health and Sociocultural Correlates
(Abstract)
This study identified socio-cultural and reproductive health correlates of knowledge about AIDS among rural women using multivariate analysis of 1998-1999 National Family Health Survey (NFHS) data from two Indian states, Maharashtra and Tamil Nadu, where the urban HIV prevalence is relatively high.

Failure to Obtain Desired Postpartum Sterilization: Risk and Predictors
(Abstract)
Related News Article: Requested Sterilization Often Not Performed
Only about half of pregnant women who express a desire for sterilization following delivery actually undergo the procedure, according to a report in the journal Obstetrics and Gynecology. Young age and African-American race were both factors that predicted postpartum sterilization would not be performed. The new findings are based on a study of 712 pregnant women who expressed a desire for postpartum sterilization at the authors' institution between March 2002 and November 2003.

WOMEN'S HEALTH NEWS

Japan's Virgin Wives Turn to Sex Volunteers
(Feature Article)
The 200 women a year who seek help at a clinic in the Tokyo suburbs have not had sex with their husbands in up to 20 years, and some never, according to Kim Myong-gan, who runs the clinic.Kim's short-term solution is unconventional. After an initial 20,000 yen (about US$185) counselling session, he produces photographs of 45 men, mostly professionals in their 40s, with whom the women are invited to go on dates and then, in almost all cases, arrange regular assignations in hotel rooms. Kim dismissed charges that his service was little more than a male prostitution ring. The sexless marriage is one of several reasons why experts fear Japan is on the verge of a demographic disaster.

Israel: Women Say 'No' to Pill
(News Article)
More and more women in their 20s and 30s have stopped taking the pill, and experts say the trend has significantly added to the annual number of abortions being performed in Israel.

US: Survey Shows Women Overestimate Effectiveness for Most Widely Used Forms of Contraception
(Press Release)
What women don't know about birth control could be contributing to the fact that more than half of the nation's unplanned pregnancies, which number over 2.6 million annually, occur among women who are using contraception.

YOUTH HEALTH RESEARCH

Case-study: Guy to Guy Project: Engaging Young Men in Violence Prevention and in Sexual and Reproductive Health
(Report)
(You need Adobe Acrobat Reader to access this document)
This case study (available only in Portuguese) presents Instituto PROMUNDO´s experience in engaging young men as change agents in gender-based violence prevention and the promotion of sexual and reproductive health. The change agents, or peer promoters, are young men from low income areas of Rio de Janeiro who reach other young men with educational materials, condoms, a lifestyle magazine, and a play about reducing violence against women.

Biological and Hormonal Markers of Chlamydia, Human Papillomavirus, and Bacterial Vaginosis among Adolescents Attending Genitourinary Medicine Clinics
(Abstract)
Related News Article: Late Developers More at Risk from Sexually Transmitted Disease
Researchers at the Academic Unit of Obstetrics and Gynaecology, St Mary's Hospital, Manchester, UK, have found that late developers may run a higher risk of infection than sexually mature younger teens. The study, which examined biological and hormonal markers of STIs among adolescents attending genitourinary medicine clinics, suggests sexual maturity, rather than age at first sex, seems to be a critical factor.

Street Youths Are the Only High-Risk Group for HIV in a Low-Prevalence South American Country
(Abstract)
The authors carried out HIV surveys in high- and low-risk populations in Bolivia. Prevalence was extremely low except in homeless street youths. All cases were attributed to sexual transmission.

Differences in the Use of Family Planning Methods by Adolescent Females According to the Education Model Utilized during Pregnancy. Monterrey, Mexico
(Abstract)
This article (English abstract, Spanish text) compared the use of family planning methods during the immediate postpartum period and 2 years following childbirth among adolescent females who had followed two different intervention programs during their pregnancies.

YOUTH HEALTH NEWS

US: Teens Say Oral Sex Not Really Sex
(News Article)
About one in five ninth-graders report having had oral sex and almost one-third say they intend to try it during the next 6 months, a small study of teens at two California schools reports. The teenagers, whose average age was 14½, also say oral sex is less risky, more common and more acceptable for their age group than intercourse.

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Volume 5, Number 14 4 April 2005