Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 28, Number 2, June 2002
UPDATE


TWO-CHILD FAMILIES ARE BECOMING THE NORM

Contrary to earlier United Nations (UN) projections that fertility rates would continue to rise in developing countries, population experts now predict that rates in some countries may fall below replacement level by 2050.1 At a UN Population Division meeting in March, 40 international population experts concluded that in 74 "intermediate-fertility" countries--where women have between two and five children--fertility levels will fall below 2.1 children per family, the number required for long-term population replacement. According to the most recent UN statistics, these countries, including India, Bangladesh, Brazil, Indonesia and Mexico, are following fertility patterns similar to those in low-fertility countries such as Japan and those in Europe and North America. Since 1965, fertility in less- developed regions has declined from six to slightly fewer than three children per family. Even with this decline in fertility, the experts said, the world's population will likely increase by three billion by mid-century, and less-developed countries will account for almost all of that growth. According to John Caldwell, of the Australian National University, who participated in the meeting, "There no longer seem to be any barriers to most countries reaching replacement level and subsequently falling below that level."

1. United Nations Population Division, Experts concur: fertility in developing countries may fall below two-child family norm, press release, Mar. 21, 2002, <http://www.un.org/News/Press/docs/2002/pop816.doc.htm>, accessed Apr. 12, 2002; and United Nations Population Division, Press briefing by director, Population Division, Mar. 12, 2002, <http://www.un.org/News/briefings/docs/2002/ Populationbrf.doc.htm>, accessed Apr. 12, 2002.

EMERGENCY CONTRACEPTION IN LATIN AMERICA

Emergency contraception is available rarely or not at all in Latin America and the Caribbean, according to a survey of 37 affiliates of the International Planned Parenthood Federation (IPPF) conducted between September and November 2000.1 Sixty-two percent of affiliates said the method was "hardly" or "not at all" available in the private sector, and 89% said the same about its availability in the government sector. The survey findings suggest that the affiliates may be among the few sources of the method in the region: Twenty-three of the affiliates (62%) responded that they provide one or more forms of the method. Thirteen (57%) of the affiliates that provide emergency contraception said they had received support to do so from IPPF or another clinical group, and 12 (52%) said they began offering the method in response to client demand. Among the 14 affiliates that do not provide the method, 11 (79%) decline to do so because they believe its use constitutes abortion. Other reasons for not providing the method were that training and protocols do not exist, client demand is low, use of the method is illegal and dedicated products are not available. While dedicated emergency contraceptive products are available in 11 countries, most affiliates that offer the method reported using cut-up packets of one of 13 brands of combined oral contraceptives. The investigators conclude that availability of the method may increase in these countries if programs received "specifically targeted [emergency contraception] information and model clinical protocols" as well as technical assistance and support.

1. Diaz-Olavarrieta C et al., Policy climate, scholarship, and provision of emergency contraception at affiliates of the International Planned Parenthood Federation in Latin America and the Caribbean, Contraception, 2002, 65(2):143-149.

REPRODUCTIVE HEALTH AMONG AFGHAN REFUGEES

Pregnancy and childbirth complications are the leading cause of death among reproductive-age Afghan women in 12 refugee settlements in Pakistan.1 Between January 1999 and August 2000, deaths to women of reproductive age accounted for close to 6% of all deaths in the settlements, where health care and other services were provided by a nongovernmental organization. Interviews with female relatives indicated that of the 66 women aged 15-49 who had died, 41% had died from maternal causes, the most common cause of death. Hemorrhage, which was directly responsible for 11 deaths, was the most frequent cause of maternal death. Compared with women who had died of other causes, women who had died of maternal causes were significantly more likely to have had a barrier to obtaining health care, such as difficulty recognizing an illness or complication, deciding to seek health care once they recognized a complication, or reaching quality health care in a timely manner, or at all. The researchers estimated that two-thirds of the maternal deaths could have been prevented. Given that the study settlements were stable and had established health care services, the investigators conclude that maternal mortality may be even higher among women in new settlements, where the barriers to health care may be greater.

1. Bartlett LA et al., Maternal mortality among Afghan refugees in Pakistan, 1999-2000, Lancet, 2002, 359(9307): 643-649.

CONSISTENT CONDOM USE IS KEY TO PREVENTION

Consistent condom use protects against HIV, syphilis, gonorrhea and chlamydia infection but inconsistent use does not, according to a longitudinal study of condom use among 17,264 Ugandans.1 At 10-month intervals between 1994 and 1998, researchers interviewed men and women aged 15-59 and collected blood and urine samples to test for HIV and other sexually transmitted infections. At the first interview, 4% of men and women reported using condoms consistently and 17% reported using them irregularly. Among consistent condom users, HIV incidence was 1.0 new infection per 100 person-years, compared with 1.7 among nonusers and 2.1 among inconsistent users. In multivariate analyses, the risk of HIV infection was significantly reduced among people who used condoms consistently, but there was no effect on the risk among inconsistent condom users. Consistent condom users had reduced odds of contracting syphilis (odds ratio, 0.7), gonorrhea or chlamydia (0.5) and, among women, bacterial vaginosis (0.8). Inconsistent condom users, on the other hand, had elevated odds of contracting gonorrhea or chlamydia (1.4). The researchers estimate that the reduction of incidence of infection in the population attributable to consistent condom use is 5% for HIV, 1% for syphilis and 3% for gonorrhea and chlamydia. The investigators conclude that "It is critical that programs discourage irregular use of condoms and emphasize consistency of use."

1. Ahmed S et al., HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda, AIDS, 2001, 15(16):2171-2179.

BURDEN OF REPRODUCTIVE ILL HEALTH IN INDIA

Reproductive tract problems account for half of all days of illness among southern Indian women younger than 35, according to a survey of mothers in Karnataka State.1 For one year, researchers interviewed 421 women with young children monthly about any illnesses they had experienced, the severity and duration of symptoms and what action they took, if any. Forty-four percent of the women reported experiencing genitourinary illness and 10% reported illness related to pregnancy or the side effects of contraceptive use. They described 30% of genitourinary illnesses and 10% of pregnancy-and contraceptive-related illnesses as severe. On average, reproductive ill health was responsible for 49 days of illness--out of a total of 101 days reported--and for 15 of 32 days of reported severe ill health. Women spent a mean of 53 rupees annually on home remedies and visits to providers (including transportation) for reproductive ill health. These costs represent 31% of women's annual average expenditure (172 rupees, or approximately US$5.50) on all illnesses they experienced. The investigators note that Karnataka State allocates 3% of its health budget--approximately 15 rupees annually for each adult woman and child younger than six--to reproductive and child health, which is much less than women's own expenditures for addressing these health problems. According to the researchers, "there appear to be grounds for substantially increasing the allocation of funds" for reproductive and child health.

1. Bhatia J and Cleland J, The contribution of reproductive ill-health to the overall burden of perceived illness among women in southern India, Bulletin of the World Health Organization, 2001, 79(11):1065-1069.

MEN ARE EFFECTIVE CONDOM DISTRIBUTORS

Men can be effective agents in community-based condom distribution programs, according to a review of research on programs in 13 countries.1 Studies in Cameroon, Kenya, Ghana, Mali and Pakistan have found that male agents are acceptable to men and women in the community. In Cameroon, for example, four in five villagers said they approved of male agents. Moreover, studies in Peru and Kenya have found that men may be more effective than women in reaching men: In Trujillo, Peru, 52 male distributors sold a median of 162 condoms per month to men, compared with a median of 88 condoms sold by 94 female distributors. Three studies have found that men are either more productive than women or equally productive in distributing condoms (measured in couple years of protection). In Kilifi, Kenya, for example, male agents distributed an average of 277 couple years of protection in 18 months, compared with an average of 130 for female agents. The researchers note that incorporating men into community distribution programs presents challenges, including overcoming prejudice among female managers of programs that have typically involved women providing health services to other women. They conclude, however, that "By specifically reaching out to men in the community, male...agents may help to increase men's acceptance of family planning," which may lead to men sharing more equally in responsibility for contraception.

1. Green CP, Joyce S and Foreit JR, Using men as community-based distributors of condoms, Frontiers in Reproductive Health Program Brief, Washington, DC: Population Council, 2002, No. 2.

IN BRIEF

• Beginning in September, Iranian children and adolescents will receive AIDS awareness information in school, according to the country's National Committee to Fight AIDS. Although Iranian schools do not teach sexuality education, the material for high school students will explain that people can be infected through sexual intercourse and will discuss condoms, while emphasizing abstinence until marriage. The number of new HIV infections in Iran, which reached 3,340 in January, has increased rapidly. [Dareini AA, Iran to start teaching AIDS awareness, Boston Globe, Apr. 16, 2002, p. A12.]

• Emergency contraception has been banned by Argentina's Supreme Court. A narrow majority of the court ruled that the method, which has been legal in the country since 1996, causes abortion. In its decision, the court defined life as beginning at fertilization, reversing a previous interpretation that life begins when an embryo reaches the uterus. [Day-after pill outlawed in Argentina, BBC News, Mar. 6, 2002.]

• China has passed legislation codifying the country's one-child policy. According to the new law, which takes effect in September, couples will face fines if they have more than one child. There are exceptions for urban couples who are members of ethnic minorities or who are both only children. In addition, rural couples will be permitted to have two children if their first child is a girl. [China's one-child policy becomes law, Population Today, 2002, 30(2):7.]