Volume 8, Number 20
19 May 2008

Change to The Pop Reporter: Starting with the June 2, 2008, issue of The Pop Reporter, the scope will change to include only research items. News, guest editorials, and events will be discontinued until further notice.

ADOLESCENT HEALTH RESEARCH

Adolescent refugees and migrants: A reproductive health emergency
(Report; Global)
Watertown, Massachusetts, Pathfinder International, 2008 Apr. 15 p.
Lane C
As young people transition from childhood to adulthood, threats to their health shift from infectious disease that can easily be prevented or treated through vaccinations, improved hygiene, and access to antibiotics, to illnesses and injuries that are grounded in their behaviors. Unsafe reproductive health behaviors in youth, such as early age of sexual debut and low rates of condom and contraceptive use, result in high rates of unwanted pregnancies, Sexually Transmitted Infections (STIs) and HIV/AIDS. Young people who are displaced from their homes and communities may suddenly experience a lack of social support from family, friends, and mentors, as well as increased exposure to violence, coercion, and new sources of pressure. These factors can affect the ability of youth to practice safe reproductive health behaviors and create risky situations that may lead to unhealthy and potentially fatal choices.

Factors associated with Estonian adolescents' sexuality-related knowledge: Findings from the 1994 and 1999 KISS studies
(Abstract; subscription needed for full text; Europe)
European Journal of Contraception and Reproductive Health Care. 2008 Jun;13(2):173-181.
Part K | Rahu K | Rahu M | Karro H
The objective was to identify changes in factors associated with Estonian adolescents' sexuality-related knowledge. The relationship between self-reported school sexuality education and good sexuality-related knowledge is addressed. The study is based on the results of two consecutive studies conducted in 1994 and 1999, based on anonymous self-completed questionnaires in schools, which involved 2256 respondents from random samples of primary school 9th grade pupils. Information on 16 sexual knowledge items, experience of sexual intercourse, discussions about sexuality with parents and school sexuality education was collected. A multivariate logistic regression analysis was used to account for the simultaneous effects of independent determinants on good sexuality-related knowledge. The results showed improvement in the respondents' level of sexuality-related knowledge between the two study years. Whereas in 1994, good sexual knowledge was positively associated solely with experience of sexual intercourse, in 1999, good sexual knowledge was also positively associated with school sexuality education. The improvement of sexuality-related knowledge and its positive association with school sexuality education in 1999 may be a result of the mandatory sexuality education introduced into the school curriculum in 1996. These findings have important implications for the further provision of school sexuality education in Estonia.

Effects of the culturally-sensitive comprehensive sex education programme among Thai secondary school students
(Abstract; subscription needed for full text; Asia)
Journal of Advanced Nursing. 2008 May;62(4):457-469.
Thato R | Jenkins RA | Dusitsin N
This paper reports on a study to evaluate the effectiveness of a culturally-sensitive comprehensive sex education programme among Thai secondary school students. Increasing number of adolescents in Thailand have been engaging in premarital sex. No theory-based, abstinence-oriented models of sex education have been evaluated in this population. A quasi-experimental study was conducted in 2006-2007. Outcome measures included sexual behaviour, condom use, intention to refuse sex, intention to use condoms, and knowledge regarding sexually transmitted infections/human immunodeficiency virus/acquired immunodeficiency syndrome and pregnancy. Students in the experimental group had lower levels of reported sexual intercourse at 3- and 6-month follow-ups, compared with those in control group (P less than 0.01). Students participating in the programme had significantly greater intention to refuse sex in the future across time than controls (P less than 0.05). Sexually active adolescents participating in the programme reported significantly lower frequencies of sexual intercourse across time than controls (P less than 0.01). However, the programme did not influence consistent condom use (P greater than 0.05), although the intervention was associated with increased intention to use condoms (P less than 0.01). Knowledge about sexually transmitted infections/human immunodeficiency virus/ acquired immunodeficiency syndrome and pregnancy among students in the intervention group was significantly greater than that of the controls (P less than 0.05). School nurses can play a major role by applying this kind of sex education programme. For nurse researchers, it would be useful to extend this research by considering alternative ways to foster condom use in the non-commercial partnerships that have become common among adolescents.

Health providers' perceptions of adolescent sexual and reproductive health care in Swaziland
(Abstract; subscription needed for full text; Sub-Saharan Africa)
International Nursing Review. 2008 Jun;55(2):148-155.
Mngadi PT | Faxelid E | Zwane IT | Hojer B | Ransjo-Arvidson AB
The aim was to explore health providers' perceptions of adolescent sexual and reproductive healthcare services in Swaziland. Fifty-six healthcare providers, working in 11 health clinics in Swaziland in 2005, were surveyed using a semi-structured questionnaire. The data were analysed by descriptive statistics and content analysis to identify key themes. Most participants were women with a mean age of 36 years and a mean number of 6 years in the profession. Services provided included STIs/HIV/AIDS advice, pre- and post-test counselling and testing on HIV, contraceptives and condom use. Half of the nurses/midwives had no continued education and lacked supervision on adolescent sexual and reproductive health care. The majority had unresolved moral doubts, negative attitudes, values and ethical dilemmas towards abortion care between the law, which is against abortion, and the reality of the adolescents' situation. Forty-four wanted to be trained on post-abortion care while eight on how to perform abortions. Twenty-six wanted the government to support adolescent-friendly services and to train heathcare providers in adolescent sexual and reproductive health services. The curricula within nursing and midwifery preservice education need to be reviewed to incorporate comprehensive services for adolescents. There is need for provision of comprehensive services for adolescents in Swaziland and appropriate youth-friendly services at all levels. There is need for nurse/ midwifery participation, advocacy and leadership in policy development.

FAMILY PLANNING NEWS

New vaginal ring offers nonhormonal contraception: Presented at ACOG
(News Article; Global)
14 May 2008
Brown E, Doctor's Guide Channels

Key challenges and issues facing the world contraceptives markets
(News Article; Global)
15 May 2008
Market Wire

South Africa: Unwanted pregnancies rife
(News Article; Sub-Saharan Africa)
15 May 2008
Health 24

FAMILY PLANNING RESEARCH

Consistent use of a combination product versus a single product in a safety trial of the diaphragm and microbicide in Harare, Zimbabwe
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Contraception. 2008 Jun;77(6):435-443.
van der Straten A | Moore J | Napierala S | Clouse K | Mauck C | Hammond N | Padian N
We examined the use and acceptability of a combination product (diaphragm and gel) compared to a single product (gel) during a 6-month safety trial in Zimbabwe. Women were randomized to the use of a diaphragm with gel or the use of gel alone, in addition to male condoms. Ever use and use of study product on the last act of sexual intercourse were assessed monthly by Audio Computer-Assisted Self-Interviewing. Acceptability, correct use and consistent use (use at every sexual act during the previous 3 months) were measured on the last visit by face-to-face interview. Predictors of consistent use were examined using multivariate logistic regression analyses. In this sample of 117 sexually active, monogamous, contracepting women, rates of consistent use were similar in both groups (59.7% for combination method vs. 56.4% for gel alone). Product acceptability was high, but was not independently associated with consistent use. Independent predictors of consistent use included age [adjusted odds ratio (AOR)=1.08; 95% confidence interval (95% CI)=1.01-1.16], consistent condom use (AOR=3.85; 95% CI=1.54-9.63) and having a partner who approves of product use (AOR=2.66; 95% CI=1.10-6.39). Despite high reported acceptability and few problems with the products, the participants reported only moderate product adherence levels. Consistent use of condoms and consistent use of products were strongly associated. If observed in other studies, this may bias the estimation of product effectiveness in future trials of female-controlled methods.

The impact of intrauterine devices on subsequent fertility
(Abstract; subscription needed for full text; Global)
Current Opinion in Obstetrics and Gynecology. 2008 Jun;20(3):275-280.
Skjeldestad FE
The purpose of the review was to investigate the impact of intrauterine devices on subsequent fertility. Intrauterine devices are safe, well tolerated and used by millions of women worldwide. Subsequent fertility is studied among women who remove the intrauterine contraceptive device for planning pregnancy or among women who have removed the intrauterine contraceptive device because of intrauterine contraceptive device-related complications and later on have become pregnant. Study participants are recruited from randomized clinical trials on intrauterine contraceptive device performance or in case series among women who remove the intrauterine contraceptive device. Pregnancy rates after removal are high and are similar to time-to-pregnancy rates in the general population. The birth rates are high with a normal distribution of preterm deliveries, normal birth weight and sex ratio of newborns. The ratio of extra-intrauterine pregnancies and the need for infertility work up are low, and the distribution of infertility causes among fully investigated couples is as seen in the general population. Despite small sample size of studies investigating impact of intrauterine contraceptive devices on subsequent fertility, the results are consistent and reassuring on high pregnancy rates, and a normal distribution of pregnancy outcomes. There are limited data on return of fertility after usage of medicated intrauterine contraceptive devices -- more studies are warranted among women who have used hormone-releasing intrauterine contraceptive devices.

Men's involvement in family planning in rural Bangladesh
(Abstract; subscription needed for full text; Asia)
Journal of Biosocial Science. 2008;:[26] p..
Clark J | Yount KM | Rochat R
Contraceptive prevalence has risen markedly in rural Bangladesh due in part to a doorstep-delivery system initiated by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). This study investigates effects of residence in the Matlab MCH-FP treatment area on men's involvement in family planning. The analysis compares for treatment and comparison areas knowledge of and attitudes toward contraception, as well as levels of contraceptive use, among 413 married men interviewed at the baseline of an ICDDR,B men's involvement project. Although residence in the MCH-FP area is associated with a higher overall contraceptive prevalence, it also is associated with a lower adjusted ratio of male-to-female method use, and lower odds of other indicators of men's involvement in family planning. Historical decisions to exclude men from contraceptive decision-making may place the 'burden' of contraception on women and may preclude the productive involvement of men. These and other implications and strategies for increased men's involvement are discussed.

Immediate start of hormonal contraceptives for contraception (Review)
(Review/Synthesis; Global)
Cochrane Database of Systematic Reviews. 2008 Apr 16;(2):1-31.
Lopez LM | Newmann SJ | Grimes DA | Nanda K | Schulz KF
Health care providers often tell women to wait until the next menses to begin hormonal contraception. The main intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was first introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. How immediate start compares to conventional menses-dependent start is unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception. This review examined randomized controlled trials of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability. We searched MEDLINE, CENTRAL, POPLINE, EMBASE, and LILACS for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies. We included randomized controlled trials that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other. Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated. Five studies were included. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a 'bridge' method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a 'bridge' method (OR 1.99; 95% CI 1.05 to 3.77). A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. For satisfaction, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22). We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, that is, immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.

Are Serbian gynaecologists in line with modern family planning?
(Abstract; subscription needed for full text; Europe)
European Journal of Contraception and Reproductive Health Care. 2008 Jun;13(2):158-163.
Sedlecky K | Rasevic M
In Serbia, gynaecologists could play an important role in achieving the transition from an abortion-based family planning culture to a modern contraception-based one. Exploring their knowledge, attitudes and practice regarding birth control is of particular importance for ensuring the quality of contraceptive counselling. A questionnaire was sent to all the 1,139 members of the Gynaecology and Obstetrics Section of the Serbian Medical Society. The response rate was 27%. Of the respondents, 61.8% reported that either they or their partner had had one or more induced abortions; 37.6% stated that they usually used either coitus interruptus or no contraceptive method at all; 51.0% were unwilling to prescribe combined oral contraceptives (COCs) to girls younger than 18 years, and 76.5% advised women against the use of COCs for more than two years. Irrational concerns about the health risks of contraception were identified. The contraceptive needs of women aged 20+ were particularly hampered by the fact that 75.5% of respondents thought that intrauterine device use was unsafe for women with benign, non infectious cervicitis. The results indicate that a significant number of Serbian gynaecologists neither use modern methods of contraception themselves nor have adequate knowledge to advise their patients. Thus, education and training of gynaecologists in all methods of available contraception is a priority in Serbia.

GENDER and HEALTH NEWS

Mauritania: Justice not working for rape victims
(News Article; North Africa)
13 May 2008
IRIN

Djibouti: Country to work with UN to eliminate female genital mutilation
(News Article; Sub-Saharan Africa)
9 May 2008
UN News Centre

GENDER and HEALTH RESEARCH

Domestic violence and chronic malnutrition among women and children in India
(Abstract; subscription needed for full text; Asia)
American Journal of Epidemiology. 2008;167(10):1188-1196.
Ackerson LK | Subramanian SV
Domestic violence has harmful physical and psychological health correlates, but there is little evidence regarding a relation between domestic violence and malnutrition. To investigate this relation, the authors analyzed data from 69,072 women aged 15-49 years and 14,552 children aged 12-35 months in the 1998-1999 Indian National Family Health Survey. Physical domestic violence victimization was self-reported by the women. Aspects of nutritional status included in this study were anemia and underweight. Anemia was measured with a blood test for hemoglobin. Underweight was calculated from anthropometric measurements and was determined as body mass index for women, and it included stunting and wasting for children. Results indicate associations of multiple incidents of domestic violence in the previous year with anemia (odds ratio = 1.11, 95% confidence interval: 1.04, 1.18) and underweight (odds ratio = 1.21, 95% confidence interval: 1.13, 1.29) in women and a suggested relation among children. Possible mechanisms for this relation include withholding of food as a form of abuse and stress-mediated influences of domestic violence on nutritional outcomes. These findings indicate that reducing domestic violence is important not only from a moral and intrinsic perspective but also because of the instrumental health benefits likely to accrue.

Intimate partner violence and reproductive health of women in Kenya
(Abstract; subscription needed for full text; Sub-Saharan Africa)
International Nursing Review. 2008 Mar;55(1):97-102.
Emenike E | Lawoko S | Dalal K
Reproductive age represents an augmented risk of intimate partner violence (IPV) despite its occurrence in women of all ages. IPV has been associated with various reproductive health outcomes (e.g., terminated pregnancies and infant mortality), although multi-country studies indicate that the findings may not be consistent across all cultures. The current work describes the association between IPV and reproductive health of women in Kenya using the Demographic and Health Survey of 2003. A significant association between physical/emotional/sexual abuse of women and negative reproductive health outcomes such as terminated pregnancies and infant mortality was identified. In addition, IPV exposure was associated with use of family planning methods and high fertility. Practitioners in the healthcare sector should inquire about abuse. Provision of counselling services and information regarding IPV effects on reproductive outcomes as well as referring abused women to relevant institutions is recommended in secondary prevention of IPV and to improve the reproductive health status of abused women.

Prospects and prejudices of human papillomavirus vaccines in India
(Abstract; subscription needed for full text; Asia)
Vaccine. 2008 May 23;26(22):2669-2679.
Das BC | Hussain S | Nasare V | Bharadwaj M
Cervical cancer is the most common cancer and a leading cause of cancer deaths among women in developing countries. The disease is caused due to persistent infection of one or more of about 15 high-risk human papillomaviruses (HR-HPVs), most commonly by HPV types 16/18. In India, over 98% of cervical cancer cases harbor HPV infection and HPV 16 is the type exclusively (80-90%) prevalent. Unlike the West, HPV infection is most common in women in their third decade (26-35 years) of sexual activity and invasive cancer also arises much later with a peak at about 45-55 years of age. Recently, two successful prophylactic HPV vaccines, a quadrivalent (HPV16/18/6/11) 'Gardasil' by Merck and a bivalent (HPV16/18) 'Cervarix' by GSK have been developed. Several other approaches including plant-based edible, pentameric capsomere-based intranasal and DNA-based vaccines have also been employed to develop prophylactic vaccines. Also, several therapeutic vaccines either protein/peptide based or DNA based are in clinical trials but are yet to establish their efficacy. Though there are several issues regarding implementation of the already developed vaccines in resource limited countries, efforts are being made to develop cost-effective second-generation vaccines. If cost minimized, HPV related new technologies involved in screening tests and vaccines are expected to reduce incidence of cervical cancer and deaths it causes in women from developing countries.

Gender biases and discrimination: A review of health care interpersonal interactions
(Abstract; subscription needed for full text; Global)
Global Public Health. 2008;3(Suppl 1):90-103.
Govender V | Penn-Kekana L
A good interpersonal relationship between a patient and provider, as characterized by mutual respect, openness, and a balance in their respective roles in decision-making, is an important marker of quality of care. This review is undertaken from a gender and health equity perspective and illustrates that gender biases and discrimination occur at many levels in the healthcare delivery environment, and affects the patient-provider interaction which can result in health inequities affecting individual health seeking behaviour, access to good quality healthcare, and, ultimately, health outcomes. Interventions will have to be introduced at multiple levels, from health system legislation and policy and gender sensitive training to the development of women and men centred services and health literacy programmes.

HIV/AIDS and STIs NEWS

Uganda: Aids Commission in Bid to Fight HIV Stigma
(News Article; Sub-Saharan Africa)
13 May 2008
The Monitor/AllAfrica

Sierra Leone: 2,181 Pregnant Women Tested HIV Positive
(News Article; Sub-Saharan Africa)
13 May 2008
Vandi M, Concord Times/AllAfrica

United States: World Bank says HIV/AIDS to remain a challenge in sub-Saharan Africa
(News Article; North America | Sub-Saharan Africa)
14 May 2008
Associated Press

HIV/AIDS and STIs RESEARCH

Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Lancet. 2008 May 10;371(9624):1603-1611.
Jahn A | Floyd S | Crampin AC | Mwaungulu F | Mvula H
Malawi, which has about 80 000 deaths from AIDS every year, made free antiretroviral therapy available to more than 80 000 patients between 2004 and 2006. We aimed to investigate mortality in a population before and after the introduction of free antiretroviral therapy, and therefore to assess the effects of such programmes on survival at the population level. We used a demographic surveillance system to measure mortality in a population of 32 000 in northern Malawi, from August, 2002, when free antiretroviral therapy was not available in the study district, until February, 2006, 8 months after a clinic opened. Causes of death were established through verbal autopsies (retrospective interviews). Patients who registered for antiretroviral therapy at the clinic were identified and linked to the population under surveillance. Trends in mortality were analysed by age, sex, cause of death, and zone of residence. Before antiretroviral therapy became available in June, 2005, mortality in adults (aged 15-59 years) was 9.8 deaths for 1000 person-years of observation (95% CI 8.9-10.9). The probability of dying between the ages of 15 and 60 years was 43% (39-49) for men and 43% (38-47) for women; 229 of 352 deaths (65.1%) were attributed to AIDS. 8 months after the clinic that provided antiretroviral therapy opened, 107 adults from the study population had accessed treatment, out of an estimated 334 in need of treatment. Overall mortality in adults had decreased by 10% from 10.2 to 8.7 deaths for 1000 person-years of observation (adjusted rate ratio 0.90, 95% CI 0.70-1.14). Mortality was reduced by 35% (adjusted rate ratio 0.65, 0.46-0.92) in adults near the main road, where mortality before antiretroviral therapy was highest (from 13.2 to 8.5 deaths per 1000 person-years of observation before and after antiretroviral therapy). Mortality in adults aged 60 years or older did not change. Our findings of a reduction in mortality in adults aged between 15 and 59 years, with no change in those older than 60 years, suggests that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy in rural Malawi, which led to a decline in adult mortality that was detectable at the population level.

The impact of pre-exposure prophylaxis (PrEP) on HIV epidemics in Africa and India: A simulation study
(Research Article; Asia | Sub-Saharan Africa)
PLoS One. 2008;3(5):e2077.
Vissers DC | Voeten HA | Nagelkerke NJ | Habbema JD | de Vlas SJ
Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method, especially for women. An urgent demand for implementation of PrEP is expected at the moment efficacy has been demonstrated in clinical trials. We explored the long-term impact of PrEP on HIV transmission in different HIV epidemics. We used a mathematical model that distinguishes the general population, sex workers and their clients. PrEP scenarios varying in effectiveness, coverage and target group were modeled in the epidemiological settings of Botswana, Nyanza Province in Kenya, and Southern India. We also studied the effect of condom addition or condom substitution during PrEP use. Main outcome was number of HIV infections averted over ten years of PrEP use. PrEP strategies with high effectiveness and high coverage can have a substantial impact in African settings. In Southern India, by contrast, the number of averted HIV infections in different PrEP scenarios would be much lower. The impact of PrEP may be strongly diminished or even reversed by behavioral disinhibition, especially in scenarios with low coverage and low effectiveness. However, additional condom use during low coverage and low effective PrEP doubled the amount of averted HIV infections. The public health impact of PrEP can be substantial. However, this impact may be diminished, or even reversed, by changes in risk behavior. Implementation of PrEP strategies should therefore come on top of current condom campaigns, not as a substitution.

Reassessing HIV prevention
(Abstract; subscription needed for full text; Global)
Science. 2008 May 9;320(5877):749-750.
Potts M | Halperin DT | Kirby D | Swidler A | Marseille E
Several decades into the AIDS pandemic, HIV transmission in most of the world remains firmly concentrated among sex workers, men who have sex with men (MSM), injecting drug users (IDUs), and their sex partners. In some parts of Africa, where over two-thirds of infections occur globally, HIV has expanded outside these high-risk groups, creating generalized, predominantly heterosexual epidemics. In nine southern African countries, more than 12% of adults are infected with HIV. Such devastating epidemics have frequently been attributed to poverty, limited health services, illiteracy, war, and gender inequity. Although these grave problems demand an effective response in their own right, they do not appear to be the immediate causes of generalized epidemics. Some assumptions that drive current HIV prevention strategies are unsupported by rigorous evidence. The presumption, for example, that poverty increases vulnerability to HIV infection is challenged by studies such as an analysis of recent Demographic and Health Surveys (DHSs) from Africa, which shows a strong positive correlation between HIV prevalence and wealth in eight countries examined [see supporting online material (SOM)]. Among Kenyan women, HIV prevalence is 3.9% in the lowest economic quintile and 12% in the highest. A study of serodiscordant couples found that, across 12 African nations, the woman was the HIV-infected partner in 34 to 62% of these couples, which suggests that many infections are not, as is commonly assumed, brought into the relationship by the man. African regions suffering from conflict, genocide, and rape, such as Rwanda, Congo, and Angola, are much less affected by AIDS than peaceful, wealthier, and more literate countries such as Botswana or Swaziland, which have the world's highest HIV prevalence.

Barriers to access to antiretroviral treatment in developing countries: A review
(Abstract; subscription needed for full text; Global)
Tropical Medicine and International Health. 2008 Jul;13(7):1-10.
Posse M | Meheus F | van Asten H | van der Ven A | Baltussen R
The objective was to present a review of barriers impeding people living with HIV/AIDS in developing countries from accessing treatment, and to make recommendations for further studies. Electronic databases, websites of main global agencies and international AIDS conferences were searched for relevant articles published between 1996 and 2007. Articles were reviewed using the Andersen and May framework of access to health services and barriers were categorized as either population-level or health system-level barriers. A total of 19 studies (7 articles and 12 abstracts) in English were reviewed. The barriers most frequently cited at the population level were lack of information about antiretroviral therapy (ART), perceived high costs for ART and stigma. Barriers most frequently cited at the health system level were long distance from home to the health facility, lack of co-ordination across services and limited involvement of the community in the programme planning process. Dissemination of information about HIV/AIDS and alternative related care, and alternative health financing policies seem to be the most relevant policy measures to remove barriers. In view of the paucity of evidence on barriers to access to ART, research should address the relative importance of barriers, include a mix of qualitative and quantitative research methods and evaluate barriers in different settings.

An assessment of the Positive Partnership Project in Thailand: Key considerations for scaling-up microcredit loans for HIV-positive and negative pairs in other settings
(Abstract; subscription needed for full text; Asia)
Global Public Health. 2008 Apr;3(2):115-136.
Viravaidya M | Wolf RC | Guest P
Stigmatization and discrimination against people living with HIV/AIDS (PLHA), and their families, remains a barrier to participation in prevention and care programmes. This barrier takes on added significance as Thailand expands provision of free antiretroviral therapy (ART). This paper documents an innovative approach to improve quality of life for PLHA, while reducing levels of stigma and discrimination. The Population and Community Development Association (PDA) began implementing the Positive Partnership Project (PPP) in 2002. In this project, an HIV-negative person must team up with an HIV-positive person to become eligible for a loan for income-generating activities. The use of microcredit to explicitly reduce stigma and discrimination is a unique feature of the PPP. While the microcredit component of the project is an important dimension for improving the status of participating PLHA, the impacts of the project extend far beyond the PLHA who receive loans. Both directly and indirectly, it has contributed to improved quality of life and economic conditions for PLHA, while raising their visibility and acceptance in hundreds of communities throughout urban and rural Thailand. This paper identifies key features of the project and considerations for adapting its use in other settings.

MATERNAL AND CHILD HEALTH NEWS

Zimbabwe: Pregnancy complications surge in Binga - Official
(News Article; Sub-Saharan Africa)
10 May 2008
The Herald (Harare)

Makati taps breastfeeding to fight child malnutrition
(News Article; Asia)
16 May 2008
Fabella F, Manila Standard Today

Tanzania launches "One Plan" for reducing maternal and child deaths
(News Article; Sub-Saharan Africa)
13 May 2008
Mtenga G, UNICEF

MATERNAL AND CHILD HEALTH RESEARCH

Maternal healthcare needs assessment survey at Rabia Balkhi Hospital in Kabul, Afghanistan
(Abstract; subscription needed for full text; Asia)
International Journal of Gynecology and Obstetrics. 2008 Jun;101(3):259-263.
Khorrami H | Karzai F | Macri CJ | Amir A | Laube D
Since the Department of Health and Human Services chose Rabia Balkhi Hospital (RBH) in Kabul, Afghanistan, as a site for intervention in 2002, the status of women's health there has been of interest. This study created a tool to assess accessibility and quality of care of women admitted from May to July, 2005. A 39-item questionnaire was created in English and translated into Dari. Hospital staff administered the survey to 292 women admitted to RBH for obstetric and gynecological complaints. Approximately 40% of the women traveled between 1 and 5 hours to reach RBH. Only 54% (158/292) of women reported having their blood pressure monitored during their pregnancy. About one-third of women reported that they had never received an immunization. This survey tool ascertained that women who received care at RBH traveled great lengths to reach the facility. Preventative measures such as blood pressure checks and immunizations are areas that need improvement.

Breastfeeding duration and postpartum psychological adjustment: Role of maternal attachment styles
(Abstract; subscription needed for full text; Europe)
Journal of Paediatrics and Child Health. 2008 Jun;44(6):369-373.
Akman I | Kuscu MK | Yurdakul Z | Ozdemir N | Solakoglu M | Orhon L | Karabekiroglu A | Ozek E
Depressive and anxiety symptoms are common in new mothers. The aim of this study is to explore the link between postpartum psychological adjustment and feeding preferences of the mothers. Sixty mothers and newborns were enrolled in this prospective, longitudinal study. Maternal depressive symptoms were screened by the Edinburgh Postpartum Depression Scale (EPDS), and maternal anxiety level was assessed by the State-Trait Anxiety Inventory at 1 month postpartum. The Multidimensional Scale of Perceived Social Support was used for the assessment of maternal social support. The Adult Attachment Scale was used to determine the attachment style of the mother. Infants were examined and evaluated at 1 and 4 months of life. All mothers started breastfeeding their infants postpartum; 91% and 68.1% continued exclusive breastfeeding at 1 and 4 months, respectively. The first-month median EPDS score of mothers who breastfeed at the fourth month was statistically significantly lower than those who were not breastfeeding (6 and 12, respectively) (P = 0001). The first-month median EPDS score of mothers with secure attachment was lower than the median score of mothers with insecure attachment (5 and 9, respectively) (P less than 0001). Exclusive breastfeeding rate was not statistically different among mothers with secure and insecure attachment styles. The median state and trait anxiety scores and social support scores of mothers were not different between groups according to breastfeeding status. This study has shown an association between higher EPDS scores and breastfeeding cessation by 4 months after delivery.

Impact of round-the-clock, rapid oral fluid HIV testing of women in labor in rural India
(Research Article; Asia)
PLoS Medicine. 2008 May;5(5):e92.
Pai NP | Barick R | Tulsky JP | Shivkumar PV | Cohan D | Kalantri S | Pai M | Klein MB | Chhabra S
Testing pregnant women for HIV at the time of labor and delivery is the last opportunity for prevention of mother-to-child HIV transmission (PMTCT) measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counseling of pregnant women in labor is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counseling services. In this context, the authors investigated the impact of introducing round-the-clock, rapid, point-of-care HIV testing and counseling in a busy labor ward at a tertiary care hospital in rural India. After they provided written informed consent, women admitted to the labor ward of a rural teaching hospital in India were offered two rapid tests on oral fluid and finger-stick specimens (OraQuick Rapid HIV-1/HIV-2 tests, OraSure Technologies). Simultaneously, venous blood was drawn for conventional HIV ELISA testing. Western blot tests were performed for confirmatory testing if women were positive by both rapid tests and dual ELISA, or where test results were discordant. Round-the-clock (24 h, 7 d/wk) abbreviated prepartum and extended postpartum counseling sessions were offered as part of the testing strategy. HIV-positive women were administered PMTCT interventions. Of 1,252 eligible women (age range 18 y to 38 y) approached for consent over a 9 mo period in 2006, 1,222 (98%) accepted HIV testing in the labor ward. Of these, 1,003 (82%) women presented with either no reports or incomplete reports of prior HIV testing results at the time of admission to the labor ward. Of 1,222 women, 15 were diagnosed as HIV-positive (on the basis of two rapid tests, dual ELISA and Western blot), yielding a seroprevalence of 1.23% (95% confidence interval [CI] 0.61%-1.8%). Of the 15 HIV test-positive women, four (27%) had presented with reported HIV status, and 11 (73%) new cases of HIV infection were detected due to rapid testing in the labor room. Thus, 11 HIV-positive women received PMTCT interventions on account of round-the-clock rapid HIV testing and counseling in the labor room. While both OraQuick tests (oral and finger-stick) were 100% specific, one false-negative result was documented (with both oral fluid and finger-stick specimens). Of the 15 HIV-infected women who delivered, 13 infants were HIV seronegative at birth and at 1 and 4 mo after delivery; two HIV-positive infants died within a month of delivery. In a busy rural labor ward setting in India, we demonstrated that it is feasible to introduce a program of round-the-clock rapid HIV testing, including prepartum and extended postpartum counseling sessions. The data suggest that the availability of round-the-clock rapid HIV testing resulted in successful documentation of HIV serostatus in a large proportion (82%) of rural women who were unaware of their HIV status when admitted to the labor room. In addition, 11 (73%) of a total of 15 HIV-positive women received PMTCT interventions because of round-the-clock rapid testing in the labor ward. These findings are relevant for PMTCT programs in developing countries.

Tracking progress in maternal, newborn and child survival: The 2008 report
(Abstract; subscription needed for full text; Global)
New York, New York, UNICEF, 2008. 206 p. (Countdown to 2015: Maternal, Newborn and Child Sur)
Bryce J | Requejo JH
This report is intended to help policy makers and their partners assess progress and prioritise actions to reduce maternal, newborn and child mortality. Almost all the data presented can be found elsewhere, however the report adds value by collecting in one place the basic information needed to decide whether maternal and child mortality reductions can be expected in countries with the highest rates or numbers of such deaths. It adds further value by creating a context that can make policy makers, development agencies and donors more likely to notice challenges to progress and to respond to them with sound decisions. Chapter 2 explains how and why the Countdown priority countries were selected, and summarises the selection of Countdown indicators and the data sources and methods used to track progress. Chapter 3 summarises the findings of the 2008 Report. Specific note is taken of countries with demonstrated progress in raising coverage levels, and areas where intensified effort is needed within and across the priority countries. Chapter 4 introduces the individual country profiles. These profiles represent the basic information to be analysed at Countdown conferences, and evidence for assessing progress since the first Countdown Report in 2005. Each profile presents the most recent available information on selected demographic measures of maternal, newborn and child survival and nutritional status, coverage rates for priority interventions, and selected indicators of equity, policy support, human resources and financial flows.

POPULATION/FERTILITY/DEMOGRAPHY NEWS

Vietnam: Gender imbalance at alarming stage
(News Article; Asia)
13 May 2008
Vietnam News Agency

Africa's greatest challenge is to reduce fertility
(News Article; Sub-Saharan Africa)
12 May 2008
Financial Times

Uganda: Population to hit 43 million in 2017
(News Article; Sub-Saharan Africa)
11 May 2008
New Vision

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

The graying of the great powers: Demography and geopolitics in the 21st century
(Report; Global)
Washington, D.C., Center for Strategic and International Studies [CSIS], 2008. 184 p. (Advance Proofs)
Jackson R | Howe N | Strauss R | Nakashima K
This report explores the geopolitical implications of "global aging"-the dramatic demographic transformation in population age structures and growth rates being brought about by falling fertility and rising longevity worldwide. Its viewpoint is that of the United States in particular and today's developed countries in general. Its timeframe is roughly the next half-century, from today through 2050. The report assesses how population aging and population decline in the developed world may affect the ability of the United States and its traditional allies to maintain national and global security. The analysis not only considers the impact of the demographic trends on population numbers, wealth, and defense capability, it also explores how they could change the temperament of society (by affecting risk tolerance, voter behavior, job mobility, religious extremism, and family structure) - and thus change national goals themselves. The report also looks closely at how demographic trends in the developing world will shape the future global security environment-and the threats and opportunities they pose for today's graying great powers. This overview summarizes the report's main findings under two headings: findings about the demographic transformation and findings about its geopolitical implications. It also lays out the organization of the report and summarizes the ground covered in the different chapters.

Hepatitis B does not explain male-biased sex ratios in China
(Working Paper; Asia)
Cambridge, Massachusetts, National Bureau of Economic Research, 2008 Apr. 12 p. (NBER Working Paper No. 13971)
Oster E | Chen G | Yu X | Lin W
Earlier work (Oster, 2005) has argued, based on existing medical literature and analysis of cross country data and vaccination programs, that parents who are carriers of hepatitis B have a higher offspring sex ratio (more boys) than non-carrier parents. Further, since a number of Asian countries, China in particular, have high hepatitis B carrier rates, Oster (2005) suggested that hepatitis B could explain a large share { approximately 50% - of Asia's "missing women". Subsequent work has questioned this conclusion. Most notably, Lin and Luoh (2008) use data from a large cohort of births in Taiwan and find only a very tiny effect of maternal hepatitis carrier status on offspring sex ratio. Although this work is quite conclusive for the case of mothers, it leaves open the possibility that paternal carrier status is driving higher sex offspring sex ratios. To test this, we collected data on the offspring gender for a cohort of 67,000 people in China who are being observed in a prospective cohort study of liver cancer; approximately 15% of these individuals are hepatitis B carriers. In this sample, we find no effect of either maternal or paternal hepatitis B carrier status on offspring sex. Carrier parents are no more likely to have male children than non-carrier parents. This finding leads us to conclude that hepatitis B cannot explain skewed sex ratios in China.

World Fertility Patterns 2007. [Wallchart]
(Chart; Global)
New York, New York, United Nations, 2008 Jan. 2 p. (ST/ESA/SER.A/269)
The last decades of the twentieth century witnessed a major transformation in world fertility: total fertility fell from an average of 4.5 children per woman in 1970-1975 to 2.6 children per woman in 2000-2005. This change was driven mostly by developing countries whose fertility dropped by nearly half (from 5.4 to 2.9 children per woman) with the decline being less marked among the least developed countries where fertility remains high (their average fertility declined from 6.6 children per woman in 1970-1975 to 5.0 in 2000-2005). This chart presents some of the data available to assess the change in fertility taking place in the countries of the world. For each of the 195 countries or areas with at least 100,000 inhabitants in 2007, it displays available unadjusted data on total fertility, age-specific fertility and the mean age at childbearing for two points in time: the first as close as possible to 1970 and the second as close as possible to 2005. Data on total fertility for the world as a whole, the development groups and major areas are estimates referring to 1970-1975 and 2000-2005 derived from the 2006 Revision of World Population Prospects. The chart thus presents regional estimates of fertility change and part of the basic data underlying those estimates.

Calendar of Events

See All Events

May 27, 2008
Reception with Private Sector Leaders in Community Health
The Abt Associates' Private Sector Health Practice cordially invites you to meet with private health sector leaders to share and exchange experiences about improving community health in developing countries. When: May 27, 2008, 6:30 - 8:00 pm Where: Diplomat Ballroom, Omni Shoreham Hotel, Washington, DC RSVP: Send an email to RSVP@psp-one.com Refreshments and hors d'oeuvres will be served Special Guests Include: Nils Daulaire, President, Global Health Council Rihanna Kola, Director, Global HIV/AIDS Programs, Merck & Co. Dr. Berangere Magarinos, Senior Manager, Investments and Partnerships Program, Global Alliance for Improved Nutrition Paul Meyer, Co-Founder Chairman and President, Voxiva Tessie San Martin, Group Vice President, International, Abt Associates Sanjeev Vyas, Program Director, PSP-One India/Abt Associates Hope to see you there! Please note Global Health Council Conference registration is required for attendance.
E-Mail: RSVP@psp-one.comEvent Location: Washington, D.C.

May 27, 2008
The Private Sector: An Essential Resource for Community Health
USAID's PSP-One project, led by Abt Associates, invites you to attend our expert panel event at this year's Global Health Council Conference. When: May 27, 2008, 1:00 - 4:45 pm Where: Diplomat Ballroom, Omni Shoreham Hotel, Washington, DC RSVP: Send an email to RSVP@psp-one.com Registration and Lunch: 12:30 - 1:00 pm (A boxed lunch will be provided on a first come basis) Presentations and Panelists: * Filipino Midwives Reaching out to Communities Patricia Gomez, President, Integrated Midwives Association, Philippines * Tapping the Potential of Traditional Providers to Enhance Access to Reproductive Health Services Sanjeev Vyas, Program Director, PSP-One India/Abt Associates * Harnessing IT for Community Health Paul Meyer, Co-Founder, Chairman and President, Voxiva * Enabling Communities to Improve Health: Two African HIV/AIDS Case Studies Rihanna Kola, Director, Global HIV/AIDS Programs, Merck & Co. * Business Strategies for Reaching the Poor Dr. Berangere Magarinos, Senior Manager, Investments and Partnerships Program, Global Alliance for Improved Nutrition
E-Mail: RSVP@psp-one.comEvent Location: Washington, D.C.

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Volume 8, Number 2019 May 2008