Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 32, Number 3, September 2006
UPDATE


SMALL CHANGE IN DELIVERY MAY MAKE A BIG DIFFERENCE

A slight delay in clamping the umbilical cord after delivery may prevent newborns from developing iron deficiency early in life.1 As part of a study conducted between October 2003 and July 2004 in a large obstetrics hospital in Mexico City, 358 expecting mothers were randomly selected into two groups: early clamping, in which infants' umbilical cords were clamped an average of 17 seconds after delivery, and delayed clamping, in which the cords were clamped an average of 94 seconds after delivery. At six months of age, infants from the delayed clamping group had a higher average red blood cell volume (81.0 vs. 79.5 femtoliters), a greater concentration of the iron-binding protein ferritin (50.7 vs. 24.4 micrograms per liter) and greater total body iron (47.9 vs. 43.9 micrograms per kilogram of bodyweight) than did infants from the early clamping group. In addition, delayed clamping had greater effects among infants born to mothers who had low ferritin at delivery, those with birth weights of 2,500–3,000 grams and those still breastfed at six months. Given the high prevalence of maternal iron deficiency and of birth weights lower than 3,000 grams in developing countries, the authors comment that delaying clamping presents "an invaluable opportunity to increase an infant's iron endowment at birth, thereby ensuring adequate iron status until other interventions can be more easily implemented."

1. Chaparro CM et al., Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomized controlled trial, Lancet, 2006, 367(9527):1997–2004.

BANGLADESHI WOMEN RARELY SEEK HELP FOR ABUSE

Although the prevalence of physical violence against women by their husbands is high in Bangladesh, only a small proportion of women discuss the problem and an even smaller proportion seeks help.1 Of 2,702 ever-married Bangladeshi women who participated in a cross-sectional survey, 40% of those living in urban areas and 42% of those living in rural areas had ever been physically abused by their husband. Among women who had experienced physical violence, 66% reported never talking to anyone about their abuse; common reasons for not talking included stigma, fear of repercussions and the belief that violence is the husband's right. When abused women did talk to someone, the most common confidants were their parents, siblings or neighbors; only 2% of women sought assistance from institutional sources. More than half of women who had experienced physical violence reported that nobody ever helped them. Given the small proportion of abused women who sought help from formal sources, the authors comment that "providing only institutional support to help women living in violent relationships would not achieve desirable goals." They suggest that "education and mass media are probably the two most powerful tools" to help women overcome the barriers to accessing services.

1. Naved RT et al., Physical violence by husbands: magnitude, disclosure and help-seeking behavior of women in Bangladesh, Social Science & Medicine, 2006, 62(12):2917–2929.

AN UNINTENDED CONSEQUENCE OF CHINA’S ONE-CHILD POLICY?

Although China's "one-child" policy has substantially reduced the country's birthrate and women's preferred family size, it seems to have increased the male-to-female birth ratio as well.1 According to data from 39,585 women collected by the Chinese National Family Commission between July and September 2001, women older than 35 had an average of 1.9 births and women younger than 35 who said they had completed their families had an average of 1.7 births; before the one-child policy, the average fertility rate was 2.9. The low fertility rate was accompanied by a preference for small families: Overall, 35% of women wanted to have one child and 57% wanted two; only 6% preferred to have more than two children. However, the male-to-female birth ratio across the entire cohort was 1.15, substantially higher than the normal sex ratio of 1.03–1.07. And when analyzed by five-year periods, the sex ratio was 1.21 in 1990–1995 and 1.23 in 1996–2001. The authors suggest the imbalance is most likely caused by sex-selective abortion, female infanticide, less aggressive management of newborn girls who are sick and nonregistration of girls.

1. Ding QJ and Hesketh T, Family size, fertility preferences, and sex ratio in China in the era of the one child policy: results from national family planning and reproductive health survey, BMJ, 2006, <http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38775.672662.80v1>, accessed Aug. 9, 2006.

ANTENATAL CARE LEADS TO USE OF OTHER HEALTH SERVICES

Women who receive antenatal care are significantly more likely than those who do not to use other maternal health services before, during and after delivery, according to a study using 2002 District Level Household Survey data from 11,454 currently married women aged 15–44 in Uttar Pradesh, India.1 The study examined the factors associated with women's use of maternal health services, including seeking treatment for pregnancy-related complications (among those who experienced problems), delivering a baby in a medical facility, receiving assistance from a trained professional when delivering outside of a medical facility and seeking treatment for postpartum complications. In descriptive analysis, the proportions of women who used the four maternal health services varied by social, demographic and community characteristics. In multivariate analyses controlling for such characteristics, women receiving antenatal services had odds of using other maternal health services up to 4.9 times those of other women, depending on the service and the level of antenatal care received. Noting that women in Uttar Pradesh are at high risk of pregnancy-related morbidity and mortality because a majority deliver outside medical facilities, the authors conclude that "concerted efforts are required to motivate women to utilize antenatal services."

1. Ram F and Singh A, Is antenatal care effective in improving maternal health in rural Uttar Pradesh? Evidence from a district level household survey, Journal of Biosocial Science, 2006, 38(4):433–448.

SYNDROMIC MANAGEMENT: NOT FOR PREGNANT WOMEN

The low effectiveness of syndromic management algorithms for women may leave many pregnant women with untreated vaginal infections that could lead to adverse pregnancy outcomes, according to a study of 250 pregnant women aged 15–40 who attended an antenatal clinic in Entebbe, Uganda, in March or April of 2004.1 Laboratory tests determined that 48% of the women had bacterial vaginosis and 17% had trichomoniasis. However, 40% of women with bacterial vaginosis and 31% of those with trichomoniasis were asymptomatic, and thus would not have been treated under syndromic management guidelines. If the clinic's health workers had followed the syndromic management algorithm exactly, the sensitivity in targeting bacterial vaginosis and trichomoniasis would have been 60% and 70%, respectively; however, as the workers tended to use their own judgment and deviate from the guidelines, the actual sensitivities were 50% and 67%, respectively. The authors comment that "While there is some evidence that effective treatment of vaginal infections during pregnancy may prevent adverse birth outcomes, reliance on syndromic management is unlikely to achieve this goal." They suggest that clinics institute presumptive treatment instead.

1. Tann CJ et al., Lack of effectiveness of syndromic management in targeting vaginal infections in pregnancy in Entebbe, Uganda, 2006, Sexually Transmitted Infections, 82(4):285–289.

NEONATAL INTERVENTIONS AND INFANT DEATHS IN CHILE

Neonatal care interventions may help explain the reduction of mortality among newborns during the 1990s, according to an analysis of Chilean Ministry of Health data from 2.9 million births that occurred between 1990 and 2000.1 The overall mortality rate in Chile among infants younger than 28 days decreased from 8.3 deaths per 1,000 live births in 1990 to 5.7 in 2000. This decrease, however, did not occur because of reductions in the rates of premature, low-birth-weight and very low birth weight deliveries, as those rates remained stable throughout the decade. When patterns of neonatal mortality were examined by birth weight and gestational age, reductions were observed in all groups; however, the greatest proportional reductions were seen in the lowest birth weight and gestational age categories. In analyses by year, reductions were more noticeable in the years after implementation of certain neonatal care interventions nationwide, such as neonatal cardiorespiratory resuscitation training in 1994 and surfactant therapy in 1998. The authors conclude that such interventions may have "played a role in the decline of neonatal mortality that was observed between 1990 and 2000."

1. Gonzalez R et al., Reduction in neonatal mortality in Chile between 1990 and 2000, Pediatrics, 2006, <http:// pediatrics.aappublications.org/cgi/ content/full/117/5/e949>, accessed Aug. 17, 2006.

MIGRANT MEN MAY ACT AS A BRIDGE FOR HIV IN PAKISTAN

Unsafe sex practices and low levels of HIV knowledge among migrant male workers in Pakistan could accelerate transmission of HIV from high-risk groups, such as sex workers, to the general population.1 Of the sample of 590 migrant men in Lahore, Pakistan, who completed interviews, three-quarters were sexually experienced; of those, 22% had ever had sex with a female sex worker. Only 10% of men had used a condom at last sex with a sex worker, and 72% reported never using condoms with sex workers. And although 87% of men were aware of AIDS, about two-thirds believed that a good diet was protective against infection, and only 11% believed that a person infected with HIV could look healthy. Furthermore, of men who were aware of AIDS and had had a nonmarital partner within the last year, 80% thought that they were at no risk of infection. The authors hypothesize that "If HIV spreads among sex workers…then further transmission to the general population via young migrant men…is a plausible scenario." They suggest that "renewed information and publicity about STI/HIV protection is clearly needed" and that "greater investment in condom social marketing might be justified."

1. Faisel A and Cleland J, Migrant men: a priority for HIV control in Pakistan? Sexually Transmitted Infections, 2006, 82(4): 307–310.

MANY COUNTRIES’ CONTRACEPTIVE USERS HAVE LIMITED CHOICE

According to an analysis of 96 countries with a population of at least one million people and a Demographic and Health Survey conducted since 1980, 34 have a skewed contraceptive method mix—defined as 50% or more of all contraceptive users reporting use of a single method.1 In 16 such countries, traditional methods (mainly periodic abstinence and withdrawal) prevail; most of these countries are located in Sub-Saharan Africa. In three Latin American countries and India, the contraceptive method mix is dominated by female sterilization. In the remaining 14 countries, a single reversible female method—the pill, the IUD or the injectable—accounts for at least half of all use. A complimentary review of the literature on the topic of method choice finds that many factors contribute to skewed method mix, but suggests that government policies can strongly influence method prevalence, and limited method availability may result in a "self-perpetuating cycle of acceptance of a method that has been available and widely used for a long time." The authors comment that skewed contraceptive method mix is not a problem in itself, but is "particularly problematic if driven by supply factors such as a restrictive population policy, lack of availability of a range of methods, lack of information on method choices, or provider bias toward one or two methods."

1. Sullivan TM et al., Skewed contraceptive method mix: why it happens, why it matters, Journal of Biosocial Science, 2006, 38(4):501–521.