Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 30, Number 1, March 2004
UPDATE


MATERNAL MORTALITY AROUND THE WORLD

Of the estimated 529,000 maternal deaths that occurred worldwide in 2000, the vast majority were in Africa and Asia (251,000 and 253,000 deaths, respectively), according to a joint report from the World Health Organization, United Nations (UN) Children's Fund and UN Population Fund.1 Only 4% of maternal deaths occurred in Latin America and the Caribbean, and fewer than 1% in the developed regions of the world. Overall, the maternal mortality ratio was 400 deaths per 100,000 live births; the ratio was highest in Africa (830 per 100,000), which also had the highest lifetime risk of dying as a result of pregnancy—one in 20, compared with one in 61 for all developing regions and one in 2,800 for all developed regions. Of all subregions, Sub-Saharan Africa had the highest maternal mortality in terms of absolute number (247,000 deaths), maternal mortality ratio (920 per 100,000 live births) and lifetime mortality risk (one in 16).

1. World Health Organization, United Nations (UN) Children’s Fund and UN Population Fund, Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA, 2003, , accessed Feb. 10, 2004.

ADOLESCENTS' REPRODUCTIVE HEALTH NEEDS

Approximately 1.2 billion people—one-fifth of the world's population—are aged 10-19 and urgently need help to avoid unwanted pregnancy, unsafe delivery and sexually transmitted infections (including HIV), according to the United Nations Population Fund (UNFPA).1 Adolescent females have a particularly high risk of experiencing adverse reproductive health outcomes: Each year, some 14 million women aged 15-19 give birth and an estimated five million undergo unsafe abortions. Furthermore, UNFPA notes that women younger than 20 are 2-5 times as likely to die in childbirth as women in their 20s, the unmet need for family planning among young people is twice that among adults, and one-half of all new HIV infections occur among 15-24--year-olds. In its recommendations, the agency calls for "youth-friendly" reproductive and sexual health services, and stresses that efforts aimed at improving the reproductive health and rights of adolescents and young people need to empower individuals, ensure their well-being, curb the HIV epidemic and improve socioeconomic prospects.

1. United Nations Population Fund, State of World Population 2003, Making 1 Billion Count: Investing in Adolescents' Health and Rights, 2003, , accessed Feb. 10, 2004.

PROGRAMS THAT CHANGE YOUTH BEHAVIOR

In Sub-Saharan Africa, youth-oriented programs can motivate young people to use reproductive health services, use condoms and be tested for HIV, according to a joint report by the Population Reference Bureau and Population Services International.1 The programs—implemented in 1999-2000 and tailored to each of the three participating countries—used social marketing techniques to promote the use of condoms and other reproductive health products and services among youth. In Madagascar, the number of 15–24-year-olds seeking treatment for sexually transmitted infections and other reproductive health services at youth-oriented clinics increased during the program, from 527 in 2001 to 2,202 in 2002. In Cameroon, unmarried youth with high levels of program exposure were less likely than those with low levels to be shy about buying condoms (64% vs. 72% of males and 52% vs. 67% of females) and more likely to know how to use one correctly (79% vs. 68% of males and 64% vs. 38% of females); men with high levels of program exposure were also more likely to have used a condom at last sex (69% vs. 56%). And in Rwanda, youth were more likely to have had an HIV test in the previous year if their program exposure was high instead of low (9% vs. 2% of males and 7% vs. 2% of females).

1. Neukom J and Ashford L, Changing Youth Behavior Through Social Marketing: Program Experiences and Research Findings from Cameroon, Madagascar, and Rwanda, Population Reference Bureau, 2003, , accessed Feb. 10, 2004.

ANTENATAL SYPHILIS SCREENING IS COST-EFFECTIVE

Antenatal syphilis screening is at least as cost-effective as other maternal and child health interventions, according to a study conducted among 9,713 women who attended antenatal clinics in Mwanza, Tanzania, between September 1997 and November 1999.1 The intervention—implemented as part of routine antenatal care—consisted of a rapid blood test to detect syphilis, followed by single-dose antibiotic treatment if indicated. During the study period, 7% of women tested positive and were treated. The researchers estimated that the intervention averted 44 stillbirths and 31 cases of low birth weight—equivalent to 1,195 and 127 disability-adjusted life-years (DALYs), respectively. Once all the resources that were used were included, the intervention cost $1.44 per woman screened, $20.05 per woman treated and $10.56 per DALY saved. Noting that prevention of mother-to-child HIV transmission and childhood immunizations cost $11 and $17-42 per DALY saved, respectively, the analysts conclude that syphilis screening and treatment as part of antenatal care "are extremely good value for money and...are urgently in need of scaling up to national level in Sub-Saharan African countries."

1. Terris-Prestholt F et al., Is antenatal syphilis screening still cost effective in sub-Saharan Africa? Sexually Transmitted Infections, 2003, 79(5):375–381.

AIR DRIED PAP SMEARS ARE AS GOOD AS WET FIXED ONES

Rehydrated air-dried cervical smear specimens provide a viable alternative to wet-fixed specimens for Pap testing in settings with limited resources.1 In a study comparing the two techniques, paramedical workers collected a pair of cervical smears from each of 1,000 women attending a service camp in an urban slum in Delhi, India. One set of samples was immediately fixed in alcohol and the other was air-dried for 30-120 minutes and rehydrated in saline within two hours. After the samples had been stained, they were examined for cellular preservation, staining quality and the presence of red blood cells. Of the 950 usable pairs of smears, similar proportions of rehydrated and wet-fixed slides showed satisfactory cytoplasmic staining (61% and 64%, respectively); however, a larger proportion of rehydrated slides showed excellent staining (27% vs. 15%) and a smaller proportion showed unsatisfactory staining (12% vs. 21%). Although cellular diagnoses were similar, the background was cleaner in rehydrated than in wet-fixed samples (3% vs. 12% contained red blood cells)—a result attributable to the rehydration process, the researchers comment. Given the "comparable" staining results of the two types of smear, the researchers suggest that the "rehydration of air-dried smears is a simple and convenient method that can easily be adopted in remote, resource-limited settings."

1. Gupta S, Sodhani P and Chachra KL, Rehydration of air-dried cervical smears: a feasible alternative to conventional wet fixation, Obstetrics & Gynecology, 2003, 102(4):761-764.

AIDS ORPHANS IN AFRICA

In 2001, some 11 million Sub-Saharan African children younger than 15 had lost one or both parents to AIDS, making up one-third of all orphans in the region.1 According to a report from the United Nations Children's Fund (UNICEF), the projected number of AIDS orphans will roughly double—to 20 million—by 2010, and will constitute one-half of the region's orphan population. The agency attributes the increase to the large proportion of adults currently living with HIV/AIDS and to difficulties in making antiretroviral drugs more widely available in Sub-Saharan Africa. UNICEF also comments that the escalating number of orphans, who are likely to be poorer and less healthy than nonorphans, will strain many extended family networks, increase the number of children living on the street and have "implications for stability and human welfare that extend far beyond the region." Noting that Africa's AIDS orphans made up 80% of the global total in 2001, the report concludes, "Wealthy nations must recognize that in the spirit of the Convention on the Rights of the Child and in terms of global interests, they have a vital role to play in accelerating the response to the orphan crisis."

1. United Nations Children's Fund, Africa's Orphaned Generations, 2003, , accessed Feb. 10, 2004.

USE OF INJECTABLES IS ON THE RISE IN KENYA

In Kenya, the use of injectable contraceptives is becoming increasingly popular, according to an analysis of data from national Demographic and Health Surveys.1 Between 1984 and 1998, the proportion of married women aged 15-49 using this method increased from less than 1% to 12%, accounting for much of the overall increase in contraceptive use during this period (from 17% to 39%). In multivariate analyses of data from sexually experienced women, the predicted probability of injectable use increased from 19% in 1989 to 45% in 1998, whereas that of IUD or implant use decreased from 21% to 8% and that of pill use decreased from 39% to 28%. By 1998, the injectable became the most commonly used method among married women younger than 35 who wanted to end childbearing (42%). The researchers suggest that Kenyan women "who previously would have chosen other reversible contraceptive methods...are shifting to injectable contraceptives," and they cite service availability as a possible factor in method choice. However, the analysts warn that "costing of programs, logistics and staff training all must take into account the rising popularity of injectables over alternative methods."

1. Magadi MA and Curtis SL, Trends and determinants of contraceptive method choice in Kenya, Studies in Family Planning, 2003, 34(3):149–159

IN BRIEF

•A manual on how to incorporate gender concerns into reproductive health and HIV/AIDS programs has been published by the U.S. Agency for International Development. Intended for program managers and technical staff, the manual aims at promoting gender equity to maximize program access, quality and sustainability. [U.S. Agency for International Development (USAID) Bureau for Global Health Interagency Gender Working Group, A Manual for Integrating Gender Into Reproductive Health and HIV Programs: From Commitment to Action, Washington, DC: USAID, 2003.]

•International Planned Parenthood and the United Nations Population Fund have produced a set of guidelines to assist program planners, managers and service providers who want to offer voluntary HIV testing and counseling. Integrating HIV Voluntary Counselling and Testing (VCT) Services into Reproductive Health Settings is available in English, French and Spanish through the two organizations' Web sites at <http://www.unfpa.org> and <http://www.ippf.org>.

•Two reports from The Alan Guttmacher Institute (AGI) identify deficits in reproductive health care around the world. In Their Own Right: Addressing the Sexual and Reproductive Health Needs of Men Worldwide analyzes the sexual and reproductive behavior and needs of men in 45 countries, from sexual initiation through marriage and parenthood. Adding it Up, jointly published with the United Nations Population Fund, estimates global burdens resulting from gaps in sexual and reproductive health care, and illustrates the broad societal and individual impact—especially in poor countries—that investments in such care would have. Both publications are available from AGI's Web site: <http://www.guttmacher.org>.