Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 34, Number 3, September 2008
UPDATE


SMOKING MAY RAISE WOMEN’S RISK OF HPV

Women who smoke cigarettes may have an increased risk of human papillomavirus (HPV) infection, according to an analysis of HPV Prevalence Survey data from 10,577 women aged 15 years or older from nine countries around the world (Argentina, Chile, Colombia, Korea, Mexico, Nigeria, Spain, Thailand and Vietnam).1 Overall, the HPV prevalence of the sample was 13%, ranging from3% in Spain to 26% in Nigeria. Twenty-two percent of women reported ever having smoked cigarettes; the proportion ranged from2%in Nigeria to 56% in Chile. Compared with women who had never smoked, current smokers had higher odds of HPV infection, which increased with the number of cigarettes smoked per day (odds ratios, 1.2–2.0); former smokers’ odds of HPV infection did not differ fromthose of nonsmokers. In further analyses by lifetime number of partners, the association between smoking and HPV for current smokers remained significant only for women who had had only one lifetime partner (1.6 for women who smoked 5–14 cigarettes per day, and 3.0 for those who smoked 15 cigarettes or more per day). The authors suggest that the association between current smoking and HPV “could be explained by the local immunosuppressive effect of smoking that could facilitate the establishment or persistence of HPV infections.” However, they recommend that their “results should be interpreted with caution, mainly because residual confounding by sexual behaviour is difficult to rule out.”

1. Vaccarella S et al., Smoking and human papillomavirus infection: pooled analysis of the International Agency for Research on Cancer HPV Prevalence Surveys, International Journal of Epidemiology, 2008, 37(3):536–546.

MATERNAL EDUCATION AND LOW BIRTHWEIGHT IN CHINA

Education-related inequalities associated with low birth weight persisted in China from the early to late 1990s, despite an overall reduction in the proportion of low-birth-weight births during that time.1 According to an analysis of Perinatal Health Care Surveillance System data from 111,181 women in six counties in rural southern China who delivered a live singleton infant in either the early 1990s (1993–1994) or the late 1990s (1999–2000), the proportion of women with 12 or more years of education increased between the two times (7% and 12%, respectively). The overall rate of low birth-weight (i.e., less than 2,500g) births decreased, from 3% in the early 1990s to 2% in the late 1990s; low-birth-weight births decreased at all levels of maternal education for both male and female births. In multivariate analyses controlling for place of residence, the risk of having a low-birth-weight birth was negatively associated with maternal education at both time points: Compared with women who had fewer than nine years of education, those who had 9–11 years of schooling and those who had 12 or more years of schooling had lower odds of having a low-birth-weight birth in the early 1990s (odds ratios, 0.5–0.8) and the late 1990s (0.6–0.8). The authors comment that “education-related inequalities in low birthweight persisted in spite of an overall reduction in its frequency, suggesting that strategies to address and to monitor inequalities in child health should be implemented even before a child is delivered.”

1. Liu Y et al., Association of education and the occurrence of low birthweight in rural southern China during the early and late 1990s, American Journal of Public Health, 2008, 98(4)687–691.

HIV-POSITIVE WOMEN AND BREAST-FEEDING

Early, abrupt weaning of breast-fed infants by HIV-infected mothers does not increase the children’s HIV survival rates, according to a case-control study conducted in Lusaka, Zambia.1 Of the 958 pregnant HIV-positive women recruited for the study between May 2001 and September 2004, half were randomly assigned to the intervention group, in which women were counseled to breast-feed their baby exclusively for four months and then abruptly stop; the other half were assigned to a control group, in which women were counseled to breast-feed their baby exclusively for at least six months and then for as long as they chose after that. The median time HIV-positive women breast-fed their infants was four months for the intervention group and 16 months for the control group. After 24 months of follow-up, the two groups did not differ significantly in the proportion of children who were alive and without HIV infection (68% and 64%, respectively); similarly, the two groups did not differ in their HIV transmission rate (21% and 26%, respectively) or their mortality rate for uninfected children (14% each). Among children infected with HIV by four months, those in the intervention group had a higher 24-month mortality rate than did those in the control group (74% vs. 55%). The authors note that they “intentionally studied women in a region where economic circumstances were insufficient to ensure safe replacement feeding, so that [the] results would be generalizable to the populations that are most affected by the epidemic of HIV.”

1. Kuhn L, Effects of early, abrupt weaning on HIV-free survival of children in Zambia, New England Journal of Medicine, 2008, 359(2):130–141.

NO LINK BETWEEN STI RISK AND CIRCUMCISION

Male circumcision is not associated with women’s risk of acquiring chlamydia, gonorrhea or trichomonas from an infected partner, according to an analysis of data from a prospective cohort study conducted in Uganda, Zimbabwe and Thailand between 1999 and 2004.1 Of the 5,925 sexually active 18–35- year-old women who were interviewed at study enrollment and again every three months for approximately two years, 71% reported at baseline that their primary partner was uncircumcised; 19% had a circumcised partner and 10% did not know. A greater proportion of the partners of women in Uganda (26%) than of partners of women in Zimbabwe (9%) and Thailand (7%) were circumcised. Over the follow-up period, 408 women acquired chlamydia, 305 gonnorhea and 362 trichomonas. In multivariate analyses controlling for contraceptive method type, women’s age, women’s age at first sex and country, there were no differences in women’s risk of infection (each or any) by their primary partner’s circumcision status.

1. Turner AN et al., Male circumcision and women’s risk of incident chlamydial, gonococcal, and trichomonal infections, Sexually Transmitted Diseases, 2008, 35(7):689–695.

EMERGENCY OBSTETRIC CARE IN PAKISTAN IS DEFICIENT

Provision of emergency obstetric care in Punjab, Pakistan, needs to be increased and improved, according to a study of health care facilities in a random sample of 11 of the province’s 34 districts between July and September 2003.1 In the selected districts as a group, 16 facilities provide basic emergency obstetric services and 31 provide comprehensive emergency obstetric services; to meet the United Nations’ (UN) recommendations, the districts should have at least 203 basic and 52 comprehensive facilities to serve the combined population ofmore than 25 million. Only 2% of the districts’ births occurred in hospitals—far fewer than the minimum 15% recommended by the UN on the basis of the proportion of pregnant women who develop obstetric complications. Moreover, the UN recommends that all women who experience complications have access to and receive treatment froma health facility; of the estimated number of women in Punjab who experience complications, only 5% receive treatment. The authors suggest first focusing on “providing at least basic [emergency obstetric] services and making them accessible to the population.” Once available, “process indicators should bemonitored...to follow progress and track the availability, use, and quality of [emergency obstetric] services.”

1. Ali M, Ahmed KM and Kuroiwa C, Emergency obstetric care in Punjab, Pakistan: improvement needed, European Journal of Contraception and Reproductive Health Care, 2008, 12(2): 201–207.

MATERNAL MORTALITY HIGH FOR MONTHS AFTER BIRTH

Women in rural Bangladesh have an extremely high risk of death directly after giving birth and remain at elevated risk for up to six months.1 According to an analysis of data collected between 1983 and 2001 from more than 100,000 women aged 15–50, the mortality rate on the day of the pregnancy outcome was 2.6 deaths per 1,000 person-years. The rate was highest on the day after the pregnancy outcome (136.7 deaths per 1,000 person years) and then decreased steadily, but remained significantly elevated for up to 180 days. The 11% of pregnancies that ended in abortion or stillbirth accounted for half of all pregnancy related deaths within six weeks of pregnancy outcome. Compared with pregnancies that ended in live birth, those that ended in spontaneous abortion, induced abortion or stillbirth were associated with a greater risk ofmortality (relative risks, 1.7, 3.1 and 4.1, respectively); the length of time for which pregnancy-related mortality remained elevated did not vary by outcome. The authors suggest that “data on the causes of late post-partum deaths could help to shed light on the mechanisms underlying mortality up to six months after pregnancy.”

1. Hurt LS et al., Duration and magnitude of mortality after pregnancy in rural Bangladesh, International Journal of Epidemiology, 2008, 37(2):397–404.

INJECTABLE USE LINKED TO INCREASED HIV RISK

African women who have ever used an injectable hormonal contraceptive may have an increased risk of acquiring HIV, according to a study of Demographic and Health Survey data from 4,549 women aged 15–24 from Kenya, Lesotho, Malawi and Zimbabwe.1 HIV prevalence among women differed by country, from 8% in Kenya to 20% in Lesotho. The proportions of women who had ever used a hormonal contraceptive ranged from 16% to 29% for the injectable and from 15% to 58% for the pill. In multivariate analyses of the combined sample, women who had ever used the injectable had greater odds of being HIV-positive than did women who had never used the injectable, those who had ever used the pill and those who had ever used a traditional method (odds ratios, 1.3–1.4); having ever used the pill was not associated with HIV, regardless of reference group. The authors comment that the association between injectable use and HIV appears to be the result of some biological effect, but given the association’s small size, the injectable is “unlikely to play any major role in the HIV/AIDS epidemic in these countries.”

1. Leclerc PM, Dubois-Colas N and Garenne M, Hormonal contraception and HIV prevalence in four African countries, Contraception, 2008, 77(5): 371–376.

IN BRIEF

•Each year, the International Federation of Red Cross and Red Crescent Societies releases its World Disaster Report, which details the latest trends, facts and analyses of contemporary natural and manmade crises. Their 2008 edition focuses entirely on HIV and AIDS, calling for “humanitarian organisations, working in partnership with governments and local communities, to increase the scale and scope of programmes for HIV prevention, treatment and care, and for tackling the associated stigma and discrimination.” The full report is available at .

•In its 2008 World Population Data Sheet, the Population Reference Bureau provides up-to-date demographic, health and environment data for 209 countries and 25 regions of the world. The data sheet, which shows that the inequality in the population and health profiles of rich and poor countries is widening, is available at .