Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 31, Number 4, December 2005
UPDATE


FAMILY PLANNING OUTREACH MAINTAINS WOMEN'S USE OF MODERN METHODS

Bangladeshi women who have had contact with family planning outreach workers are less likely than those who have not to switch from using modern contraceptive methods to not using a method, according to a study in four rural subdistricts.1 Using longitudinal surveillance data from 1990-1992, researchers studied contraceptive switching among women who adopted a modern method. Twelve months after beginning use, 51% of 1,706 women who chose the pill continued to use the method, and 30% were no longer using any method and were at risk of unintended pregnancy. Among 1,474 women who initiated another modern method (i.e., the injectable, the IUD or condoms), 32-69% continued to use the method after a year, and 15-31% no longer used a method and were at risk of unintended pregnancy. Among pill users, a greater proportion of those who had not had contact with a family planning worker than of those who had were not using any method and were at risk of unintended pregnancy (38% vs. 28%); those proportions were similar among women who had used a modern method other than the pill (39% vs. 25%). In analyses controlling for selected social, demographic and economic variables, contact with family planning outreach workers was associated with a decreased risk of switching from use of the pill or another modern method to nonuse of a method and being at risk of unintended pregnancy. Given that outreach workers at the time of data collection visited only about one-third of married women in any given six-month period, the authors conclude that if that level of family planning outreach services is maintained or increased, "one may expect that contraceptive use and continuity of use in Bangladesh will increase."

1. Hossain MB, Analysing the relationship between family planning workers' contact and contraceptive switching in rural Bangladesh using multilevel modeling, Journal of Biosocial Science, 2005, 37(5):529-554.

MALE CIRCUMCISION AS AN HIV INTERVENTION

Circumcised men have a significantly lower risk of acquiring HIV than do uncircumcised men, according to a controlled intervention trial in and around Orange Farm, South Africa.1 Between July 2002 and February 2004, researchers recruited 3,128 uncircumcised, HIV-negative men aged 18-24 and randomly assigned them either to the intervention (circumcision) group or to the control group. Although the study was designed to follow men over 21 months, the trial was stopped early, and the researchers were not able to follow all participants over the full trial period (mean follow-up time, 18.1 months). Overall, 69 participants became infected with HIV during the study—11 during the first three months after screening, 22 during the next nine months and 36 during the following nine months. Of the men who became infected, 20 were in the intervention group and 49 were in the control group, corresponding to a 60% reduction in the risk of HIV infection. In multivariate analyses controlling for condom use and other sexual and health-seeking behaviors, circumcised men had a 61% reduction in risk. The authors conclude that male circumcision may be an important way to reduce HIV transmission to males in Sub-Saharan Africa, especially "at a time when no vaccine or microbicides are currently available and when delivering antiretroviral treatments under WHO guidelines will have only a small impact on the spread of HIV."

1. Auvert B et al., Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial, PLoS Medicine, 2005, 2(11):e298.

INTERVENTIONS FAIL TO REACH MANY POOR CHILDREN

Around the world, economic inequities create substantial disparities in the proportions of children who receive preventive health interventions—even in countries where many such programs are available.1 Using Demographic and Health Survey data from Bangladesh, Benin, Brazil, Cambodia, Eritrea, Haiti, Malawi, Nepal and Nicaragua, researchers assessed coverage of eight preventive interventions for children aged 12-59 months, such as measles vaccine, vitamin A supplementation and safe water. The proportion of children who did not receive even one of the eight interventions ranged from less than 1% in Bangladesh, Brazil, Malawi and Nicaragua to 19% in Cambodia; the mean number of interventions received by children ranged from 2.7 in Cambodia to 5.9 in Brazil and Nicaragua. In all countries, there were substantial inequities by economic status, with the poorest children receiving the fewest number of interventions. In Haiti, for example, 32% of the poorest children received 0-1 interventions, compared with only 1% of the most affluent children. Economic disparity seemed to be inversely related to the country's level of coverage: Countries with the least coverage had the greatest inequity between wealthy and poor children (e.g., Cambodia, Eritrea and Haiti), and the countries with the highest coverage had the least inequity (e.g., Brazil and Nicaragua). In light of the variability in inequity patterns, the authors comment that "although the ultimate objective should be universal coverage with essential interventions, approaches may vary from country to country," suggesting broad dissemination in countries where a large proportion of children remain uncovered and "geographical or family-level targeting" in countries where a "relatively small proportion of all children are lagging behind."

1. Victora CG et al., Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys, Lancet, 2005, 366(9495):1460-1466.

CIRCUMCISION REDUCES CHLAMYDIA TRANSMISSION

Women who have circumcised partners have a reduced risk of having ever been infected with chlamydia, according to a study using pooled couples data from Brazil, Colombia, the Philippines, Spain and Thailand.1 Among 300 women who reported having a husband or stable male partner and who provided a blood sample to be tested for the presence of chlamydia antibodies, 28% tested positive—20% of women with circumcised partners and 33% of women with uncircumcised partners. The risk of ever having had chlamydia was elevated among women who reported having had two or more lifetime sexual partners, having been 17 or younger at first sex, having a partner who had had 11 or more lifetime sexual partners, or having a partner who had had 11 or more partners who were sex workers (odds ratios, 2.2-2.7). In multivariate analysis, women who had a circumcised partner were significantly less likely than those who had an uncircumcised partner to test positive for chlamydia antibodies (0.2); other factors negatively associated with testing positive for chlamydia included being 49 or older, having had only one lifetime sexual partner and having been 18 or older at first sex (0.1-0.2). The authors conclude that their study "supports the possibility that, as reported for other sexually transmitted infections, male circumcision reduces the risk of transmitting C. trachomatis to the female partner."

1. Castellsagué X et al., Chlamydia trachomatis infection in female partners of circumcised and uncircumcised adult men, American Journal of Epidemiology, 2005, 162(9):907-916.

U.S. LAW AIMS TO PROTECT WORLD'S ORPHANS

On November 8, 2005, President Bush signed into law a bill that creates a special advisor position within the U.S. Agency for International Development to coordinate U.S. assistance to orphans and other vulnerable children in developing countries.1 The law, known as the Assistance for Orphans and Other Vulnerable Children in Developing Countries Act of 2005, requires that the United States develop a comprehensive strategy to improve children's access to services, such as basic care, psychosocial support, school food programs and HIV/AIDS treatment. According to congressional findings, as of July 2004, there were an estimated 143 million children living in Sub-Saharan Africa, Asia, Latin America and the Caribbean who had lost at least one parent. Of those, approximately 16 million had lost both parents—the vast majority of whom died of AIDS.

1. The White House, Office of the Press Secretary, <http://www.whitehouse.gov/news/releases/2005/11/20051108-9.html>, accessed Dec. 9, 2005; and Kaiser Family Foundation, <http://www.kaisernetwork.org/daily_reports/rep_index. cfm?hint=1&DR_ID=33322>, accessed Dec. 9, 2005.

MISOPROSTOL REDUCES POSTPARTUM HEMORRHAGE

Postpartum administration of misoprostol, which does not require refrigeration, beneath the tongue could reduce morbidity and mortality from hemorrhage among women in low-resource areas of developing countries, according to a double blind clinical trial in Guinea-Bissau.1 Between March 2003 and August 2004, researchers recruited 660 women who presented at the national hospital in Bissau to give birth. Before their deliveries, participants were asked to choose an envelope containing either misoprostol or placebo tablets. After delivery, the women placed the medication they had chosen beneath their tongues and were asked to sit on absorbent material, or wear a pad, for 60 minutes. Fifty-one percent of women in the control group lost more than 500 ml of blood, 17% lost more than 1,000 ml and 8% lost more than 1,500 ml; these proportions among women in the misoprostol group were 45%, 11% and 2%, respectively. Compared with women in the control group, those in the misoprostol group had a significantly reduced risk of experiencing postpartum hemorrhage, with the risk decreasing as the severity of blood loss increased (relative risks; 0.9, 0.7 and 0.3, respectively). The authors suggest that sublingual misoprostol could "play an important part" in reducing complications of delivery and maternal mortality in the developing world, where a large proportion of women give birth at home with only the help of unskilled birth attendants.

1. Høj L et al., Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomized double blind clinical trial, BMJ, 2005, 331(7519):723-727.

In Brief

•UNICEF has launched Unite for Children, Unite Against AIDS, a global campaign to draw attention to the impact of the AIDS epidemic on children. The campaign's imperatives include preventing mother-to-child transmission of HIV, providing pediatric treatment, preventing infection among young people, and protecting and supporting children affected by HIV/AIDS. More information can be found at <http:// www.unicef.org/uniteforchildren/index.html>.

•An advocacy brief released by the Global AIDS Alliance urges the Global Fund to Fight AIDS, Tuberculosis and Malaria to focus its next round of grants on providing comprehensive support to children in developing countries—a population that is among the most profoundly affected by epidemic disease worldwide. The brief, entitled Remember the Children: Global Fund Round 6 in 2006, is available at <http://www.globalaidsalliance.org/Remember_the_ Children. cfm>.

Human Development in South Asia 2004: The Health Challenge, a report from Pakistan's Mahbub ul Haq Human Development Centre, finds that despite the region's great economic growth, it has the second highest maternal mortality rate in the world and accounts for one of every three child deaths. The report calls on South Asian governments to improve the health care of women and children. [Mahbub ul Haq Human Development Centre, Human Development in South Asia 2004: The Health Challenge, Karachi, Pakistan: Oxford University Press, 2005.]