Volume 8, Number 22
3 June 2008

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ADOLESCENT HEALTH RESEARCH

Factors influencing teen mothers' enrollment and participation in prevention of mother-to-child HIV transmission services in Limpopo Province, South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Qualitative Health Research. 2008;18(6):786-802.
Varga C | Brookes H
In this article, we examine barriers to HIV testing uptake and participation in prevention of mother-to-child HIV transmission (PMTCT) services among adolescent mothers aged 15 to 19 years in rural and urban Limpopo Province, South Africa. We used the narrative research method involving key informants constructing typical case studies of adolescent experiences with HIV testing and entry into PMTCT. Case studies formed the basis of a community-based questionnaire and focus group discussions with adolescent mothers. Client-counselor dynamics during pretest counseling were pivotal in determining uptake and participation, and counselor profile strongly influenced the nature of the interaction. Other factors found to influence adherence to PMTCT recommendations included HIV and early premarital pregnancy stigma, fear of a positive test result, and concerns over confidentiality and poor treatment by health care providers. Adolescents described elaborate strategies to avoid HIV disclosure to labor and delivery staff, despite knowing this would mean no antiretroviral therapy for their newborn infants. Theoretical, methodological, and programmatic implications of study findings are also discussed.

Reasons for multiple sexual partnerships: Perspectives of young people in Zambia
(Abstract; subscription needed for full text; Sub-Saharan Africa)
African Journal of AIDS Research. 2008 May;7(1):37-44.
Nshindano C | Maharaj P
Epidemiological evidence so far suggests that multiple sexual partnerships are an important factor driving the HIV epidemic. Recently, there has been renewed emphasis on fidelity and partner-reduction in preventing HIV infections. Like many countries in sub-Saharan Africa, Zambia is facing a severe HIV epidemic and young people are heavily affected. This study explores youths' perspectives on multiple sexual partnerships in the context of HIV and AIDS. The study draws on four focus group discussions and 10 in-depth interviews with university students in Lusaka, Zambia, in 2006. While the young people were generally aware of the HIV-related risk associated with multiple sexual partnerships, they felt several obstacles prevented them from changing their sexual behaviour. Of special interest are their perceptions related to socio-economic disadvantages and cultural factors.

Miscarriage but not stillbirth rates are higher among younger nulliparas in rural Southern Nepal
(Abstract; subscription needed for full text; Asia)
Journal of Adolescent Health. 2008 Jun;42(6):587-595.
Katz J | Khatry SK | LeClerq SC | Shrestha SR | West KP Jr
The purpose of this study was to examine the impact of young maternal age on miscarriages and stillbirths in rural Southern Nepal. Pregnancies, miscarriages, and stillbirths were prospectively identified in two randomized trials of maternal micronutrient supplementation. This analysis included 5861 women of parity 0 (nulliparas) and 4459 of parity 1 (primiparas) who were less than 26 years of age. Among nulliparous women, 5.7% and 4.6% of pregnancies ended in miscarriage and stillbirth. The adjusted relative risk of miscarriage was 2.07 for girls less than 15 (95% confidence interval [CI] = 1.17-3.66) compared with those 18 and 19 years, and was 1.40 (95% CI = 1.06 -1.84) among those 15-17 years. Stillbirth rates did not differ significantly by maternal age. There were no differences in miscarriage or stillbirth rates by maternal age among primiparas. Young maternal age increased the risk of miscarriages but not stillbirths for nulliparas. Miscarriages and stillbirths did not differ by maternal age for primiparous women.

Young males' gendered sexuality in the era of HIV and AIDS in Limpopo Province, South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Qualitative Health Research. 2008;18(6):739-746.
Ragnarsson A | Onya HE | Thorson A | Ekstrom AM | Aaro LE
This article is focused on young males' sexual identity and behaviors in rural South Africa. The study comprised 19 focus group discussions with adolescents aged 12 to 14 years. The informants depict male sexuality as biologically predetermined, where physical needs and practices such as circumcision legitimize early sexual debut. Furthermore, the construction of male sexual identity and power imbalances in relationships are already evident at an early age, and age and economics are pertinent factors affecting social relations. Violent behavior and sexual abuse are supported by constructed gender inequalities forming an often negative and nonsupportive environment for young people. We stress the importance of planned HIV and sexuality education for young adolescents with support structures that can help endorse individual actions and informed choices. This is especially important in resource-poor settings where young people are likely to be less empowered than is the case in more affluent settings.

FAMILY PLANNING RESEARCH

Catholics using contraceptives: Religion, family planning, and interpretive agency in rural Mexico
(Abstract; subscription needed for full text; North America)
Studies in Family Planning. 2008 Jun;39(2):93-104.
Hirsch JS
Research on how religion shapes contraceptive practices and fertility has paid insufficient attention to how people interpret religious teachings. This study draws on ethnographic fieldwork in Degollado, Mexico, to describe generational and social-contextual differences in how women interpret and use religious doctrine to achieve their fertility desires without jeopardizing their standing as devout Catholics. Contrasting the family planning beliefs and practices of young Mexican women with those of older women (many of whom are the younger women's parents and in-laws), in a rural town in which the religious regulation of everyday life is pervasive, reveals how a common set of religious teachings and principles can be used to guide two different generational strategies for fertility regulation. The ethnographic data presented here highlight the creativity with which people use religious frameworks to justify their behavior. Research exploring how religion-and culture more broadly-influences fertility and contraceptive use should give greater attention to the dynamic interplay between cultural beliefs and institutions, social context, and interpretive agency.

Progress and prospects in male hormonal contraception
(Abstract; subscription needed for full text; Global)
Current Opinion in Endocrinology, Diabetes and Obesity. 2008 Jun;15(3):255-260.
Amory JK
Testosterone functions as a contraceptive by suppressing the secretion of luteinizing hormone and follicle-stimulating hormone from the pituitary. Low concentrations of these hormones deprive the testes of the signals required for spermatogenesis and results in markedly decreased sperm concentrations and effective contraception in a majority of men. Male hormonal contraception is well tolerated and acceptable to most men. Unfortunately, testosterone-alone regimens fail to completely suppress spermatogenesis in all men, meaning that in some the potential for fertility remains. Because of this, novel combinations of testosterone and progestins, which synergistically suppress gonadotropins, have been studied. Two recently published testosterone/progestin trials are particularly noteworthy. In the first, a long-acting injectable testosterone ester, testosterone decanoate, was combined with etonogestrel implants and resulted in 80-90% of subjects achieving a fewer than 1 million sperm per milliliter. In the second, a daily testosterone gel was combined with 3-monthly injections of depot medroxyprogesterone acetate producing similar results. Testosterone-based hormone combinations are able to reversibly suppress human spermatogenesis; however, a uniformly effective regimen has remained elusive. Nevertheless, improvements, such as the use of injectable testosterone undecanoate, may lead to a safe, reversible and effective male contraceptive.

The latest advances in hormonal contraception
(Abstract; subscription needed for full text; Global)
Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2008 May-Jun;37(3):369-374.
Fontenot HB | Harris AL
Millions of women each year start or continue to use some type of hormonal contraceptive method. Choosing a method may be anxiety provoking. In this article, we review some of the latest advances in and options for hormonal contraception, including extended-dose oral contraceptives, the vaginal ring, injectable methods, and emergency contraception. Nurses can facilitate women's decision making for healthy reproductive options.

New options for barrier contraception
(Abstract; subscription needed for full text; Global)
Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2008 May-Jun;37(3):384-389.
Yranski PA | Gamache ME
Barrier contraceptives are a safe alternative to hormonal methods of fertility management. Newer barrier method options include the Today Sponge, the FemCap, and the Lea's Shield. Understanding the use, benefits, and limitations of these barrier methods of birth control will assist women's health care providers to better meet the family planning needs of their patients.

IUD use and discontinuation in Bangladesh
(Report; Asia)
New York, New York, EngenderHealth, ACQUIRE Project, 2007 Nov. [80] p. (Array)
Mahboob-E-Alam | Bradley J | Shabnam F
The ACQUIRE Project is a five-year cooperative agreement awarded by the U.S. Agency for International Development (USAID). Building on an earlier project focusing on long-term and permanent methods of family planning (LAPMs), ACQUIRE has undertaken a number of interventions in collaboration with the Directorate General of Family Planning (DGFP) since 2001 to support the Bangladesh Government's National Population Policy. One aspect of the ACQUIRE Project has been to rebuild capacity for LAPM service delivery within the public sector. Awareness of the intrauterine device (IUD) as a long-term contraceptive method is fairly high among married women (89.6%) and married men (69.5%) in Bangladesh. The current use of IUDs, however, remains low (0.6%) compared with the use of other modern methods. According to the recent Bangladesh Demographic and Health Survey (BDHS), contraceptive discontinuation rates are very high for all methods in Bangladesh: About half of Bangladeshi couples discontinue their family planning method within one year, a rate much higher than in other countries in the Asian region. Worldwide, discontinuation rates for the IUD are generally lower than for other modern methods, yet the 12-month IUD discontinuation rate in Bangladesh was reported to be 35.4% in 2004, not much lower than that of oral contraceptives (46.5%) and injectables (48.7%). The majority of Bangladeshi IUD users (63.7%) state that side effects and health concerns are the major reasons behind method-specific IUD discontinuation (NIPORT, Mitra and Associates, and ORC Macro, 2005). The study's overall objectives were to quantify the outcomes of IUD use 12 months after insertion and to examine factors associated with IUD discontinuation in six districts of Bangladesh. Specific objectives were to examine: the sociodemographic characteristics of IUD acceptors and discontinuers; the outcome of IUD use among IUD acceptors within the first 12 months and the reasons given for discontinuation; common side effects, how they were experienced by both continuers and discontinuers, and factors associated with experience with and tolerance of those side effects; key determinants of discontinuation; and preinsertion and postinsertion health-sector support for IUD clients.

GENDER and HEALTH RESEARCH

Emergency obstetric care in Punjab, Pakistan: Improvement needed
(Abstract; subscription needed for full text; Asia)
European Journal of Contraception and Reproductive Health Care. 2008 Jun;13(2):201-207.
Ali M | Ahmed KM | Kuroiwa C
This paper describes an approach to maternal mortality reduction in Pakistan that uses UN emergency obstetric care (EmOC) process indicators to examine if public health care centres in Pakistan's Punjab province comply with minimum recommendations for basic and comprehensive services. In a cross sectional study in September 2003, through random sampling at area and health-facility levels from 30% of districts in Punjab province (n = 11/34 districts), all public health facilities providing EmOC were included (n = 120). Facility data were used for analysis. No district in Punjab met the minimum standards laid down by the UN for providing EmOC services. The number of facilities providing basic and comprehensive EmOC services fell far short of recommended levels. Only 4.7% of women with complications attended hospitals. Caesarean section was carried out in only 0.4% of births. The case fatality rate was hard to accurately calculate due to poor record keeping and data quality. The study may be taken as a baseline for developing and improving the standards of services in Punjab province. It is vital to upgrade existing basic EmOC facilities and to ensure that staff skills be improved, facilities be better equipped in critical areas, and record keeping be improved. Hence to reduce maternal mortality, facilities for EmOC must exist, be accessible, offer quality services, and be utilized by patients with complications.

Intimate partner violence and interference with women's efforts to avoid pregnancy in Jordan
(Abstract; subscription needed for full text; Middle East)
Studies in Family Planning. 2008 Jun;39(2):123-132.
Clark CJ | Silverman J | Khalaf IA | Ra'ad BA | Al Sha'ar ZA
This study examines the association between intimate partner violence (IPV) and women's experience of interference with their attempts to avoid pregnancy among 353 women surveyed at reproductive health clinics throughout Jordan. Approximately 20 percent of respondents indicated that their husbands or someone else had interfered. Among those others than husbands who were identified, mothers-in-law were the most frequently mentioned, followed by the respondents' mothers and sisters-in-law. Multivariate logistic regression was used to control for potential confounders in determining whether each of the three measures of intimate partner violence (physical violence, sexual violence, and controlling behaviors) was significantly associated with having an increased risk of experiencing interference, as were several sociodemographic variables: nonconsanguineous marriage, residence with in-laws, and rural residence. Physicians, nurses, and family planning counselors must be made aware of the challenges that women may face from their families when they attempt to regulate their fertility.

Innate immunity and disorders of the female reproductive tract
(Abstract; subscription needed for full text; Asia)
Reproduction. 2008 Jun;135(6):739-749.
Horne AW | Stock SJ | King AE
Sexually transmitted infections, and their associated sequelae, such as tubal infertility, ectopic pregnancy and preterm labour, are a major worldwide health problem. Chlamydia trachomatis infection is thought to be the leading global cause of tubal infertility and tubal ectopic pregnancy. Preterm birth occurs in around 10% of all deliveries, and nearly 30% of preterm deliveries are associated with intrauterine infection. The mucosal innate immune system of the female reproductive tract has evolved to eliminate such sexually transmitted pathogens whilst maintaining its ability to accommodate specialized physiological functions that include menstruation, fertilization, implantation, pregnancy and parturition. The aim of this review was to describe the role and distribution of key mediators of the innate immune system, the natural antimicrobial peptides (secretory leukocyte protease inhibitor, elafin and the defensins) and the pattern recognition toll-like receptors in the normal female reproductive tract and in the context of these pathological processes.

Where do they go, whom do they consult, and why? Health-seeking behaviors in the northern areas of Pakistan
(Abstract; subscription needed for full text; Asia)
Qualitative Health Research. 2008;18(6):747-755.
Shaikh BT | Haran D | Hatcher J
This study presents an ethnographic account of health-seeking behaviors and determinants of health service utilization of people living in the rural Northern Areas of Pakistan. Data was gathered from 2004 to 2005 through 10 gender-specific focus group discussions. Sociodemographic characteristics, economic conditions, cultural forces, physical and environmental conditions, and health care service features form the behaviors. The complex composition of health care systems drives us to study the most intricate phenomenon of health care-seeking behaviors. Inappropriate or delayed health care-seeking could lead to undesirable health outcomes, high fertility, unwanted pregnancies, medical complications, and amplified susceptibility to future illnesses. At times it results in a significant economic burden when a simple illness becomes drawn out because of improper health-seeking behaviors. This study is an effort to present relevant information to the policy makers to reorient the health care services to make them more acceptable. It is recommended that this research be used for designing behavior change communication modules or social marketing campaigns in raising awareness about health in the community and sensitizing health care providers to the needs of their clients.

REV1 genetic variants associated with the risk of cervical carcinoma
(Abstract; subscription needed for full text; Global)
European Journal of Epidemiology. 2008 Jun;23(6):403-409.
He X | Ye F | Zhang J | Cheng Q | Shen J
The purpose of this study was to explore the REV1 genetic variants effects on the risk of cervical carcinoma. A total of 543 cases, including 282 carcinoma and 261 CIN, and 480 normal controls were performed. Two single nucleotide polymorphisms (SNPs) (REV1 Phe257Ser and REV1 Asn373Ser) were genotyped by PCR-sequencing, and analysis the correlation to clinical character including HPV infection. Compared with the REV1 Phe257Ser, women carrying Ser257Ser and Phe257Ser genotypes had a significantly decreased the risk for cervical carcinoma or cervical squamous cell carcinoma. On contrary, homozygous Ser373Ser increased the risk for carcinoma. In addition, we found that the association of Phe257Ser and Asn373Ser with the risk for cervical carcinoma was specific to squamous cell carcinomas and not relevant for adenocarcinoma. Our results suggest that women carry Phe257Ser variant genotype decrease the risk for cervical carcinoma, more in women that have high-risk sexual reproductive histories, when women who carried Asn373- Ser variant genotype and had high-risk sexual and reproductive histories had a significantly elevated risk for cervical carcinoma. Our results support Phe257Ser and Ser257Ser genotypes are associated with a decreased risk for cervical carcinoma, while Asn373Ser and Ser373Ser genotypes increased the risk. In addition, the effects were more significant in the groups with high risk sexual and reproductive histories.

HIV/AIDS and STIs RESEARCH

A systematic review on the meaning of the concept 'AIDS Orphan': Confusion over definitions and implications for care
(Abstract; subscription needed for full text; Global)
AIDS Care. 2008 May;20(5):527-536.
Sherr L | Varrall R | Mueller J | Richter L | Wakhweya A
Global publications on the international AIDS epidemic report on the existence of an ever-increasing number of orphans and vulnerable children. It has been suggested that by the end of this decade there will be in excess of 25 million AIDS orphans globally, an issue which will require understanding and organisation of long-term medical, psychological and social support. This study provides a systematic review to examine the use, overuse and misuse of the term orphan and explores the benefits and limitations of this approach. It then summarises the knowledge on orphans to date. Using a search strategy of published studies and recent conference abstracts, 383 papers were identified where the concept of AIDS and Orphan was raised. The papers were systematically coded and reviewed to understand when and how a child is labelled an orphan, and to summarise the effect of orphanhood on outcome measures, most notably psychologically and physically. All controlled studies published prior to 2006 were reviewed. A consistent picture of negative effects of parental death (however defined) on a wide range of physical, socioeconomic and psychological outcomes were recorded. Seventeen studies met criteria for in-depth review (empirical, fully published, control group). The majority of studies are cross-sectional (two are longitudinal) and employ a very wide array of measures - both standardised and study specific. This detailed analysis shows a mixed picture on outcome. Although most studies report some negative effects, there are often no differences and some evidence of protective effects from quality of subsequent care and economic assistance. The lack of consistent measures and the blurring of definitions are stumbling blocks in this area.

Costing adult male circumcision in high HIV prevalence, low circumcision rate countries
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS Care. 2008 May;20(5):515-520.
Fieno JV
The dramatic evidence that male circumcision has a substantial effect in preventing HIV infection might be the most important medical finding in the course of the AIDS epidemic since the introduction of highly active antiretroviral therapy (HAART). The transition from clinical trails to implementation of a general adult male circumcision (AMC) program is beginning, and this paper uses an AMC cost model (in Microsoft Excel) to estimate the cost of a rapid scale-up of an AMC program in Mozambique, a country with a generalized epidemic and low rate of male circumcision. There are three major findings: (1) Even the most modest of AMC programs would place great stress on human resources, and task-shifting might lead to more accidents or adverse events that would increase the cost per AMC. (2) The fiscal burden of AMC is surprisingly low, but a rapid scale-up of AMC poses additional fiscal stress for Mozambique's already under-funded public health system. (3) AMC as an HIV prevention tool is very robust in terms of its cost-effectiveness in Mozambique, even at a high AMC accident or complication rate. Any AMC roll-out in Mozambique would face severe constraints in the health system (namely human resources) that would likely limit the scale of an AMC program and perhaps its effectiveness against its generalized epidemic.

Perceived influence of an HIV vaccine on sexual-risk behaviour in the Dominican Republic
(Abstract; subscription needed for full text; Central America and the Caribbean)
Culture, Health and Sexuality. 2008 May;10(4):391-401.
Barrington C | Moreno L | Kerrigan D
This study explored local perceptions regarding the potential influence of an HIV vaccine on sexual risk behaviours in Santo Domingo, Dominican Republic. Qualitative in-depth interviews were carried out with 25 participants, including 15 women and 10 men. Approximately half of the male study participants stated that they would increase their number of sexual partners and/or would not use condoms if they received an HIV vaccine. In contrast, women reported that they would be unlikely to change their own behaviour, but stated that an HIV vaccine would allow them to worry less about the sexual-risk behaviour of their male partners. Our findings suggest the need to utilize existing HIV prevention programmes to support future HIV vaccine research and distribution efforts and minimize increased risk behaviour. Such efforts should actively assess and address the role of culturally-defined gender norms on behavioural responses to the introduction of HIV vaccines.

Natural history and risk factors associated with early and established HIV type 1 infection among reproductive-age women in Malawi
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Clinical Infectious Diseases. 2008 Jun;46(12):1913-1920.
Kumwenda JJ | Makanani B | Taulo F | Nkhoma N | Kafulafula G
Data evaluating the biological events and determinants of early human immunodeficiency virus type 1 (HIV-1) infection are limited in sub-Saharan Africa. We examined plasma viral levels and trends during early and established HIV-1 infection among reproductive-age women who participated in a randomized trial to treat genital tract infection in Malawi. We also assessed the association of injectable hormonal contraceptive use with HIV-1 infection. We studied 3 groups of women who were infected or uninfected with HIV-1: seroconverters, seroprevalent women, and seronegative women. Questionnaires and blood samples were collected at baseline and every 3 months for 1 year. The virus set point in seroconverters and levels and trends of viral load over time were determined. The associations of injectable hormonal contraceptive use with HIV-1 infection and viral load were assessed using conditional logistic regression and mixed-effect models, respectively. In the original clinical trial, 844 women infected with HIV-1 and 842 women not infected with HIV- 1 were enrolled. Of 31 women who experienced seroconversion during 12 months, 27 were matched with 54 seroprevalent and 54 seronegative women. The estimated median plasma virus set point was 4.45 log10 copies/mL (interquartile range, 4.32-5.14 log10 copies/mL). Injectable hormonal contraceptive use was significantly associated with HIV-1 seroconversion (adjusted odds ratio, 10.42; Pp.03) but not with established HIV-1 infection. Among the seroconverters, a statistically significant interaction was found between the linear association of viral load and time of injectable hormonal contraceptive use (regression coefficient, _0.14; Pp.02). Knowledge of virus set point and trends of viral load in HIV-1 seroincident and seroprevalent asymptomatic women could assist in antiretroviral treatment management.

HIV and AIDS: Responding to a threat to education for sustainable development
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Natural Resources Forum. 2008 May;32(2):142-151.
Allemano E
The article seeks to sensitize the development community, particularly outside the education sector, about the issues surrounding education as a vehicle for promoting sustainable development in an AIDS environment in Africa. By illustrating how the epidemic impacts education sector staff as well as parents and students at all levels, the article intends to suggest how national authorities, NGOs and donor agencies can work out strategies to enhance the role of education in promoting sustainable development in Africa. Analysis will demonstrate how the AIDS epidemic weakens the education sector, particularly in countries with a generalized epidemic (defined as more than 3% of the adult population being HIV-positive), undermining the sector's ability to contribute to general literacy and sustainable development. The article will demonstrate that HIV and AIDS is still not fully accepted as an educational issue, which has hampered efforts to deal with its ravages in the educational sector. The need for holistic policy frameworks for supporting teachers and administrators living with HIV and AIDS will be discussed as well as how changes in curriculum and better relations with the community are important in addressing the needs of students. The article will highlight options for developing innovative responses to HIV and AIDS in African education, showing how different forms of education can serve as vehicles for responding to the challenges of the epidemic. The examples emphasize the importance of learner-centered instruction and partnerships with the health sector and other resources needed in an AIDS-affected environment. Key messages of the article are that the HIV and AIDS epidemic is a multi-sectoral problem and that responding to it effectively in the education sector requires coherent responses that address the needs of learners and instructors, including those who are personally affected or infected by HIV and AIDS. Adapting the Education for Sustainable Development initiative to address the challenges posed by the epidemic must be supported by policy development, leadership and advocacy. Diverse partnerships are essential, as the education sector alone cannot deal with the challenge of HIV and AIDS to sustainable development.

MATERNAL AND CHILD HEALTH RESEARCH

Measuring maternal mortality: An overview of opportunities and options for developing countries
(Research Article; Global)
BMC Medicine. 2008 May 26;6:12.
Graham WJ | Ahmed S | Stanton C | Abou-Zahr | Campbell OM
There is currently an unprecedented expressed need and demand for estimates of maternal mortality in developing countries. This has been stimulated in part by the creation of a Millennium Development Goal that will be judged partly on the basis of reductions in maternal mortality by 2015. Since the launch of the Safe Motherhood Initiative in 1987, new opportunities for data capture have arisen and new methods have been developed, tested and used. This paper provides a pragmatic overview of these methods and the optimal measurement strategies for different developing country contexts. There are significant recent advances in the measurement of maternal mortality, yet also room for further improvement, particularly in assessing the magnitude and direction of biases and their implications for different data uses. Some of the innovations in measurement provide efficient mechanisms for gathering the requisite primary data at a reasonably low cost. No method, however, has zero costs. Investment is needed in measurement strategies for maternal mortality suited to the needs and resources of a country, and which also strengthen the technical capacity to generate and use credible estimates. Ownership of information is necessary for it to be acted upon: what you count is what you do. Difficulties with measurement must not be allowed to discourage efforts to reduce maternal mortality. Countries must be encouraged and enabled to count maternal deaths and act.

Prospective community-based cluster census and case-control study of stillbirths and neonatal deaths in the West Bank and Gaza Strip
(Abstract; subscription needed for full text; Middle East)
Paediatric and Perinatal Epidemiology. 2008;:1-13.
Kalter HD | Khazen RR | Barghouthi M | Odeh M
Obstetric complications and newborn illnesses amenable to basic medical interventions underlie most perinatal deaths. Yet, despite good access to maternal and newborn care in many transitional countries, perinatal mortality is often not monitored in these settings. The present study identified risk factors for perinatal death and the level and causes of stillbirths and neonatal deaths in the West Bank and Gaza Strip. Baseline and follow-up censuses with prospective monitoring of pregnant women and newborns from September 2001 to August 2002 were conducted in 83 randomly selected clusters of 300 households each. A total of 113 of 116 married women 15-49 years old with a stillbirth or neonatal death and 813 randomly selected women with a surviving neonate were interviewed, and obstetric and newborn care records of women with a stillbirth or neonatal death were abstracted. The perinatal and neonatal mortality rates, respectively, were 21.2 [95% confidence interval (CI) 16.5, 25.9] and 14.7 [95% CI 10.2, 19.2] per 1000 livebirths. The most common cause (27%) of 96 perinatal deaths was asphyxia alone (21) or with neonatal sepsis (5), while 18/49 (37%) early and 9/19 (47%) late neonatal deaths were from respiratory distress syndrome (12) or sepsis (9) alone or together (6). Constraint in care seeking, mainly by an Israeli checkpoint, occurred in 8% of pregnancies, 9% of labours and 31% of neonates prior to perinatal or late neonatal death. Poor quality care for a complication associated with the death was identified among 40% of pregnancies, 20% of labour/deliveries and 43% of neonates. Risk factors for perinatal death as assessed by multivariable logistic regression included preterm delivery (odds ratio [OR] = 11.9, [95% CI 6.7, 21.2]), antepartum haemorrhage (OR = 5.6, [95% CI 1.5, 20.9]), any severe pregnancy complication (OR = 3.4, [95% CI 1.8, 6.6]), term delivery in a government hospital and having a labour and delivery complication (OR = 3.8, [95% CI 1.2, 12.0]), more than one delivery complication (OR = 4.4, [95% CI 1.8, 10.5]), mother's age greater than 35 years (OR = 2.9, [95% CI 1.3, 6.8]) and primiparity in a full-term pregnancy (OR = 2.6, [1.1, 6.3]). Stillbirths are not officially reportable in the West Bank and Gaza Strip and this is the first time that perinatal mortality has been examined. Interventions to lower stillbirths and neonatal deaths should focus on improving the quality of medical care for important obstetric complications and newborn illnesses. Other transitional countries can draw lessons for their health care systems from these findings.

Uptake of voluntary counselling and testing for HIV by pregnant women in a prevention-of-mother-to-child-transmission programme at Aminu Kano Teaching Hospital, Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
African Journal of AIDS Research. 2008 May;7(1):143-148.
Galadanci HS | Iliyasu Z | Tukur J | Muktar-Yola M | Adeleke SI
Mother-to-child transmission is the main mode of HIV infection among children in developing countries. In 2003, as a result of government policy, a prevention-of-mother-to-child-transmission (PMTCT) programme was introduced at Aminu Kano Teaching Hospital in Nigeria. The aim of this study was to determine the pattern of voluntary counselling and testing (VCT) uptake and HIV seroprevalence among pregnant women using the service. VCT has become part of routine antenatal care at the hospital; in addition, antiretroviral prophylaxis/treatment, modification of obstetric practices, and counselling on infant feeding options are provided for HIV-positive pregnant women. Data on clients? socio-demographic characteristics, VCT uptake, and HIV seropositivity for a three-year period (from January 2004 to December 2006) were taken from nationally prepared PMTCT registers kept at the hospital, and prospectively entered into a database. During the period, 6,887 women newly accessed antenatal care (i.e. repeat pregnancies were excluded). All the women were group counselled, and 6 702 (97.3%) agreed to undergo HIV testing. Overall HIV prevalence among these pregnant women for the study period was 5.9% (95% CI 5.2-6.3%). The data have shown a statistically significant trend of rising HIV prevalence in this group: at 4.5%, prevalence was lowest in 2004; rose to 4.9% in 2005; and peaked at 7.6% in 2006 ( 2 trend = 21.9; p less than 0.001). Overall HIV seroprevalence was 3.5% among 15- to 19-year-old women, 7% among 25- to 29-year-old women, and 4.5% among women over age 40. There was an inverse relationship between parity (number of children borne) and HIV seroprevalence such that women of low parity had high HIV prevalence, and vice versa ( 2 trend = 13.1; p less than 0.01). Respectively, 11.4%, 5.7%, and 5.5% of the pregnant women first using VCT in the first, second, and third trimesters of their pregnancy were found to be HIV-positive. All women testing HIV-positive were informed of their serostatus and the modes of preventing mother-to-child transmission of HIV. There is a relatively high uptake of VCT for PMTCT at this tertiary hospital, while an increasingly higher proportion of HIV-positive pregnant women are being identified and provided with opportunities to prevent HIV transmission to their babies. PMTCT should be universally accessible to women in developing countries.

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (Review)
(Abstract; subscription needed for full text; Global)
Cochrane Database of Systematic Reviews. 2008 Apr 16;(2):1-76.
McDonald SJ | Middleton P
Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord greater than one minute after the birth or when cord pulsation has ceased. The objective of this study was to determine the effects of different policies of timing of cord clamping at delivery of the placenta on maternal and neonatal outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2007), with a selection criteria of randomised controlled trials comparing early and late cord clamping. Two review authors independently assessed trial eligibility and quality and extracted data. We included 11 trials of 2989 mothers and their babies. No significant differences between early and late cord clamping were seen for postpartum haemorrhage or severe postpartum haemorrhage in any of the five trials (2236 women) which measured this outcome (relative risk (RR) for postpartum haemorrhage 500 mls or more 1.22, 95% confidence interval (CI) 0.96 to 1.55). For neonatal outcomes, our review showed both benefits and harms for late cord clamping. Following birth, there was a significant increase in infants needing phototherapy for jaundice (RR 0.59, 95% CI 0.38 to 0.92; five trials of 1762 infants) in the late compared with early clamping group. This was accompanied by significant increases in newborn haemoglobin levels in the late cord clamping group compared with early cord clamping (weighted mean difference 2.17 g/dL; 95%CI 0.28 to 4.06; three trials of 671 infants), although this effect did not persist past six months. Infant ferritin levels remained higher in the late clamping group than the early clamping group at six months.

Maternal mortality in Bahrain 1987 - 2004: An audit of causes of avoidable death
(Research Article; Middle East)
Eastern Mediterranean Health Journal. 2008 May-Jun;14(3):720-730.
Sandhu AK | Mustafa Fe
The aim of this report was to establish the national maternal mortality rate in Bahrain over the period 1987-2004, to identify preventable factors in maternal deaths and to make recommendations for safe motherhood. There were 60 maternal deaths out of 243 232 deliveries giving an average maternal mortality rate of 24.7 per 100 000 total births. The main causes of death were sickle-cell disease (25.0%), hypertension (18.3%), embolism (13.3%), haemorrhage (13.3%), heart disease (11.7%), infection (8.3%) and other (10.0%). In an audit of care, 17 (28.3%) out of 60 deaths were judged to be avoidable, nearly half of which were due to a shortage of intensive care beds. We recommend that a confidential enquiry of maternal deaths be conducted at the national level every 3 to 5 years.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Population survey sampling methods in a rural African setting: Measuring mortality
(Research Article; Sub-Saharan Africa)
Population Health Metrics. 2008 May 20;6:2.
Fottrell E | Byass P
Population-based sample surveys and sentinel surveillance methods are commonly used as substitutes for more widespread health and demographic monitoring and intervention studies in resource-poor settings. Such methods have been criticised as only being worthwhile if the results can be extrapolated to the surrounding 100-fold population. With an emphasis on measuring mortality, this study explores the extent to which choice of sampling method affects the representativeness of 1% sample data in relation to various demographic and health parameters in a rural, developing-country setting. Data from a large community based census and health survey conducted in rural Burkina Faso were used as a basis for modelling. Twenty 1% samples incorporating a range of health and demographic parameters were drawn at random from the overall dataset for each of seven different sampling procedures at two different levels of local administrative units. Each sample was compared with the overall 'gold standard' survey results, thus enabling comparisons between the different sampling procedures. All sampling methods and parameters tested performed reasonably well in representing the overall population. Nevertheless, a degree of variation could be observed both between sampling approaches and between different parameters, relating to their overall distribution in the total population. Sample surveys are able to provide useful demographic and health profiles of local populations. However, various parameters being measured and their distribution within the sampling unit of interest may not all be best represented by a particular sampling method. It is likely therefore that compromises may have to be made in choosing a sampling strategy, with costs, logistics the intended use of the data being important considerations.

Constant global population with demographic heterogeneity
(Research Article; Global)
Demographic Research. 2008 May 27;18(14):409-436.
Cohen JE
To understand better a possible future constant global population that is demographically heterogeneous, this paper analyzes several models. Classical theory of stationary populations generally fails to apply. However, if constant global population size P(global) is the sum of all country population sizes, and if constant global annual number of births B(global) is the sum of the annual number of births of all countries, and if constant global life expectancy at birth e(global) is the population-weighted mean of the life expectancy at birth of all countries, then B(global) · e(global) always exceeds P(global) unless all countries have the same life expectancy at birth, in which case B(global) · e(global) = P(global).

Fertility transitions in developing countries: Progress or stagnation?
(Abstract; subscription needed for full text; Global)
Studies in Family Planning. 2008 Jun;39(2):105-110.
Bongaarts J
Over the past quarter-century, fertility has declined rapidly in many developing countries. Projections typically assume that this trend will continue until replacement level is reached. Recent evidence suggests, however, that ongoing fertility declines may have slowed or stalled in a number of countries in transition. This study examines the pace of fertility change in developing countries that have multiple Demographic and Health Surveys to determine whether ongoing transitions are decelerating or stalling. The main findings are that in sub-Saharan African countries, the average pace of decline in fertility was lower around 2000 than in the mid-1990s and that more than half the countries in transition in this region have stalled.

Further support for the hypothesis that parental hormone levels around the time of conception are associated with human sex ratios at birth
(Abstract; subscription needed for full text; Global)
Journal of Biosocial Science. 2008;:1-7.
James WH
During the past year, data have been published on the offspring sex ratios of people diagnosed with toxoplasmosis, hepatitis B, and pre- and post-menopausal breast cancer. It is shown here how these offspring sex ratios constitute further support for the hypothesis that mammalian (including human) parental hormone concentrations around the time of conception partially control the sexes of the resulting infants. If this interpretation were correct, then hormonal treatments might be considered for some or all of these conditions. It is intended that anyone who has read the present note and my two previous papers (James, 1996, 2004) should be aware of all the data relating to the hypothesis.

Sexual and reproductive health in the Middle East and North Africa: A guide for reporters
(Report; North Africa | Middle East)
Washington, D.C., Population Reference Bureau [PRB], 2008. 84 p.
Roudi-Fahimi F | Ashford L
Sexual and reproductive health is a broad concept encompassing health and well-being in matters related to sexual relations, pregnancies, and births. It deals with the most intimate and private aspects of people's lives, which can be difficult to write about or discuss publicly, particularly in the Middle East and North Africa (MENA) region. Cultural sensitivities and taboos surrounding sexuality are particularly pronounced in the MENA region, and make the role of the media vital in providing objective information about sexual and reproductive health matters. The media has the power to break the culture of silence that surrounds sexual and reproductive health, a silence that all too often prevents people from seeking information and care and prevents governments from putting the issues on their development agendas. This guide aims to bring together the latest available data on sexual and reproductive health for countries in the MENA region, to help journalists educate the public and make the case for policymakers that poor sexual and reproductive health contributes to social inequalities and hinders social and economic development.

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