Advancing Sexual and Reproductive Health and Rights
International Perspectives on Sexual and Reproductive Health
Volume 35, Number 3, September 2009


China's one-child policy and the use of sex-selective abortion have resulted in an estimated excess of nearly 33 million males under the age of 20, according to an analysis of data from China's 2005 intercensus survey, which was based on a representative sample of 1% of the country's total population.1 In the 12 months before the survey, 120 male children were born for every 100 females—equaling 11,320 more males than females born among the sample that year. If extrapolated to the whole Chinese population, an estimated excess of 1,132,000 males were born during the year prior to the survey, and among the entire population younger than 20 in 2005, males outnumbered females by 32,706,400. For all children younger than 20, the sex ratio peaked at 124 among 1–4-year-olds and decreased among older age-groups, suggesting that China's bias toward male children increased between 1986 and 2004, corresponding to the growing availability of ultrasound equipment used to detect fetal sex. Furthermore, in rural "type 2" provinces—those where most couples are allowed to have a second child if their first is a female—sex ratios for second-order births were as high as 190, strongly suggesting that couples are aborting female fetuses. The researchers comment that their data "suggest that the sex ratio is related to the way in which the [one-child policy] is implemented." They conclude that "changing the regulations in force in type 2 provinces, which permit most couples a second child after a female birth, could help to reduce the sex ratio."

1. Zhu WX, Lu L and Hesketh T, China's excess males, sex selective abortion, and one child policy: analysis of data from 2005 national intercensus survey, BMJ, 2009, <>, accessed May 4, 2009.


HIV-related stigma and discrimination against people living with HIV are associated with lack of knowledge of antiretroviral medications and never having discussed HIV.1 According to a 2005–2006 study of 14,203 people aged 18–32 in five sites in four countries (Soweto, South Africa; Vulindlela, South Africa; Kisarawe, Tanzania; Chiang Mai, Thailand; and Mutoko, Zimbabwe), one-third reported having ever been tested for HIV (ranging from 9% in Zimbabwe to 49% in Soweto), about half (53%) had heard of antiretroviral medications (ranging from 28% in Zimbabwe to 76% in Soweto) and two-thirds (69%) had ever discussed HIV/AIDS (ranging from 51% in Tanzania to 89% in Soweto). In all five sites, respondents who had never talked about HIV/AIDS were more likely than others to believe that people living with HIV should be ashamed and isolated (odds ratios, 1.5–2.3); having no knowledge of antiretroviral medications was positively associated with such negative attitudes in all sites except Soweto (1.5–3.3), and never having been tested for HIV was positively associated with negative attitudes in Thailand (1.7). Lack of knowledge of antiretroviral medications was positively associated with perceived discrimination against people living with HIV in Thailand (4.0) and negatively associated with perceived discrimination in South Africa and Zimbabwe (0.7–0.8). Never having talked about HIV was positively associated with discrimination in Tanzania (1.6) and negatively associated with discrimination in Soweto (0.7). Overall, the sites with the lowest HIV prevalence (Tanzania and Thailand) had the most negative attitudes toward people living with HIV, whereas the sites with the lowest antiretroviral coverage (Tanzania and Zimbabwe) had the greatest perceived discrimination against HIV-positive individuals. The authors suggest that "universal access to treatment for HIV and widespread educational and prevention efforts…may reduce HIV/AIDS-related stigma and discrimination."

1. Genberg BL et al., A comparison of HIV/AIDS-related stigma in four countries: negative attitudes and perceived acts of discrimination towards people living with HIV/AIDS, Social Science & Medicine, 2009, 68(2009):2279–2287.


Cessation of breast-feeding plays a small mediating role in the association between maternal CD4 count and child mortality, according to an analysis of data from the Zambia Exclusive Breastfeeding Study conducted in Lusaka.1 Of the pregnant HIV-positive women recruited for the study between May 2001 and September 2004 and counseled to breast-feed their baby exclusively for at least six months, 357 had live-born, singleton infants who did not test positive for HIV during the 18-month follow-up period. Forty-five of those infants died during the study period, 17 within the first six months. Fifty-five percent of mothers had a CD4 count during pregnancy of more than 500, 28% had a CD4 count between 200 and 500, and 18% had a CD4 count of less than 200. Compared with children whose mother had a CD4 count of more than 500, those whose mother had a CD4 count of less than 200 had an increased risk of death (incidence rate ratio, 3.2). Similarly, a low maternal CD4 count was positively associated with cessation of breast-feeding (1.8). In regression analyses that estimated the association between maternal CD4 count and child mortality, with and without adjustment for breast-feeding, only a small amount of the association was mediated through cessation of breast-feeding. The authors suggest that in addition to breast-feeding, factors such as infectious disease, low birth weight and poor growth also explain the association between maternal CD4 count and child mortality.

1. Fox MP et al., Role of breastfeeding cessation in mediating the relationship between maternal HIV disease stage and increased child mortality among HIV-exposed uninfected children, International Journal of Epidemiology, 2009, 38(2):569–576.


Bangladeshi children whose mothers have experienced intimate partner violence have increased odds of diarrhea and acute respiratory tract infection—two leading causes of childhood mortality.1 According to a study of data from matched couples collected in the 2004 Bangladesh Demographic Health Survey, of the 1,592 currently married women who had at least one child five years old or younger, 42% had had violence perpetrated against them by their husband in the past year. The prevalence of recent intimate partner violence was significantly higher among younger women, those with lower levels of education or wealth and those with a child younger than two years old. Sixteen percent of mothers reported having a child who had an illness that fit the criteria of acute respiratory tract infection within the past two weeks, and 9% said that their child had had diarrhea during that time. In multivariate analyses adjusted for maternal, household and environmental characteristics, children of women who had experienced intimate partner violence in the past year were more likely than children of women who had not to have had an acute respiratory tract infection or diarrhea within the past two weeks (odds ratios, 1.4 and 1.7, respectively). The authors conclude that "associations of maternal experiences of [intimate partner violence] with two leading causes of childhood mortality…strongly suggest that this violence threatens not only the health and well-being of women but also that of their young children."

1. Silverman JG et al., Maternal experiences of intimate partner violence and child morbidity in Bangladesh, Archives of Pediatric & Adolescent Medicine, 2009, 163(8):700–705.


Rates of infection with five common STIs—HIV, herpes simplex virus type 2 (HSV-2), chlamydia, gonorrhea and syphilis—among Pakistan's general urban male population are low, according to a study of 16–45-year-old men living in six major Pakistani cities in 2007.1 Overall, one or more of the infections were diagnosed in 4.4% of the 2,400 males who participated in the cross-sectional survey and provided urine and blood samples for laboratory analyses; the prevalence rates for individual infections were HIV 0.1%, HSV-2 3.4%, chlamydia 0%, gonorrhea 0.8% and syphilis 1.3%. In multivariate analyses, having an STI was positively associated with being younger than 27, having 10 or fewer years of education and having had four or more sexual partners in the 12 months prior to the survey (odds ratios, 2.1–4.3). The authors comment that in spite of low overall STI rates, the prevalence of genital herpes is "a matter of concern because of its perceived link with the spread of HIV."

1. Mir AM et al., STI prevalence and associated factors among urban men in Pakistan, Sexually Transmitted Infections, 2009, 85(3):199–200.


The proportion of women in Malaysia who would have their children vaccinated against human papillomavirus (HPV) is comparable to that among women in other Asian countries, according to a study conducted in Kuala Lumpur in May 2007.1 Of the sample of 362 women who reported having at least one child younger than 18, 33% had knowledge of genital warts, 12% had heard of HPV and 11% were familiar with the HPV vaccine. Of women who had knowledge of HPV or genital warts, 68% knew that the virus is sexually transmitted and 56% knew that it is associated with cervical cancer. Sixty-eight percent of mothers reported being willing to have their daughters vaccinated against HPV, and 56% would allow their sons to be vaccinated. Vaccination acceptance was positively associated with personally knowing someone with cancer and negatively associated with increased age; acceptance was not associated with HPV knowledge, religion, education or income. More than 84% of women cited cost as a reason for not being willing to have their daughters and sons vaccinated against HPV. If the vaccine were provided free of cost, nearly all (98%) of mothers would have their children vaccinated. The authors comment that the HPV vaccination acceptance rates in Malaysia were within the range of those previously reported for other Asian countries, despite Malaysia's sexual conservatism.

1. Sam IC et al., Maternal acceptance of human papillomavirus vaccine in Malaysia, Journal of Adolescent Health, 2009, 44(2009):610–612.


Sexual violence among young women is common in Swaziland, and is associated with serious long-term health outcomes, according to a nationally representative survey of 13–24-year-old women conducted between May and June 2007.1 Of the 1,242 respondents, 33% reported experiencing at least one incident of sexual violence before age 18; 19% reported attempted unwanted intercourse, 14% unwanted touching, 9% coerced intercourse and 5% forced intercourse. Most commonly, a respondent's first experience of sexual violence came at the hands of a man or boy from the neighborhood or her boyfriend or husband, in her home or the house of a friend, relative or neighbor. In multivariate analysis adjusted for age, community setting, socioeconomic status and orphan status, women's experience of sexual violence was positively associated with depression, suicidal thoughts, unwanted pregnancy, pregnancy complications or miscarriage, sexually transmitted infections, difficulty sleeping and use of alcohol (odds ratios, 1.2–3.7). The authors comment that "The true extent and severity of the effect…from exposure to violence in early childhood is unknown, but the magnitude of the problem and the documented consequences of this type of violence is cause for great concern."

1. Reza A et al., Sexual violence and its health consequences for female children in Swaziland: a cluster survey study, Lancet, 2009, 373(9679):1966–1972.