Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 28, Number 1, March 2002
UPDATE


FOR EMERGENCIES ONLY

Indian women who receive a supply of emergency contraception in addition to information about the method are no more likely than women who receive only information to have unprotected intercourse.1 Between 1997 and 2000, researchers recruited 411 women who used condoms from a family planning clinic in Pune, India. Women randomly received either information about emergency contraception--including where to obtain it and how to use it--or information and a three-course supply of emergency contraception. Of the 366 women who remained in the study, 23 reported having unprotected intercourse at some point, and 15 reported using emergency contraception. Women who had received an advance supply of emergency contraception were not significantly more likely to have had unprotected intercourse than women who did not receive supplies (8% vs. 6%, respectively). Almost all (98%) of the women who had pills on hand said they had not been tempted to have unprotected intercourse. All of the women who had received only information said they wished they had received supplies. The researchers conclude that there is no "evidence that easy access to emergency contraception caused condom users to abandon their primary method" of contraception.

1. Ellertson C et al., Emergency contraception: randomized comparison of advance provision and information only, Obstetrics & Gynecology, 2001, 98(4):570-575.

ALTERNATIVE CARE FOR UNDERWEIGHT INFANTS

Low-birth-weight infants in Colombia who receive outpatient treatment fare just as well as those who receive standard hospital care in an incubator.1 A sample of 777 low-birth-weight infants were randomized to receive either standard inpatient care or an alternative intervention called Kangaroo Mother Care. Infants receiving the intervention were discharged from the hospital after approximately four days to an outpatient clinic, where they spent the day with their mothers and returned home with them at night. Infants were kept in an upright position with skin-to-skin contact with their mother's chest 24 hours a day, were breastfed regularly and were given supplements of special formula to ensure weight gain if needed. Infants remained in alternative care until they no longer accepted the kangaroo position. Infants in the standard-care group were kept in incubators, had little contact with their parents and usually were discharged after they weighed 1,700 g. During 12 months of follow-up, the two groups had similar numbers of infections and similar growth and developmental outcomes. Infants receiving the outpatient intervention were no more likely to be readmitted to the hospital after primary discharge than were infants who had received inpatient care. Infants in the intervention group spent fewer overall days in the hospital than the standard-care group; this was especially the case among infants born weighing 1,500 g or less. The researchers conclude that because Kangaroo Mother Care can reduce the number of neonatal hospital beds in use without negative health effects, it can "alleviate the pressure on the already strained neonatal care facilities in less developed countries."

1. Charpak N et al., A randomized, controlled trial of Kangaroo Mother Care: results of follow-up at 1 year of corrected age, Pediatrics, 2001, 108(5):1072- 1079.

THE LATEST ON HIV AND AIDS

Eastern Europe and Central Asia have the fastest-growing AIDS epidemic of any world region; 250,000 of the one million HIV-infected people living there in 2001 received their diagnosis that year.1 In Russia, new HIV diagnoses have almost doubled annually since 1998. Ukraine has the highest prevalence of HIV in the region (1%), and Estonia stands out for its soaring number of reported infections (from 12 in 1999 to 1,112 in the first nine months of 2001). With rates of other sexually transmitted diseases, as well as rates of injection-drug use among young people, high in the region, no end to these trends is in sight. In higher-income countries, increases in unsafe sexual behavior, widespread public complacency and stalled prevention efforts overshadow progress in treatment. In terms of sheer numbers, the profile of the epidemic remains staggering in Sub-Saharan Africa, where more than three million new infections were reported in 2001; 28 million people are now infected. National prevalence levels throughout Asia, the Pacific, Latin America and the Caribbean vary and can be quite low; in these regions, however, particular areas or population groups are disproportionately affected. Finally, prevalence is low in most parts of North Africa and the Middle East, but the number of infections is growing in several countries.

1. Tarmann A, Contraceptive shortages loom in less developed countries, Population Today, 2001, 29(6):1 & 4.

MEETING THE CHALLENGE?

The cost of supplying contraceptives (including condoms to prevent sexually transmitted infections) to developing countries is expected to rise to $1.8 billion by 2015, according to projections from the United Nations Population Fund (UNFPA).1 The $990 million increase in projected costs--from $810 million in 2000--reflects an estimated 40% leap in contraceptive demand, driven by a growing number of women in their reproductive years and by rising contraceptive prevalence. UNFPA estimates that the number of condoms needed to prevent AIDS and other sexually transmitted diseases will more than double by 2015, boosting funding needs from $239 million to $557 million a year, totals that do not include counseling, training or distribution costs. Yet after rising from $79 million in 1990 to $172 million in 1996, donor funding for condoms and other contraceptive supplies has fallen: Between 1996 and 1999, allocations for population assistance declined by $41 million.

1. Tarmann A, Contraceptive shortages loom in less developed countries, Population Today, 2001, 29(6):1 & 4.

THE HEAVY TOLL OF AIDS IN SOUTH AFRICA

AIDS became the single most important cause of death in South Africa in 2000, accounting for an estimated one-quarter of all deaths, according to a report released by the Medical Research Council of South Africa.1 Using a model developed by the Actuarial Society of South Africa, the organization estimates that approximately 40% of deaths among adults aged 15-49 and 25% of all deaths in that year were attributable to AIDS. The model projects that, without treatment, 5-7 million people will die of AIDS between 2000 and 2010--twice the number who will die from all other causes combined. The Council researchers note in their report that the epidemic has spread very rapidly in South Africa: According to annual seroprevalence surveys at public prenatal clinics, the percentage of pregnant women who were HIV-positive rose from less than 1% in 1990 to nearly 25% in 2000.

1. Dorrington R et al., The Impact of HIV/AIDS on Adult Mortality in South Africa, Medical Research Council of South Africa, Sept. 2001, <http://www. mrc. ac.za/bod>, accessed Nov. 1, 2001.

ONE SERVICE LEADS TO ANOTHER...

Receipt of prenatal care and previous use of a modern contraceptive are the most consistent factors predicting postpartum contraceptive use among women in Bolivia, Egypt and Thailand, according to an analysis based on Demographic and Health Survey data.1 The analysis, which controlled for women's demographic and background characteristics, their desire for more children, and characteristics of their community, found that in all three countries, women who had previously used a modern method and those who had received prenatal care during their most recent pregnancy were significantly more likely than other women to adopt a modern method after they gave birth. The effects of both factors were strongest in Bolivia, the country with the lowest contraceptive prevalence (12%) and the lowest level of prenatal care use (47%). Given that previous contraceptive use also predicts receipt of prenatal care, the investigators conclude that access to multiple services through the formal health system can "encourage women to utilize both prenatal care and family planning advice and resources."

1. Zerai A and Tsui AO, The relationship between prenatal care and subsequent modern contraceptive use in Bolivia, Egypt and Thailand, African Journal of Reproductive Health, 2001, 5(2):68-82.

BETTER CERVICAL CANCER SCREENING NEEDED

Cervical cancer screening programs in developing countries, when they exist, are generally ineffective, according to a review of programs in South and Central America, Sub-Saharan Africa and South and Southeast Asia.1 Of the 231,000 women who die annually of cervical cancer, four-fifths live in developing countries. Brazil, India, Peru and Sub-Saharan African countries are all without organized cervical cancer screening programs. Even in developing countries where screening programs exist, the risk of disease and death for women with precancerous lesions is high, the review authors argue, because the testing is of poor quality, and screening is inadequate and inefficient. For example, in Mexico, 64% of negative smears were of insufficient quality, and in Costa Rica, where screening services are available to all women aged 15 and older, screening of rural women has been inadequate. To create effective programs, the researchers suggest, low-income developing countries should begin improving their capacity to diagnose and treat cervical cancer precursors before planning even a limited screening program. For middle-income countries, the researchers recommend against conducting annual screening across a wide age range (for example, all women aged 20-65). Rather, they say, it would be "more realistic and effective to screen high-risk women [those aged 35-49] only once or twice with a good quality and highly sensitive test with an emphasis on wide coverage (more than 80%) of the targeted women."

1. Sankaranarayanan R, Budukh AM and Rajkumar R, Effective screening programmes for cervical cancer in low-and middle-income developing countries, Bulletin of the World Health Organization, 2001, 79(10):954-962.

IN BRIEF

• Catholics for a Free Choice (CFFC) has launched a global campaign to end the church's ban on condom use. In the first phase of the campaign, which began in November 2001, newspaper and billboard ads aimed at raising public awareness of the effect of the ban are being placed in the United States and countries with a substantial Catholic population or AIDS crisis. The campaign's Web site, http://www.condoms4life.org, offers visitors an opportunity to view the ads and encourages them to contact local policymakers, expressing their support for the availability of condoms. [CFFC, First global campaign to end Catholic bishops' ban on condoms launched on Internet, billboards, in subways and newspapers, news release, Washington, DC: CFFC, Nov. 21, 2001.]

• By the end of the year, the Population Council will begin Phase III clinical trials in Africa of its microbicide CarraguardTM. The Council has conducted safety trials of the microbicide in seven countries, including South Africa, Thailand and the United States. The Phase III trials, which will involve 6,000 women, will test the microbicide's effectiveness in preventing the transmission of HIV and other sexually transmitted infections. [Population Council, Bill and Melinda Gates Foundation supports clinical trials of Population Council's lead candidate AIDS-fighting microbicide, news release, New York: Population Council, Feb. 2, 2002.]