Advancing Sexual and Reproductive Health and Rights
International Family Planning Perspectives
Volume 32, Number 1, March 2006


The use of a checklist that helps providers rule out pregnancy can reduce the proportion of women in developing countries who are denied their desired contraceptive method because they are not menstruating at the time of their clinic visit.1 Between 2001 and 2003, researchers collected demographic and service data from female clients of 16 family planning clinics in Guatemala, Mali and Senegal before and 3–6 weeks after instructing providers in the use of a set of World Health Organization–recommended criteria that can determine with reasonable certainty whether a woman is pregnant. After the intervention was implemented, the proportion of new family planning clients who were denied their desired contraceptive method because of menstrual requirements decreased in Guatemala (from 16% to 2%) and Senegal (from 11% to 6%); in Mali, the denial rate—which was already low (5%) at baseline—did not decrease after the intervention. In multivariate analyses, providers' exposure to the checklist was associated with decreased odds that new family planning clients in Guatemala and Senegal would be denied their desired contraceptive method because of menstrual requirements (odds ratios, 0.1 and 0.4, respectively). The authors conclude that where denial of services to non-menstruating family planning clients is a problem, the simple, low-cost introduction of a pregnancy checklist can reduce service-denial rates significantly.

1. Stanback J et al., Ruling out pregnancy among family planning clients: the impact of a checklist in three countries, Studies in Family Planning, 2005, 36(4):311–315. 1


Many reproductive health care providers are unfamiliar with important evidenced-based interventions, according to a recent study in northwest Cameroon.1 In February 2004, researchers surveyed 328 providers (including 54 physicians, 140 nurses and 102 midwives) about their awareness and use of 13 evidence-based reproductive health interventions. Six of the interventions were unfamiliar to more than half of respondents. In addition, awareness was low for two vital interventions: administering corticosteroids to prevent preterm birth (29%) and using magnesium sulfate to treat pregnancy-related seizures or coma (49%). Larger proportions of providers were aware of two other vital interventions—peripartum HIV prophylaxis (89%) and drugs to manage bleeding during the third stage of labor (83%). Only 15% of respondents were familiar with all four vital interventions, and just 4% used them all regularly. Follow-up interviews with 26 respondents indicated that lack of awareness resulting from deficiencies in education and training was the primary reason for nonuse of evidence-based interventions. However, the respondents also cited financial limitations and a lack of supplies as obstacles to use. The authors comment, There is an urgent need to design programmes to improve the awareness and use of evidence-based reproductive health care in countries like Cameroon. They note, as well, that devising mechanisms to maintain the availability of the supplies needed for these interventions is crucial.

1. Tita A et al., Evidence-based reproductive health care in Cameroon: population-based study of awareness, use and barriers, Bulletin of the World Health Organization, 2005, 83(12):895–903. 1


Mass media campaigns, interventions for female sex workers and STI treatment programs are the most cost-effective strategies developing countries can use to achieve the millennium development goal of halting and reversing the spread of HIV/AIDS by 2015, according to an analysis of the Sub-Saharan African and South East Asian regions.1 Using an epidemiological model, the researchers estimated the individual and combined effectiveness and costs of various HIV/AIDS prevention and treatment interventions. In both regions, interventions aimed at educating and treating female sex workers were the most successful in terms of the greatest number of disability adjusted life years averted; on the other hand, school-based education programs were the least successful. Mass media campaigns, education and treatment interventions for female sex workers and STI treatment programs were the most cost-effective of the HIV/AIDS interventions considered (each costing approximately $3–32 per disability adjusted life year averted), and a package including those programs and others could be offered relatively inexpensively (less than $150 per disability adjusted life year averted). And because of recent reductions in the cost of antiretroviral drugs, inclusion of such therapies in HIV/AIDS treatment interventions is now cost-effective. In light of their findings, the authors comment that financial constraints should not be regarded as the principal obstacle to implementing a comprehensive approach to combatting HIV/AIDS.

1. Hogan DR et al., Cost effectiveness analysis of strategies to combat HIV/AIDS in developing countries, BMJ, 2005, 331(7530):1431–1437.


The more tea women drink, the lower their risk of ovarian cancer, according to findings from a population-based study in Sweden.1 In a large cohort of women who were followed for an average of 15 years, those who drank two or more cups of tea every day had a 46% lower risk of ovarian cancer than those who seldom or never drank tea. And the more tea consumed, the greater the effect: For every cup of tea a woman drank per day, her risk of ovarian cancer declined by 18%. The researchers acknowledge that the relatively high level of health consciousness found among women in the cohort who drank two or more cups a day may help explain the findings, but they add that the robustness of the associations in age-adjusted analyses argues against such confounding.

1. Larsson SC and Wolk A, Tea consumption and ovarian cancer risk in a population-based cohort, Archives of Internal Medicine, 2005, 165(22):2683–2686. 1


An HIV service organization in Moshi, Tanzania, increased its average daily number of clients tested and improved the cost-effectiveness of its HIV outreach by offering free counseling and testing.1 For two weeks in July 2003, the organization waived its fee for voluntary testing and counseling as part of a widely advertised campaign. During the free testing period, the average daily number of clients who underwent testing was significantly higher than the daily average prior to the campaign (15.0 vs. 4.1); furthermore, it remained elevated during the 80 days following the campaign (7.1). Some 347 more people presented for testing during the campaign and postcampaign periods than would have been expected had the clinic not offered free testing. Researchers estimate that the per-client cost for a program offering free HIV counseling and testing year-round would be $6.35, compared with $7.38 for a program offering free testing for two weeks per year and $11.92 for a program with no free testing period—assuming no increases in fixed costs. Furthermore, the cost per infection averted and per disability-adjusted life year prevented could be decreased by 38% or 46%, depending on the duration of the free testing period. The authors comment that investing enough funds to maximize testing capacity could be a relatively simple, cost-effective step toward preventing new HIV infections and facilitating access to expanding HIV treatment programs.

1. Thielman NM et al., Cost-effectiveness of free HIV voluntary counseling and testing through a community-based AIDS service organization in Northern Tanzania, American Journal of Public Health, 2006, 96(1):1–119.


The withdrawal of donor support does not necessarily mean the end for contraceptive social marketing interventions in middle-income countries.1 Analyses of Demographic and Health Survey data and retail sales information from the Dominican Republic, Morocco, Peru and Turkey show that programs that partnered with a local contraceptive manufacturer or distributor were able to retain their market share even after donor support ended. For example, in Turkey, a joint campaign by the Turkish Family Health and Planning Foundation and a local condom distributor had achieved a two-thirds market share for their product by the time their USAID funding ended; five years later, their market share remained unchanged. Such success, however, is not guaranteed, but is determined by several factors, including reaching satisfactory levels of acceptance and use of the method, the absence of public-sector competition and having partners who are committed to continuing their funding of promotional activities.

1. Agha S, Do M and Armand F, When Donor Support Ends: The Fate of Social Marketing Products and the Markets They Help Create, Bethesda, MD, USA: Private Sector Partnerships–One Project, 2005.


Because it is a reusable, female-controlled contraceptive method that may protect against some STIs, the diaphragm could be a useful alternative for female sex workers in resource-poor areas, according to a preliminary 2004 study conducted in three urban areas of Madagascar.1 Researchers recruited female sex workers who presented at clinics for voluntary, government-recommended STI testing and treatment; 91 eligible participants were fitted with a diaphragm and were instructed to wear it at all times, except for cleaning once a day. Over the eight-week study period, which included three follow-up visits, 89–95% of women reported using the diaphragm during every act of intercourse. In addition, 39–48% of women used condoms at every intercourse—about the same proportion who did so at baseline (42%). Seven women became pregnant during the study period, equaling a pregnancy incidence of 53 per 100 woman years. The proportion of participants who reported vaginal discharge or pelvic tenderness peaked at the one-week follow-up (21%), but dropped back to the baseline level (8%) by the final visit. Given the large proportion of women who used the diaphragm consistently and the low overall level of problems reported, the authors suggest that the diaphragm could be an acceptable female-controlled method of pregnancy and STI prevention among sex workers, although more research is needed in light of the short study period and high pregnancy rate.

1. Behets F et al., Acceptability and feasibility of continuous diaphragm use among sex workers in Madagascar, Sexually Transmitted Infections, 2005, 81(6):472–476.


The prevalence of syphilis has decreased sharply among pregnant women in northern Botswana, a finding that could signal a future decline in HIV transmission in the country.1 According to test results from Botswana's second largest city, Francistown, the overall prevalence of syphilis among pregnant women remained stable at 12–14% from 1992 to 1996, but had fallen to 4% by 2003. In contrast, the overall prevalence of HIV among pregnant women in Francistown remained at 40–46% between 1996 and 2003; however, it declined among pregnant women aged 15–19. The authors note that infections in this age-group are mostly new and hence may reflect future trends in the general population. They conclude that the substantial decline in the prevalence of syphilis, growing evidence of safer sexual behavior and the recent decreases in HIV prevalence among young pregnant women may all point towards a decrease in sexual transmission of HIV in Botswana.

1. Creek TL et al., Declining syphilis prevalence among pregnant women in northern Botswana: an encouraging sign for the HIV epidemic? Sexually Transmitted Infections, 2005, 81(6):453–455.