Volume 7, Number 44
19 November 2007

WIN A CHANCE...
...to receive a free WHO Medical Eligibility Criteria (MEC) Wheel, an easy-to-use job aid that helps providers quickly identify the contraceptive methods their family planning clients can use. Just take 5 minutes out of your day to fill out a short survey telling us of your interest in online training and education courses in family planning: http://www.zoomerang.com/survey.zgi?p=WEB2274FTNWFT2. We appreciate your input!--The INFO Project

Guest Editorials (free with every subscription)

Enhancing political commitment on reproductive and sexual health in Asia-Pacific

Author: Shiv Khare, Executive Director, Asian Forum of Parliamentarians on Population and Development, Bangkok, Thailand

afppd@afppd.org

[Editor's Note: The views in this editorial are those of the author, and do not express the views of the INFO Project or USAID.]

Asia-Pacific members of parliament's (MP) observation that parliamentarians can give a push to the Sexual and Reproductive Health programme is timely and relevant because there is an urgent need to usher in balanced development in the Asia-Pacific region. Religious fundamental forces, lack of access of sexuality to youth have often obstructed the best of the plans, forcing the governments to change their stance on vital issues for their survival.

Even governments' which amended laws and formulated family planning policies in consonance with the 1994 International Conference on Population and Development (ICPD) goals often behave irresponsibly due to ideological considerations and compulsions arising out of their areas of influence. Their conflicting stand has retarded development especially relating to sexual and reproductive health and rights of the people.

Asia-Pacific MP's observation assumes greater significance since it was made at the crucial 4th Asia-Pacific conference on "Reproductive and Sexual health and rights...exploring new frontiers" held in India's Hyderabad city in the last week of October 2007. This observation can give a new meaning to the sexual and reproductive health programme with parliamentarians being in the driver's seat.

Despite the fact that elected representatives have to follow party line and have many political commitments, they can really give a push to any such programme. In fact, some of them have realised the importance of sexual and reproductive health for political reasons. Many political leaders look at sexual and reproductive health as a tool to influence electorates especially women and youth in their respective constituencies. However, they have accepted that governments should invest in sexual and reproductive health now.

In a joint letter to health ministers, a few MPs from the Asia-Pacific region made a request urging them to formulate a comprehensive reproductive health policy with a focus on youth and women. The proposed plan should place expectant mothers' health at the centre of a policy. Also, it should encourage financial contributions from private individuals and the public.

At the conference, MPs have openly spoken in favour of parliamentarians' involvement in the sexual and reproductive health programme. Some of them have shared information about efforts parliamentarians have made on the sexual and reproductive health in their respective countries. According to the Speaker of the Samoan Parliament, Tolofuavalelei Falemoe Leiataua, success of any health programme is largely dependent on the efforts of the government. Samoa, a country governing the western part of the Samoan Islands archipelago in the South Pacific Ocean, has proved it undoubtedly. The ruling Human Rights Protection party is committed to health issues and has been promoting health-related schemes in the country. The Speaker clarified that a political commitment will not only safeguard youth from teen pregnancies, sexual violence and exploitation and sexually transmitted infections (STIs) but also promote overall socio-economic development. Therefore, he said, the need is to make parliamentarians aware of sexual and reproductive health and motivate them to sensitize the masses. Their act, as he said, will enable Parliaments to enact legislations for implementing and promoting such programmes and provide overall support to sexual and reproductive health in the Pacific region. He said that political commitment for sexual and reproductive health can be accelerated through regular interactions and discussions.

In Indonesia, the situation is slightly different, though. Parliamentarians, especially from the opposition, have been extremely vocal on the sexual and reproductive health issue. Member of Parliament Tuti Indarsih L S said parliamentarians have demanded that the minimum age for marriage should be kept at 18 for boys and girls to eliminate early marriage and early pregnancy. The existing law has kept marriageable age at 19 years boys and 16 for girls, which is in contradiction with the international obligation on the elimination of a child marriage. Besides, parliamentarians have made several suggestions for amendments in population and health laws. The existing law on population allows married couples to avail family planning services. Unmarried adolescents cannot avail these services, thereby exposing themselves to unintended pregnancies and induced abortion. Even law on health does not cover reproductive health rights. Tuti suggested that parliamentarians should become a driving force in pushing governments to frame policies and programmes in consonance with international laws and treaties.

Australian MP Robert Oakeshott, however, put the onus on the community to create pressure on political leaders to act on sexual and reproductive health. He said that without any pressure from the community, politicians will do nothing. He suggested that forums of MPs from different countries to discuss the sexual and reproductive health issue and evolve sexual and reproductive health strategies and in turn tell their respective governments to increase funding and commitment. He added that MPs should pursuearliamentarians should support each other on this matter.

But, what if religious fundamental forces and culture do not support the sexual and reproductive health issue? In the Philippines, the influence of church on the social and culture fabric is so much that politicians are wary of challenging the church. However, Senator Rodolfo G Biazon faces difficulty in promoting the sexual and reproductive health issue. Senator Biazon is like a one-man mission on the sexual and reproductive health issue. He has been fighting the sexual and reproductive health issue for the last many years but has found little support from other parliamentarians in his country. Religious leaders, too, have opposed him and even hit the streets many times to protest against his efforts on the sexual and reproductive health issue.

Being a multi-religious country, India, too, has faced opposition from several quarters including Hindu religious leaders on the sexual and reproductive health issue. But the government is sensitive towards sexual and reproductive health. Reproductive and child health, which is very much a part of the National Rural Health Mission ( NHRM), is proof of the government's sensitivity to sexual and reproductive health.

Religious fundamentalism and culture are the biggest challenges to sexual and reproductive health in many countries. However, the need is to find out whether or not these factors are creating hindrances in dealing with sexual and reproductive health, given the fact that some governments and political leaders are tilted in favour of religious fundamentalism. If these are hindrances, then, how do we engage them in the sexual and reproductive health advocacy programme? Like it or not, we cannot disprove that religion and culture actually bind the people. By ignoring these factors, we would further alienate the civil society.

Sultan Aziz, Director (Asia Division), United Nation Population Fund (UNFPA) Headquarters, stated that more people should be sensitized in the Asia-Pacific region and said that there is a need to look beyond the governments in order to achieve the 2015 goals. Therefore, we need to re-examine countries' international obligations towards 1994 ICPD goals so that the sexual and reproductive health issue could be handled correctly. The 1994 ICPD had articulated a bold new vision about the relationships between population, development and individual well-being. It had also adopted a forward-looking, 20-year Programme of Action (PoA) built on the success of the population, maternal health and family planning programmes of the previous decades while addressing, with a new perspective, the needs of the early years of the twenty-first century.

The ICPD action plan was remarkable in its recognition that reproductive health and rights, as well as women's empowerment and gender equality, are cornerstones of population and development programmes. As per ICPD goals, which had been signed by 179 countries, there is a positive obligation on states to uphold sexual and reproductive rights of the people, women's rights and human rights. Surely, this makes it incumbent on the countries to frame policies and formulate appropriate legislations.

Post-ICPD era, most of the signatory countries have been supposedly oriented to achieving ICPD goals. But it is troubling to note that successive governments in many countries have done little or nothing to achieve ICPD goals even after 13 years from the time of adopting ICPD action plan. This failure to comply with the ICPD goals, while clearly signalling the intention and the willingness to do so, is of grave concern. This is especially so in the case of sexual and reproductive health, where the ability of the governments to sensitize the masses is in grave doubt. There is, thus, a need to involve elected representatives so that governments can fulfill their commitments to achieve sexual and reproductive health and other ICPD goals.

These MPs have spoken the truth, and it is for us to give up narrow perspective and invite parliamentarians to play an important role in the sexual and reproductive health programme so that ICPD goals could be achieved before the 2015 deadline. The count down has already begun.

References:

Asian Forum of Parliamentarians on Population and Development
http://www.afppd.org

ADOLESCENT HEALTH NEWS

Uganda: Celebrating science for the girl child
(News Article; Sub-Saharan Africa)
15 Oct 2006
Kasibante A, The Monitor

Uganda: 'Youth causing HIV spread'
(News Article; Sub-Saharan Africa)
13 Nov 2007
Aanyu R, New Vision

ADOLESCENT HEALTH RESEARCH

Giving girls today and tomorrow. Breaking the cycle of adolescent pregnancy
(Report; Global)
New York, New York, UNFPA, 2007.
Adolescent girls hold the key to a world without poverty. With the right skills and opportunities, they can invest in themselves now and, later, in their families. If they are able to stay in school, postpone marriage, delay family formation, and build their capacity they will have more time to prepare for adulthood and participate in the labor force before taking on the responsibilities of motherhood. They and their future children can be educated and healthy. One family at a time, they can help fuel the economic growth of their countries. The current reality, however, is hindering their potential. Adolescent girls become brides, get pregnant, and have children before they are physically, emotionally, and socially mature enough to be mothers. Married or unmarried, adolescent girls become pregnant for different reasons. For some, pregnancy is accidental and results from experimenting with sexuality or lacking knowledge about how to prevent conception. Others seek pregnancy and motherhood to achieve adult status or fill an emotional void. But most adolescent pregnancies have little to do with choice or mistake. Globally, the overwhelming majority of adolescent girls who become pregnant are married and pressured to have a child. For others, pregnancy often results from abusive, forced, or coerced sex.

Helping parents in developing countries improve adolescents' health
(Report; Global)
(You need Adobe Acrobat Reader to access this document)
Geneva, Switzerland, World Health Organization [WHO], 2007. 37 p.
Simpson R | Ferguson J
One fifth of the world's population -- a total of 1.2 billion people -- are adolescents, and 85% of them are in the developing world. Adolescence is a time of unprecedented promise -- and peril. During the second decade of life, young people can encounter a rapidly widening world of opportunities, as they gradually take on adult characteristics in size, sexual characteristics, thinking skills, identity and economic and social roles. Too often, however, the widening world also exposes adolescents to serious risks before they have adequate information, skills and experience to avoid or counteract them. Their level of maturity and social status is no match for some challenges, unless they are provided with support, information and access to resources. Without help, the consequences of health risk behaviours in adolescence can be life-threatening and life-long. Nearly two thirds of premature deaths and one third of the total disease burden in adults can be associated with conditions or behaviours that begin in youth. To protect and preserve our subsequent generations, no better investment can be made in the developing world than to foster promotion of adolescent development and prevention of health risk behaviours among adolescents.

HIV status and age at first marriage among women in Cameroon
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Biosocial Science. 2007;:[18] p..
Adair T
Recent research has highlighted the risk of HIV infection for married teenage women compared with their unmarried counterparts. This study assesses whether a relationship exists, for women who have completed their adolescence (age 20-29 years), between HIV status with age at first marriage and the length of time between first sex and first marriage. Multivariate analysis utilizing the nationally representative 2004 Cameroon Demographic and Health Survey shows that late-marrying women and those with a longer period of pre-marital sex have the highest risk of HIV. Although women in urban areas overall marry later than their rural counterparts, the positive relationship between age at marriage and HIV risk is stronger in rural areas. The higher wealth status and greater number of lifetime sexual partners of late-marrying women contribute to their higher HIV risk. Given that the age at first marriage and the gap between first marriage and first sex have increased in recent years, focusing preventive efforts on late-marrying women will be of much importance in reducing HIV prevalence among females.

Association between age at menarche and early-life nutritional status in rural Bangladesh
(Abstract; subscription needed for full text; Asia)
Journal of Biosocial Science. 2007;:[15] p..
Bosch AM | Willekens FJ | Baqui AH | van Ginneken JK | Hutter I
Age at menarche is associated with anthropometry in adolescence. Recently, there has been growing support for the hypothesis that timing of menarche may be set early in life but modified by changes in body size and composition in childhood. To evaluate this, a cohort of 255 girls aged less than 5 years recruited in 1988 were followed up in 2001 in Matlab, Bangladesh. The analysis was based on nutritional status as assessed by anthropometry and recalled age at menarche. Data were examined using lifetable techniques and the Cox regression model. The association between nutritional status indicators and age at menarche was examined in a multivariate model adjusting for potential confounding variables. Censored cases were accounted for. The median age at menarche was 15.1 years. After controlling for early-life predictors (birth size, childhood underweight, childhood stunting) it appeared that adolescent stunting stood out as the most important determinant of age at menarche. Adolescent stunting still resonates from the effect of stunting in early childhood (OR respectively 2.63 (p less than 0.01 CI: 1.32-5.24) and 8.47 (p less than 0.001 CI: 3.79-18.93) for moderately and severely stunted under-fives as compared with the reference category). Birth size was not a significant predictor of age at menarche. It is concluded that age at menarche is strongly influenced by nutritional status in adolescence, notably the level of stunting, which is in turn highly dependent on the level of stunting in early childhood. A 'late' menarche due to stunting may be detrimental for reproductive health in case of early childbearing because of the association between height and pelvic size.

Sexuality related attitudes and behaviors of Turkish university students
(Abstract; subscription needed for full text; Europe)
Archives of Sexual Behavior. 2007 Oct;36(5):741-752.
Askun D | Ataca B
In this study, sexual attitudes and behaviors of Turkish university students were explored by taking many influential agents both at the distal and the proximal levels into consideration. A total of 563 students from three universities located in three cities completed a questionnaire that assessed their virginity status, first intercourse, sexual permissiveness, pornography usage, endorsement of traditional sexual double standards, and the perception of parental attitudes about sexuality. The results showed that women and students from rural areas were more traditional and conservative in their attitudes and behaviors regarding sexuality. The perception of maternal restriction about sexuality was related to sexual conservatism, negative affective reaction at first coitus, and endorsing traditional sexual double standards. The results are discussed in terms of various degrees of influences originating from proximal and distal variables in the Turkish context.

FAMILY PLANNING NEWS

Chinese men likely to struggle harder for wives
(News Article; Asia)
15 Nov 2007
The Times of India

Jamaica: Condom controversy- Statistics say condom distribution necessary in schools, government says no
(News Article; Central America and the Caribbean)
14 Nov 2007
Roxborough-Wright P, The Jamaica Observer

FAMILY PLANNING RESEARCH

Cervical cancer and hormonal contraceptives: Collaborative reanalysis of individual data for 16 573 women with cervical cancer and 35 509 women without cervical cancer from 24 epidemiological studies
(Abstract; subscription needed for full text; Global)
Lancet. 2007 Nov 10;370(9599):1609-1621.
International Collaboration of Epidemiological Studies of Cervical Cancer
Combined oral contraceptives are classified by the International Agency for Research on Cancer as a cause of cervical cancer. As the incidence of cervical cancer increases with age, the public-health implications of this association depend largely on the persistence of effects long after use of oral contraceptives has ceased. Information from 24 studies worldwide is pooled here to investigate the association between cervical carcinoma and pattern of oral contraceptive use. Individual data for 16 573 women with cervical cancer and 35 509 without cervical cancer were reanalysed centrally. Relative risks of cervical cancer were estimated by conditional logistic regression, stratifying by study, age, number of sexual partners, age at first intercourse, parity, smoking, and screening. Among current users of oral contraceptives the risk of invasive cervical cancer increased with increasing duration of use (relative risk for 5 or more years' use versus never use, 1.90 [95% CI 1.69-2.13]). The risk declined after use ceased, and by 10 or more years had returned to that of never users. A similar pattern of risk was seen both for invasive and in-situ cancer, and in women who tested positive for high-risk human papillomavirus. Relative risk did not vary substantially between women with different characteristics. The relative risk of cervical cancer is increased in current users of oral contraceptives and declines after use ceases. 10 years' use of oral contraceptives from around age 20 to 30 years is estimated to increase the cumulative incidence of invasive cervical cancer by age 50 from 7.3 to 8.3 per 1000 in less developed countries and from 3.8 to 4.5 per 1000 in more developed countries.

Pregnancy risk among oral contraceptive pill, injectable contraceptive, and condom users in Uganda, Zimbabwe, and Thailand
(Abstract; subscription needed for full text; Asia | Sub-Saharan Africa)
Obstetrics and Gynecology. 2007 Nov;110(5):1003-1009.
Steiner NH | Kwok C | Dominik R | Byamugisha JK | Chipato T | Magwali T | Mmiro F | Rugpao S | Sriplienchan S | Morrison C
The objective was to estimate the probability of pregnancy for oral contraceptive pill (OCP), injectable contraceptive, and condom users in Uganda, Thailand, and Zimbabwe. This study is a secondary analysis of 5,224 women who participated in a prospective study evaluating the association between hormonal contraception and human immunodeficiency virus (HIV) acquisition. The overall 12-month cumulative probability of pregnancy of injectable contraceptive users was 0.6% (95% confidence interval [CI] 0.3-1.0), with similar risks in Uganda (0.3%, 95% CI 0-0.7), Thailand (0.6%, 95% CI 0-1.2), and Zimbabwe (1.0%, 95% CI 0.3-1.7). The 12-month cumulative probability of pregnancy for OCP users was 9.5% (95% CI 8.1-11.0%), with similar risks of pregnancy in Uganda and Zimbabwe (14.6%, 95% CI 11.7-17.4; and 10.2%, 95% CI 8.0 -12.5, respectively) but substantially lower risk in Thailand (0.5%, 95% CI 0-1.2). The overall 12-month cumulative probability of pregnancy for women intending to use a given method at baseline was 2.0% (95% CI 1.4-2.6%) for injectable contraceptives, 15.7% (95% CI 14.1-17.3%) for OCPs, and 25.8% (95% CI 23.2-28.4) for condoms. Women in Thailand experienced lower pregnancy risk with condoms (18.4%, 95% CI 11.1-25.7) than in Uganda (29.5%, 95% CI 25.7-33.4), and Zimbabwe (23.3%, 95% CI 19.4-27.2). The overall risk of pregnancy for injectable contraceptive users was substantially lower than for oral contraceptive pill users. However, Thai participants had similarly low cumulative pregnancy probabilities for both methods. Women receiving contraceptive counseling should be informed that their experience with a given method may differ from the average or typical-use pregnancy rates often discussed during contraceptive counseling. Tailored counseling is necessary for women to make informed choices.

The role of family planning in poverty reduction
(Abstract; subscription needed for full text; Global)
Obstetrics and Gynecology. 2007 Nov;110(5):999-1002.
Allen RH
Family planning plays a pivotal role in population growth, poverty reduction, and human development. Evidence from the United Nations and other governmental and nongovernmental organizations supports this conclusion. Failure to sustain family planning programs, both domestically and abroad, will lead to increased population growth and poorer health worldwide, especially among the poor. However, robust family planning services have a range of benefits, including maternal and infant survival, nutrition, educational attainment, the status of girls and women at home and in society, human immunodeficiency virus (HIV) prevention, and environmental conservation efforts. Family planning is a prerequisite for achievement of the United Nations' Millennium Development Goals and for realizing the human right of reproductive choice. Despite this well-documented need, the U.S. contribution to global family planning has declined in recent years.

Counseling tools alone do not improve method continuation: Further evidence from the decision-making tool for family planning clients and providers in Nicaragua
(Tool; Central America and the Caribbean)
Contraception. 2007 Nov;76(5):377-382.
Chin-Quee DS | Janowitz B | Otterness C
Related Tool: Reproductive choices and family planning for people living with HIV - Counselling tool
Related Report: Developing a Continuing-Client Strategy: How to meet clients' changing family planning needs
The decision-making tool (DMT) was developed by the World Health Organization's Department of Reproductive Health and Research and the Johns Hopkins University Center for Communication Program's staff to promote clients' informed choice and participation in family planning service delivery, to enable providers to apply evidence-based best practices during client-provider interaction and to provide the technical information necessary for optimal delivery of contraceptive methods. This tool has been tested in several countries and been shown to improve the quality of counseling for family planning clients. We conducted intercept and follow-up home interviews with new family planning acceptors in three health departments in Nicaragua to assess the impact of the DMT on method continuation and counseling experiences. The study was a quasi-experimental design with 65 experimental and control clinic sites. Analyses of overall and method-specific contraceptive use rates revealed no differences between experimental and control clinic clients. However, clients in the experimental group reported better counseling experiences than their counterparts in the control group. The authors conclude that sufficient evidence exists that counseling alone -- with or without specialized job aids -- does not influence contraceptive use rates. A new strategy is needed to help women maintain use of family planning methods.

Contraceptive practices and trends in Spain: 1997 -- 2003
(Abstract; subscription needed for full text; Europe)
European Journal of Obstetrics, Gynecology and Reproductive Biology. 2007 Nov;135(1):73-75.
Lete I | Duenas JL | Martinez-Salmean J | Parrilla JJ | Serrano I | Bermejo R | Colla C | Dovala JL | Daphne Team
The objective was to know the contraceptive use and trends in the Spanish female population. Since 1997, we have conducted a survey every 2 years on the use of contraceptive methods among a representative sample of Spanish women of childbearing potential (15-49 years). In the period 1997-2003, the percentage of use of contraceptive methods in Spain rose from 55.6% to 71.2%. The most commonly used method was the condom (21% in 1997, 21.9% in 1999, 29.5% in 2001 and 35.7% in 2003), followed by the contraceptive pill (14.2%, 16.5%, 19.2% and 18.3%, respectively). Male or female sterilization remained stable with percentages of use of 5-7%. IUDs are used by about 5% of women. The use of contraceptive methods among Spanish women of childbearing potential generally fits quite well the patterns found in other developed countries, and we observed a trend towards increased use of effective methods.

GENDER and HEALTH NEWS

Women caucus in parliament organizes breast screening for the public
(News Article; Sub-Saharan Africa)
12 Nov 2007
Patricia Ofori Atta , Public Agenda

GENDER and HEALTH RESEARCH

The goitre rate, its association with reproductive failure, and the knowledge of iodine deficiency disorders (IDD) among women in Ethiopia: Cross-section community based study
(Research Article; Sub-Saharan Africa)
BMC Public Health. 2007 Nov 8;7:316.
Abuye C | Berhane Y
Iodine deficiency is severe public health problem in Ethiopia. Although urinary iodine excretion level (UIE) is a better indicator for IDD the goitre rate is commonly used to mark the public health significance. The range of ill effect of IDD is however beyond goitre in Ethiopia. In this study the prevalence of goitre and its association with reproductive failure, and the knowledge of women on Iodine Deficiency were investigated. A cross-section community based study was conducted during February to May 2005 in 10998 women in child bearing age of 15 to 49 years. To assess the state of iodine deficiency in Ethiopia, a multistage "Proportional to Population Size" (PPS) sampling methods was used, and WHO/UNICEF/ICCIDD recommended method for goitre classification. Total goitre prevalence (weighted) was 35.8% (95% CI 34.5-37.1), 24.3% palpable and 11.5% visible goitre. This demonstrates that more than 6 million women were affected by goitre. Goitre prevalence in four regional states namely Southern Nation Nationalities and People (SNNP), Oromia, Bebshandul-Gumuz and Tigray was greater than 30%, an indication of severe iodine deficiency. In the rest of the regions except Gambella, the IDD situation was mild to moderate. According to WHO/UNICEF/ICCIDD this is a lucid indication that IDD is a major public health problem in Ethiopia. Women with goitre experience more pregnancy failure (x/2=16.5, p less than 0.001; OR = 1.26, 1.12 less than OR less than 1.41) than non goitrous women. Similarly reproductive failure in high goitre endemic areas was significantly higher (x/2 = 67.52; p less than 0.001) than in low. More than 90% of child bearing age women didn't know the cause of iodine deficiency and the importance of iodated salt. Ethiopia is at risk of iodine deficiency disorders. The findings presented in this report emphasis on a sustainable iodine intervention program targeted at population particularly reproductive age women. Nutrition education along with Universal Salt Iodization program and iodized oil capsule distribution in some peripheries where iodine deficiency is severe is urgently required.

The weakness of family ties and their perpetuating effects on gender violence. A qualitative study in Mexico
(Abstract; subscription needed for full text; North America)
Violence Against Women. 2007 Nov;13(11):1206-1220.
Agoff C | Herrera C | Castro R
Research into intimate partner violence has shown that social isolation constitutes a risk factor, and the presence of social networks can be an important source of social support. This research note presents some results of an empirical study carried out in Mexico into women's social relations, especially their family relations, and their role in the promotion of traditional gender norms. Findings indicate that some of the main conditions that are associated with the production of violence against women are either generated or reinforced within the realm of what can be regarded as women's "strong ties."

Validation of the prolapse quality of life questionnaire (P-QOL) in a Turkish population
(Abstract; subscription needed for full text; Europe)
European Journal of Obstetrics, Gynecology and Reproductive Biology. 2007 Nov;135(1):132-135.
Cam C | Sakalli M | Ay P | Aran T | Cam M
The objective was to validate the Turkish translated version of the prolapse quality of life questionnaire (P-QOL). After establishing the test-retest reliability and internal consistency in a pilot study, 310 patients were enrolled in the study and general and subscale scores of the questionnaires were calculated. All participants underwent the International Continence Society (ICS) prolapse score (POP-Q). One hundred and forty-five (49.7%) women were symptomatic and 147 (50.3%) were asymptomatic. The level of missing data ranged from 0 to 2.2%. For the test-retest reliability, Spearman's rho was from 0.91 to 1.00 for all domains (p less than 0.001). The severity of PQOL was strongly correlated with the vaginal examination findings among the symptomatic group (p less than 0.001). Items correlated with the objective vaginal examination findings. The total and domain scores for P-QOL of symptomatic and asymptomatic women were found to be statistically significant (p less than 0.001). The Turkish translated version of the P-QOL is reliable, consistent and valid instrument for assessing symptom severity, impact on quality of life in women with uterovaginal prolapse. It is easy to understand may be easily administered and self-completed by the women.

The lives of female sex workers in Vietnam: Findings from a qualitative study
(Abstract; subscription needed for full text; Asia)
Culture, Health and Sexuality. 2007 Nov-Dec;9(6):555-570.
Ngo AD | McCurdy SA | Ross MW | Markham C | Ratliff EA
To facilitate better understanding of the environment and power structures in which sex work in Vietnam takes place, this study examined the sex workers' social and economic lives, their working environment, social relationships and presentation of self in everyday social contacts and interactions. Thirty in-depth interviews and 14 focus groups were conducted with street-based and venue-based sex workers in the cities of Da Nang and Hanoi. Results show that sex workers live and work within a complex system involving multiple relationships. In any of these relations, women have limited power to protect their personal security and secure payment for services rendered. Economic hardship is a major problem facing street-level sex workers and contributes to unsafe sexual practices. Venue-based sex workers worry less about economic hardships as such, but frequently incur gambling debts. Women also reported incidents of abuse and experiences of social stigma. Although many women exhibited a strong desire to leave sex work, they found themselves trapped in the sex industry by the lack of alternative employment options. This study provides evidence that socio-psychological factors must be addressed along with risky behaviours to promote women's well-being and social integration.

HIV/AIDS and STIs NEWS

United States: Gates Foundation, China to partner in HIV prevention
(News Article; Asia | North America)
14 Nov 2007
Heim K, The Seattle Times

United States: Merck AIDS failure hurts HIV vaccine research, U.S. effort
(News Article; North America)
15 Nov 2007;
Lauerman J, Bloomberg

Zimbabwe: Decline in HIV prevalence welcome
(Editorial; Sub-Saharan Africa)
14 Nov 2007
The Herald, AllAfrica

Sub-Saharan Africa: Aids therapy rates falling off
(News Article; Sub-Saharan Africa)
12 Nov 2007
Ochieng Z, The East African

HIV/AIDS and STIs RESEARCH

Elevated iron status strongly predicts mortality in West African adults with HIV infection
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2007 Dec 1;46(4):498-507.
McDermid JM | Jaye A | van der Loeff MF | Todd J | Bates C
The objective was to comprehensively assess iron status and determine whether elevated iron status, like anemia, predicts mortality. We followed 1362 Gambian adults (53% female) in an HIV-seroprevalent clinic-based cohort over 11.5 years to ascertain all-cause mortality. Baseline iron status (iron, soluble transferrin receptor [sTfR], transferrin, ferritin, transferrin saturation, log [transferrin receptor: ferritin]), age, gender, ethnicity, hemoglobin, body mass index, HIV type, absolute CD4 count, malaria status, and a-1-antichymotrypsin were measured. The mortality rate was 25.9/100 person-years. Elevated iron universally predicted greater mortality compared to normal iron status for all iron status indices, with the exception of sTfR in unadjusted models. In fully adjusted models, transferrin (elevated vs. normal, hazard ratio [HR]: 1.77; 95% confidence interval [CI]: 1.30 to 2.42; P less than 0.001), ferritin (elevated vs. normal, HR: 1.40; 95% CI: 1.07 to 1.83; P = 0.014), and the combined iron status index (highly elevated vs. normal, HR: 2.20; 95% CI: 1.16 to 4.18; P = 0.016) remained significant predictors. As expected, hemoglobin (Hb) concentration and absolute CD4 counts were each inversely associated with mortality. Elevated iron status predicts mortality in HIV infection, even after adjustment for immunosuppression and other confounders. This finding has implications in the clinical monitoring of disease progression and for iron-supplementation practices in areas of high HIV prevalence.

Identification of novel risks for nonulcerative sexually transmitted infections among young men in Kisumu, Kenya
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Sexually Transmitted Diseases. 2007 Nov;34(11):892-899.
Mehta SD | Moses S | Ndinya-Achola JO | Agot K | Maclean I
STI prevention interventions often aim to reduce HIV incidence. Understanding STI risks may lead to more effective HIV prevention. The goal was to identify STI risks among men aged 18-24 in Kisumu, Kenya. We analyzed baseline data from a randomized trial of male circumcision. Participants were interviewed for sociodemographic and behavioral risks. Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were diagnosed by polymerase chain reaction assay and Trichomonas vaginalis (TV) by culture. The outcome for logistic regression analysis was infection with NG, CT, or TV. Among 2743 men, 214 (7.8%; 95% CI: 6.8%-8.8%) were infected with any STI. In multivariable analysis, statistically significant risks for infection were: living one's whole life in Kisumu (OR = 1.50; 95% CI: 1.12-2.01), preferring "dry" sex (OR = 1.47; 95% CI: 1.05-2.07), HSV-2 seropositivity (OR = 1.37; 95% CI: 1.01-1.86), and inability to ejaculate during sex (OR = 2.04; 95% CI: 1.15-3.62). Risk decreased with increasing age and education, and cleaning one's penis less than 1 hour after sex (OR = 0.51; 95% CI: 0.33-0.80). Understanding how postcoital cleaning, "dry" sex, and sexual dysfunction relate to STI acquisition may improve STI and HIV prevention.

Family caregivers in rural Uganda: The hidden reality
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health Care for Women International. 2007 Nov;28(10):856-871.
Kipp W | Tindyebwa D | Rubaale T | Karamagi E | Bajenja E
We conducted 16 in-depth interviews with family caregivers of AIDS patients in three rural districts in western Uganda. They were selected from a client visitation list of the home-based care program for AIDS patients, based on volunteer participation. Family caregivers reported huge problems associated with providing the necessary psychological, social, and economic care. They also said that the physical and emotional demands of caregiving are overwhelming daily challenges. Most support to AIDS patients provided by family, friends, and the churches. The study highlights the great burden of caregivers, in sub-Saharan Africa who most often are elderly women and young girls. This study examine, the burden and related health issues of family caregivers, primarily women, for AIDS patients in Uganda. It was part of a broad research project using qualitative methods on family caregiving in the home environment in sub-Saharan Africa. As the requirements for family care giving are often overwhelming for women under the conditions as they exist in Uganda and in other developing countries, it constitutes a gender issue of great importance that has not been appreciated fully in the international literature. Family caregiving is also of international relevance, as HIV/AIDS is a global pandemic of previously unknown proportions. In many poor countries, family caregiving is the most common and often the only care that AIDS patients receive, because clinic-based care often is not available close to home or is not affordable. Therefore, family caregiver support programs to alleviate this burden are essential for all those countries where HIV/AIDS is prevalent. Family caregiver burden encompasses medical, social, and economic issues at the household level, which requires an interdisciplinary approach in order to fully understand and appreciate the different dimensions of the family caregiver burden and its negative impact on the lives of so many women in so many countries.

Antiretroviral therapy: Associated toxicities in the resource-poor world: The challenge of a limited formulary
(Abstract; subscription needed for full text; Global)
The Journal of Infectious Diseases. 2007 Dec 1;196:S449-S456.
Murphy R | Sunpath H | Kuritzkes D | Venter F | Gandhi R
Toxicities related to antiretroviral therapy make long-term adherence to therapy difficult for patients and present challenges to providers, especially those in the resource-poor world who work with a limited formulary. In resource-poor settings, where limited drug options are the rule, when and how to change therapy are especially difficult problems. Drugs such as stavudine and didanosine are associated with serious metabolic complications, such as lactic acidosis, pancreatitis, and peripheral neuropathy. Antiretroviral agents associated with fewer metabolic effects, such as tenofovir and abacavir, remain widely unavailable. Because the current formulary restrictions appear to be unlikely to change quickly, providers in resource-poor countries must be familiar with the common adverse events-including metabolic complications, hypersensitivity reactions, anemia, and liver enzyme abnormalities-and must understand how to manage them with what is locally available. Most importantly, to avoid drug toxicities, a larger formulary is needed in resource-poor settings, and this must be a high priority for policy makers and health care professionals involved in treating human immunodeficiency virus infection globally.

Comparative costs of inpatient care for HIV-infected and uninfected children and adults in Soweto, South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2007 Dec 1;46(4):410-416.
Thomas LS | Manning A | Holmes CB | Naidoo S | van der Linde F
HIV/AIDS creates a massive burden of care for health systems. A better understanding of the impact of HIV infection on health care utilization and costs may enable better use of limited resources. We compared public sector inpatient costs of HIV-infected versus uninfected adults and children at a large hospital in Soweto, South Africa. Daily hotel costs estimated from hospital financial data and total patient visits were combined with utilization, abstracted from patients' charts, and costed using government price lists to estimate total inpatient costs. A total of 1185 eligible records were included over a 6-week period in 2005. Eight hundred twelve were from HIV-infected patients, and of these, 77 were on antiretroviral (ARV) therapy. The mean length of stay (LOS) and mean drug and intravenous fluid utilization of HIV-infected adults not on ARVs was greater than those of uninfected adults, resulting in a $200 higher total average admission cost. Patients on ARVs had longer LOS and incurred a total average admission cost of $750 more than HIV-infected adults not on ARVs. Inpatient costs were greater for this selected group of HIV-infected adults, and even higher for the small proportion of individuals receiving ARVs. Budget allocations should incorporate case mix by HIV and ARV status as a key determinant of hospital expenditure.

MATERNAL AND CHILD HEALTH NEWS

IMNCH endorsed by Nigerian obstetricians and gynaecologists
(News Article; Sub-Saharan Africa)
16 Nov 2007
Media Deliver Now!

Turkey: 'Let my baby live' media campaign a success
(News Article; Europe)
15 Nov 2007
Turkish Daily News

Uganda: IDP mothers get maternity wards
(News Article; Sub-Saharan Africa)
7 Nov 2007
Ocuvun C, New Vision (Kampala)

Ghana: Mother, child mortality likely to increase
(News Article; Sub-Saharan Africa)
13 Nov 2007
Ghana News Agency (GNA)

Govt makes pronouncement on post-partum haemorrhage drug
(News Article; Sub-Saharan Africa)
16 Nov 2007
Media Deliver Now!

MATERNAL AND CHILD HEALTH RESEARCH

Safe motherhood in Ghana: Still on the agenda?
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health Policy. 2007 Dec;84(2-3):359-367.
Okiwelu T | Hussein J | Adjei S | Arhinful D | Armar-Klemesu M
This paper is an exploration of health sector and programming issues that resulted from a description of safe motherhood activities in Ghana. Descriptions of safe motherhood programmes were collected from various stakeholders through structured interviews. The characteristics of the programmes were compared to national safe motherhood aims and in the context of the reproductive health and sector-wide environment in Ghana. Thirteen safe motherhood programmes were described. Their goals were wide ranging and did not necessarily target pregnant and postpartum women only. Community based interventions were slightly less dominant than service provision activities. A broad funding base was identified, strongly represented by external donors. Many funding contributions were not part of the Ghana government's Sector-Wide Approach (SWAp) to health. Although reduction in maternal mortality ratio is a priority in Ghana's policy, many funding agencies supporting what are known as "safe motherhood" programmes are actually pursuing a somewhat broader reproductive health agenda. The evidence that this situation has actually led to a dilution of the maternal mortality reduction agenda is inconclusive, although our analysis has resulted in lessons which could be used to avert any risk to achieving this key millennium development goal. Government can use the SWAp to keep interests focused on the need for maternal mortality reduction, without detriment to other priorities. Strengthening partnerships will allow civil society and community focused interests to have a voice in influencing SWAp agendas. Good programme design with clear understanding of the link between programme components and objectives will help in making sure that maternal mortality targets are indeed achieved.

Independent effects of nevirapine prophylaxis and HIV-1 RNA suppression in breast milk on early perinatal HIV-1 transmission
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2007 Dec 1;46(4):472-478.
Chung MH | Kiarie JN | Richardson BA | Lehman DA | Overbaugh J
The mechanism of action of single-dose nevirapine on reducing mother-to-child transmission of HIV-1 may involve reduction of maternal HIV-1 or prophylaxis of infants. In a study that randomized pregnant mothers to HIVNET 012 nevirapine versus short-course antenatal zidovudine, we compared breast milk HIV-1 RNA viral shedding and administration of single-dose nevirapine between mothers who transmitted HIV-1 to their infants at 6 weeks postpartum and those who did not. In multivariate analyses, maximum breast milk HIV-1 RNA levels (hazard ratio [HR] = 2.50, 95% confidence interval [CI]: 1.25 to 4.99; P = 0.01) and nevirapine use (HR = 0.12, 95% CI: 0.02 to 0.97; P = 0.05) were each independently associated with perinatal transmission at 6 weeks postpartum. Mothers who transmitted HIV-1 to their infants had significantly higher HIV-1 RNA levels in their breast milk between the second day and sixth week postpartum. Among mothers with maximum breast milk virus levels less than a median of 3.5 log10 copies/mL, the administration of nevirapine further decreased HIV-1 transmission risk from 22.2% to 0.0% (P = 0.04). Peripartum administration of single-dose nevirapine to mother and infant decreases early perinatal HIV-1 transmission by means of breast milk HIV-1 RNA suppression and, independently, by providing the infant with exposure prophylaxis.

Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: A randomised controlled trial
(Abstract; subscription needed for full text; South America)
Lancet. 2007 Nov 10;370(9599):1629-1637.
Rojas G | Fritsch R | Solis J | Jadresic E | Castillo C | Gonzalez M | Guajardo V | Lewis G | Peters TJ | Araya R
The optimum way to improve the recognition and treatment of postnatal depression in developing countries is uncertain. The authors compared the effectiveness of a multicomponent intervention with usual care to treat postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile. 230 mothers with major depression attending postnatal clinics were randomly allocated to either a multicomponent intervention (n=114) or usual care (n=116). The multicomponent intervention involved a psychoeducational group, treatment adherence support, and pharmacotherapy if needed. Usual care included all services normally available in the clinics, including antidepressant drugs, brief psychotherapeutic interventions, medical consultations, or external referral for specialty treatment. The primary outcome measure was the Edinburgh postnatal depression scale (EPDS) score at 3 and 6 months after randomisation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00518830. 208 (90%) of women randomly assigned to treatment groups completed assessments. The crude mean EPDS score was lower for the multicomponent intervention group than for the usual care group at 3 months (8.5 [95% CI 7.2-9.7] vs 12.8 [11.3-14.1]). Although these differences between groups decreased by 6 months, EPDS score remained better in multicomponent intervention group than in usual care group (10.9 [9.6-12.2] vs 12.5 [11.1-13.8]). The adjusted difference in mean EPDS between the two groups at 3 months was -4.5 (95% CI -6.3 to -2.7; p less than 0.0001). The decrease in the number of women taking antidepressants after 3 months was greater in the intervention group than in the usual care group (multicomponent intervention from 60/101 [59%; 95% CI 49-69%] to 38/106 [36%; 27-46%]; usual care from 18/108 [17%; 10-25%] to 11/102 [11%; 6-19%]). The findings suggest that low-income mothers with depression and who have newly born children could be effectively helped, even in low-income settings, through multicomponent interventions. Further refinements to this intervention are needed to ensure treatment compliance after the acute phase.

Two decades of the safe motherhood initiative: Time for another wooden spoon award?
(Abstract; subscription needed for full text; Global)
Obstetrics and Gynecology. 2007 Nov;110(5):972-976.
Tita AT | Stringer JS | Goldenberg RL | Rouse DJ
After two decades of the Safe Motherhood Initiative, meaningful reductions in maternal mortality and disability during pregnancy and childbirth in developing countries have not been realized. Herein, the authors present an overview of the Initiative and review the reasons for this lack of impact, focusing on the issue of strategic effectiveness. An appraisal of strategies that are currently recommended reveals a lack of strong evidence to support their effectiveness. Drawing from the Initiative's history, the authors propose that, among essential elements to achieve safe motherhood, recommended public health strategies should be supported by good evidence of effectiveness, through (cluster) randomized trials when feasible, before their widespread implementation.

POPULATION/FERTILITY/DEMOGRAPHY NEWS

Arab Births Down, Jewish Births Up: No Demographic Threat
(News Article; Middle East)
16 Nov 2007
Arutz Sheva

Nigeria's 'land of twins' baffles fertility experts
(News Article; Sub-Saharan Africa)
12 Nov 2007
AFP

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Demography as a spatial social science
(Abstract; subscription needed for full text; Global)
Population Research and Policy Review. 2007 Dec;26(5-6):457-476.
Voss PR
Scholars in many social science disciplines have taken note of the reemerging interest in issues concerning social processes embedded within a spatial context. While some argue that this awakening is refreshing and new and, in fact, long overdue, I demonstrate that spatially focused demographic theories and research agendas clearly predate contemporary interest in these topics. I assert that recent methodological advancements have merely encouraged and brought refinement to the expanding body of spatially oriented population research-research strongly rooted in demographic tradition and practice. Indeed, I make the claim that, until roughly the mid-20th century, virtually all demography in the United States (and elsewhere, but not specifically examined here) was spatial demography. Then, shortly after mid-century, a paradigm shift occurred, and the scientific study of population quickly came to be dominated by attention to the individual as the agent of demographic action. Traditional spatial demography - macro-demography - gave way to micro-demography, and, I argue, most demographers simply abandoned the data and approach of spatial demography. In closing the paper I include a brief discussion of the recent awakening that has come to spatial demographers from developments in other disciplines, principally geography, regional science, and spatial econometrics.

An explanatory model for projecting regional fertility differences in the Netherlands
(Abstract; subscription needed for full text; Europe)
Population Research and Policy Review. 2007 Dec;26(5-6):511-528.
de Beer J | Deerenberg I
Current differences in the level of the total fertility rate (TFR) between Dutch municipalities are smaller than they were in the 1970s and 1980s. Nevertheless, there are still considerable differences. Small municipalities have higher TFRs than large cities. This article aims to answer the question whether these differences will decline further until differences between large and small cities disappear. For that purpose we develop a regression model of regional differences in the TFR including demographic, socioeconomic, and cultural variables. Using the estimation results we decompose differences in fertility between large and small cities into the contribution of differences in levels of the determinants versus differences in the relationships between the determinants and fertility. The results show that differences in cultural variables have a larger effect on differences in the TFR than the demographic and socioeconomic variables. As cultural differences do not tend to change quickly, they will not lead to quick changes in regional differences in the TFR. Demographic differences are not expected to lead to strong changes either, as the two demographic variables (household structure and ethnic structure) have opposite effects. As the effect of the socioeconomic variable is caused by differences in the magnitude of the regression coefficient rather than by differences in the value of this variable, even if differences in this variable disappeared, this would still not lead to convergence of the TFR. Thus the article concludes that differences in the TFR between large and small cities are not likely to diminish quickly.

"The Pop Reporter" (R) Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs/INFO Project. When you click on any link, your Internet browser will access a Web site not connected to "The Pop Reporter." Information accessed through these links and contained in this issue of "The Pop Reporter" does not necessarily state or reflect the views of the INFO Project, Johns Hopkins University, or the US Agency for International Development. All links were verified at the date of mailing. Your computer and/or network configuration regarding Java script, cookies, and other security issues may not allow you to view certain Web sites. Consult your computer technician if you are having problems.

Problems and comments can be addressed to mdadamo@jhuccp.org.

Archives available at http://www.infoforhealth.org/popreporter/.

Subscribe at http://prds.infoforhealth.org/signup.php.

Modify your account at http://prds.infoforhealth.org/modify.php.

Forward this message to a friend who could benefit from INFO project activities!

The Pop Reporter--Delivering thought-provoking global health news to your desktop.

Johns Hopkins Bloomberg School of Public Health: The INFO Project

Volume 7, Number 4419 November 2007