Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 29, Number 3, September 2003
UPDATE


JUST ONE SCREENING MAY PREVENT CERVICAL CANCER

Visual inspection of the cervix after application of acetic acid and treatment by cryotherapy at the same visit is a practical approach to preventing cervical cancer in low-resource settings, according to a study conducted in Roi-Et Province, Thailand, between February and October 2000.1 In all, 5,999 women aged 30-45 who had not had a total hysterectomy, had never had cervical cancer and were not more than 20 weeks pregnant were screened by nurses in mobile and hospital clinics. The acetic acid test result was positive (i.e., it revealed raised and thickened white plaques) for 13% of the women, most of whom (93%) received immediate cryotherapy to remove the lesions. Nearly all of the women undergoing treatment (99%) were satisfied with their decision to do so, and only 2% subsequently required clinical management for complications. After one year, test results were negative for 94% of rescreened women, and no squamous cell cancers were detected. The researchers conclude that in rural Thailand, a single-visit approach to preventing cervical cancer is "safe, acceptable, and feasible," and that the strategy could be adopted in other developing countries.

1. Royal Thai College of Obstetricians and Gynaecologists (RTCOG) and the JHPIEGO Corporation Cervical Cancer Prevention Group, Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project, Lancet, 2003, 361(9360):814-820.

CAMBODIAN SEX WORKERS USE CONDOMS INCONSISTENTLY

Despite the Cambodian government's policy to promote 100% condom use in entertainment establishments, economic barriers and lack of negotiation skills may be preventing female sex workers from using condoms consistently with clients.1 In interviews conducted in 2001 among 140 registered, brothel-based sex workers undergoing screening for HIV and other sexually transmitted infections (STIs) at a health center in Siem Reap, Cambodia, 78% of women reported always using condoms with their clients. Nine in 10 women had suggested condom use with all clients, and six in 10 women had succeeded in getting all clients to comply. After adjustment for age, education, marital status, weekly number of sexual encounters and STI and HIV/AIDS knowledge, consistent condom use with clients was higher among higher-income than lower-income women (prevalence ratios, 1.6-1.9) and among women who always succeeded in persuading clients to use condoms than among those who did not (1.5). The researchers recommend that current brothel measures and client education be accompanied by strategies "at the policy and community levels to address sex workers' economic and cultural barriers to condom use, and at the personal level to develop sex workers' negotiation skills."

1. Wong ML et al., Social and behavioural factors associated with condom use among direct sex workers in Siem Reap, Cambodia, Sexually Transmitted Infections, 2003, 79(2):163-165.

IN INDIA, MORE GIRLS THAN BOYS DIE DURING INFANCY

In India, infant mortality is higher among girls than among boys, according to an analysis of births and infant deaths that were recorded between January 1997 and December 2001 in three poor areas of Delhi.1 During that period, the sex ratio at birth was 869 females per 1,000 males, and 442 children died before the age of one year. The average infant mortality rate was 72 per 1,000 for females--1.3 times the rate for males (55 per 1,000). Common causes of infant death were diarrhea (22%), birth asphyxia (14%), immaturity (12%) and respiratory infection (11%). One in 10 deaths happened with no preceding illness and, thus, were unexplained. Girls were more likely than boys to die of unexplained causes and diarrhea (odds ratios, 3.5 and 2.2, respectively), but girls and boys were equally likely to die of less preventable and less treatable conditions, such as birth asphyxia and immaturity. The analysts suggest that sex discrimination contributes to the findings and call for "improved access to health care and education of health professionals to pay attention to girls."

1. Khanna R et al., Community based retrospective study of sex in infant mortality in India, British Medical Journal, 2003, 327(7407):126-129.

DISAPPROVAL OF FEMALE GENITAL MUTILATION IN THE SUDAN

In July 2000, the majority of students at the University of Khartoum, Sudan, who answered an anonymous questionnaire on female genital mutilation said that the practice should be stopped.1 Of the 414 respondents (222 men and 192 women, nearly all of whom were Muslim), 83-84% were not in favor of female circumcision, and 79% of men and 88% of women said it should not continue. Most respondents (91-94%) knew that the procedure causes menstrual, sexual, fertility and labor complications, and three-quarters of male respondents said they preferred a noncircumcised partner. However, 57% of women had undergone the procedure. Only 47-60% of students knew that female circumcision is illegal in the Sudan, and roughly one-half answered incorrectly that it is recommended by their religion. The researchers suggest that female genital mutilation is continuing in the Sudan because of "confusing religious messages and ambiguous laws," but that the large proportion of students wanting the practice abolished reflects "a promising attitude."

1.Herieka E and Dhar J, Female genital mutilation in the Sudan: survey of the attitude of Khartoum university students towards this practice, Sexually Transmitted Infections, 2003, 79(3):220-223.

RATE OF CESAREAN DELIVERY IS RISING IN TURKEY

The proportion of hospital births occurring by cesarean section in Turkey increased from 8% in 1988-1992 to 19% in 1993-1998, according to an analysis of data from Turkish Demographic and Health Surveys.1 After adjustment for various background variables, the likelihood of having a cesarean rather than a vaginal delivery in 1993-1998 was positively associated with women's age (odds ratios, 1.7-4.3), education (1.1-1.9), household welfare (1.6) and number of antenatal visits (1.3-4.0). In addition, women who delivered in a private rather than a public hospital had elevated odds of having a cesarean birth (2.3). Noting that the projected rate of cesarean delivery in 2001 was 30%--twice the level considered medically justified by the World Health Organization--the author suggests that the trend reflects rising access to private hospitals and increases in the proportion of better-off women opting for cesarean sections.

1. Koc I, Increased cesarean section rates in Turkey, European Journal of Contraception and Reproductive Health Care, 2003, 8(1):1-10.

SEXUAL EXPERIENCE AMONG NIGERIAN STUDENTS

In Plateau state, Nigeria, secondary school students who come from polygamous families and those with a lower sense of connectedness to their parents and to school have elevated odds of ever having had intercourse.1 Of 2,705 school students aged 12-21 who participated in a questionnaire survey in 2000, 34% reported ever having had sex and 41% that their father had more than one wife at the same time. In a logistic regression that controlled for school district and type, as well as age and sex, factors independently associated with reporting sexual initiation included having a polygamous family (odds ratio, 1.6) and having a lower sense of connectedness with parents (1.9) and with school (1.3). Further analysis revealed that the effect of polygamy on sexual experience was reduced by 22-27% if students had ever been married or coerced to have intercourse. The researchers conclude that parent-teen connectedness does not mediate the association between family polygamy and adolescent sexual experience, but suggest that fostering the sense of connectedness to parents and to school could help in reducing risky sexual behavior among Nigerian youth.

1. Slap GB et al., Sexual behaviour of adolescents in Nigeria: cross sectional survey of secondary school students, British Medical Journal, 2003, 326(7379):15-20.

EXCLUSIVE BREAST-FEEDING LOWERS RISK OF DIARRHEA

Women who receive periodic counseling about exclusively breast-feeding children until the age of six months are less likely than those who do not to report infant diarrhea.1 In a randomized controlled trial conducted between October 1999 and June 2000 among 1,115 mothers and their newborns in Haryana, India, women who had received the counseling reported more commonly than did women in the control group that their child was exclusively breast-fed within the first three hours of life (50% vs. 24%), at age three months (79% vs. 48%) and at age six months (42% vs. 4%). Accordingly, women in the intervention group had elevated odds of exclusively breast-feeding their child at ages three and six months (odds ratios, 4.0 and 17.6, respectively.) These women also had reduced odds of reporting that their child, at ages three and six months, had had diarrhea in the past week (0.6 and 0.9, respectively) or had needed treatment for diarrhea outside the home at least once in the past three months (0.7 for each). However, at both ages, the mean weight and height of infants in the intervention group were similar to those of infants in the control group. The investigators conclude that the "promotion of exclusive breast-feeding until age six months...does not lead to growth faltering, and reduces the risk of diarrhoea."

1. Bhandari N et al., Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: a cluster randomized controlled trial, Lancet, 2003, 361(9367):1418-1423.

IN BRIEF

• Obstetric fistula--a condition caused by tissue injury during prolonged obstructed labor that can lead to urinary and fecal incontinence--is widespread in Sub-Saharan Africa, according to a nine-country study. Affected women--as many as one million in Nigeria alone--are usually younger than 20, illiterate and poor. In many countries, hospitals are unable to meet the demand for reconstructive surgery or to help prevent obstetric fistula by providing emergency cesarean sections. [United Nations Population Fund and EngenderHealth, Obstetric Fistula Needs Assessment: Findings from Nine African Countries, 2003, <http://www.unfpa.org/fistula/docs>, accessed June 18, 2003.]

• In its evaluation of the gaps between HIV prevention needs and current efforts, an international expert group has estimated that worldwide, fewer than one in five people at risk of HIV infection have access to prevention programs, and only two in five people who need condoms can obtain them. Among the group's recommendations are the integration of HIV/AIDS prevention and treatment services, and increased global spending on prevention activities: The estimated amount needed in 2005 will be triple that spent in 2002--$5.7 billion vs. $1.9 billion. [Global HIV Prevention Working Group, Access to HIV Prevention: Closing the Gap, 2003, <http://www.kaisernetwork.org/health_cast/uploaded_files/Funding_Report_FINAL.pdf>, accessed May 13, 2003.]

• The Center for Reproductive Rights and the University of Toronto International Programme on Reproductive and Sexual Health Law have produced a report on a broad range of reproductive rights issues related to the work of United Nations committees that monitor government compliance with six key international human rights treaties. Bringing Rights to Bear: An Analysis of the Work of UN Treaty Monitoring Bodies on Reproductive and Sexual Rights, along with an accompanying step-by-step advocacy guide, can be downloaded from <http://www.reproductiverights.org>.