Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 28, Number 4, December 2002
UPDATE


VAGINAL USE OF PILL REDUCES SIDE EFFECTS

The vaginal route of pill use is better tolerated than the oral route, according to a clinical trial conducted at a family planning clinic in Tehran, Iran.1 The study participants--143 fertile women aged 18-40 who were not lactating, had not used the pill for two months and had never used an implant--received low-dose combined pills orally for three months and then vaginally for three months, and recorded side effects before and after the switch. Participants reported nausea, vertigo and headache, breast tenderness, period pain and digestive problems less commonly during vaginal pill use than they did during oral pill use (3-21% vs. 32-58%); however, the proportion of women who bled between periods was similar (6% vs. 9%). Most participants (80%) found the vaginal route of pill administration acceptable and said they would use this method in the future. The researchers note that only one woman, who had used the vaginal method incorrectly, became pregnant during the trial. They conclude that "the systemic side effects of contraceptive pills commonly experienced with the oral route can be reduced if the same pills are administered by the vaginal route instead."

1. Ziaei S et al., Comparative study and evaluation of side effects of low-dose contraceptive pills administered by the oral and vaginal route, Contraception, 2002, 65(5): 329-331.

DEFICITS IN MATERNAL HEALTH CARE

Maternal health programs in many developing countries are highly inadequate, especially in rural areas, according to ratings from in-country experts in 1999-2000.1 The rating system, which covers policy and support services, facility capacity, access to services and provision of care, yielded an average score of 56 (on a scale of zero to 100) for 49 developing countries--23 in Africa, 13 in the Americas and 13 in Asia. Although maternal health policies were generally judged adequate, the in-country experts estimated that in 25 countries, fewer than half of women have access to adequate maternal health services. Overall, they judged that 68% of urban women and 39% of rural women could obtain adequate care. The average score for capacity of health centers to provide various services ranged from 24 for manual vacuum aspiration to 61 for administration of intravenous antibiotics. For routine services, access scores were highest for neonatal immunizations (77-79), antenatal tetanus injection (78) and counseling on breastfeeding (74), and lowest for postpartum follow-up (41) and HIV counseling (30). Noting that policy "implementation is clearly the crux of the matter," the researchers urge that financing be increased and health promotion be improved.

1. Bulatao RA and Ross JA, Rating maternal and neonatal health services in developing countries, Bulletin of the World Health Organization, 2002, 80(9):721-727.

THE TOLL OF UNWANTED PREGNANCY

Over the six years following the UN International Conference on Population and Development (ICPD), unwanted pregnancies led to the deaths of nearly 700,000 women worldwide, accounting for about 21% of maternal mortality.1 According to estimates from a Global Health Council report, at least 338 million unwanted pregnancies occurred during that period. Of these, about 251 million ended in abortion, resulting in 441,000 maternal deaths. An additional 88 million unwanted pregnancies were carried to term, with 246,000 women dying from complications of pregnancy, labor and delivery. Rates of death were much lower in industrialized countries than in developing countries, where women are less likely to have ready access to skilled obstetric care and safe abortion services. For example, 675 of every 100,000 abortions and 857 of every 100,000 births resulting from an unwanted pregnancy led to a maternal death in Africa, compared with one per 100,000 abortions and 11 per 100,000 births in North America. The authors of the report conclude that these statistics are "evidence of a serious health crisis...that will only deepen as more women move into their prime reproductive years."

1. Daulaire N et al., Promises to Keep: The Toll of Unintended Pregnancies on Women's Lives in the Developing World, Washington, DC: Global Health Council, 2002.

PHYSICAL ABUSE LINKED TO LOW BIRTH WEIGHT

Women who are physically abused by a partner during pregnancy have an increased risk of delivering a low-birth-weight infant, according to a case-control study conducted at a hospital in León, Nicaragua, between July and October 1996.1 Interviews with the mothers of 303 infants shortly after delivery revealed that a higher proportion of women with low-birth-weight infants than of those in the control group had been physically abused by their partner while pregnant (22% vs. 5%). After adjustment for parity, socioeconomic status, age and smoking, physical abuse was associated with having a low-birth-weight infant (odds ratio, 4.0) and having a low-birth-weight infant with acute or chronic growth restriction (3.5-3.6). The researchers conclude that "there is an independent effect of physical abuse during pregnancy on the birth weight of the offspring, mainly through intrauterine growth restriction."

1. Valladares E et al., Physical partner abuse during pregnancy: a risk factor for low birth weight in Nicaragua, Obstetrics & Gynecology, 2002, 100(4):700-705.

CONDOM DONATIONS ARE SHRINKING

The number of condoms donated each year to developing countries has fallen during the past decade, from 970 million to 950 million, according to the United Nations Population Fund (UNFPA).1 In particular, the U.S. donation decreased dramatically--from 800 million condoms in 1990 to 360 million in 2000--because some countries were disqualified from receiving foreign aid and because the implementation of "buy American" laws increased condom prices. Despite efforts of the United Nations and European aid agencies to make up for the decrease in U.S. donations, the gap between supply and demand in poor countries is likely to widen. UNFPA estimates that developing nations currently need 10 billion condoms a year and will need nearly twice as many by 2015. According to UNFPA, countries in Africa are the most in need of condom donations, and "if donors were to strive to meet 100% of the condom requirements in Africa, they would need to double their 2000 level of support."2

1. McNeil DG, Jr., Global war on AIDS runs short of key weapon, New York Times, Oct. 9, 2002.

2. United Nations Population Fund (UNFPA), Global Estimates of Contraceptive Commodities and Condoms for STI/HIV Prevention 2000-2015, New York: UNFPA, 2002.

WHO ENGAGES IN SEXUAL RISK BEHAVIOR?

In southern Brazil, behaviors that carry a high risk of contracting HIV or other sexually transmitted infections are concentrated among women who are young, are formerly married, have little education and are smokers.1 Data collected from 1,543 women in the urban area of Pelotas between October 1999 and January 2000 indicated that 72% had not used a condom at last intercourse, 50% had first had intercourse before they were 18, 7% had had two or more partners in the previous three months and 3% had engaged in anal sex during their last intercourse. Moreover, 14% of the women's partners and 7% of the women themselves had used alcohol or drugs before their most recent intercourse. Although 10% of the respondents reported none of these risk behaviors, 47% reported one, 33% reported two and 11% reported three or more. In an ordinal regression analysis, an elevated risk score was associated with being younger than 30 (odds ratios of 2.5-3.7), having less than five years of schooling (2.4), being separated or divorced (1.5) and being a smoker (1.5). The investigators suggest that this information will be "helpful for designing and targeting public health interventions to prevent STD and AIDS."

1. Silveira MF et al., Factors associated with risk behaviors for sexually transmitted diseases/AIDS among urban Brazilian women, Sexually Transmitted Diseases, 2002, 29(9):536-541.

HIV AND INTIMATE PARTNER VIOLENCE

Of women who attended a voluntary HIV counseling and testing clinic in Dar es Salaam, Tanzania, those who were HIV-positive were more likely than those who were not to have experienced physical violence from their current partner and from previous partners.1 During interviews conducted three months after testing, 38% of the women said they had had at least one physically violent partner and 16% at least one sexually abusive partner. Eleven percent reported that their current partner had become violent at least once in the previous three months, and 30% reported at least one such incident before being tested for HIV. Compared with women who had tested negative, those who were HIV-positive had had significantly more physically violent partners (odds ratio of 1.7). In addition, they were more likely to have experienced physical or sexual violence from their current partner in the previous three months (2.4 for each outcome), and they reported a higher number of violent episodes with their current partner. Noting that women in such settings are at risk for both HIV infection and violence "largely because of the behavior of their male partners," the investigators conclude that "efforts to change norms surrounding conflict resolution and sexual behavior are necessary and important parts of any global women's health promotion strategy."

1. Maman S et al., HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania," American Journal of Public Health, 2002, 92(8):1331-1337.

IN BRIEF

•India's Supreme Court has ordered state and territorial governments to act against unregistered clinics that advertise the use of ultrasound testing for sex selection. Noting that state governments had been ordered in February 2002 to impound ultrasound machines from such clinics, the court stated that governments must no longer "close their eyes" to the violations. [India's supreme court orders state governments to take action against clinics offering ultrasound testing for sex selection, Kaiser Daily Reproductive Health Report, Oct. 9, 2002, <kaisernetwork.org/daily_reports>, accessed Oct. 9, 2002.]

•Of women admitted to Ethiopian hospitals, more die from complications arising from illegal abortion than from any other cause except tuberculosis, according to the World Health Organization (WHO). WHO estimates that 70% of Ethiopian women admitted with abortion complications die, and urges improved access to contraceptive services to prevent unwanted pregnancies. [Illegal abortions second leading cause of death among women in Ethiopian hospitals, Kaiser Daily Reproductive Health Report, Oct. 29, 2002, <kaisernetwork.org/ daily_reports>, accessed Oct. 29, 2002.]

•According to a report from the United Nations Population Fund (UNFPA), donor contributions for contraceptive services are not keeping pace with increases in demand. The organization estimates that each $1 million shortfall in commodity support for contraceptives means 360,000 unwanted pregnancies, 150,000 induced abortions, 800 maternal deaths, 11,000 infant deaths and 14,000 deaths of children younger than five. [Reproductive Health Essentials. Securing the Supply: Global Strategy for Reproductive Health Commodity Security, UNFPA, <www.unfpa.org/publications/securingsupply>, accessed Oct. 30, 2002.]