Advancing Sexual and Reproductive Health and Rights
 
International Perspectives on Sexual and Reproductive Health
Volume 36, Number 2, June 2010
UPDATE


THREE LEADING CAUSES OF CHILD DEATH IN CHINA

Pneumonia, birth asphyxia and complications of preterm birth were the three leading causes of deaths among children younger than five in China in 2008, according to an analysis of public data on child mortality from 1990 to 2008.1 During the study period, the national under-five mortality rate decreased by 71%, from 64.6 to 18.5 child deaths per 1,000 live births—meeting the fourth Millennium Development Goal of a two-thirds reduction in the 1990 level of child mortality by 2015. The mortality rate among neonates (<1 month) decreased by 70% between 1990 and 2008 (from 34.0 to 10.2), and the rate among postneonatal infants (1–11 months) decreased by 72% over that period (from 53.5 to 14.9). Pneumonia, birth asphyxia and preterm birth complications each accounted for 15–17% of all child deaths; birth asphyxia was the most common cause of death among neonates (29%), and pneumonia was the most common cause among postneonatal infants (47%). The proportion of child deaths attributed to infections (diarrhea, pneumonia and sepsis) and birth asphyxia decreased between 2000 and 2008, whereas the proportions of deaths due to congenital abnormalities and preterm birth complications increased. The authors suggest that preterm birth complications will become the most frequent cause of child deaths in China over the short term, because the number of deaths caused by pneumonia is steadily decreasing as access to primary health care increases. They add, however, that over the long term, with increased access to secondary health care, "Birth asphyxia will then decrease in importance as a cause of death and will be replaced with congenital abnormalities."

1. Rudan I et al., Causes of deaths in children younger than 5 years in China in 2008, Lancet, 2010, 375(9720):1083–1089.

GLOBAL MATERNAL MORTALITY DROPS BETWEEN 1980 AND 2008

The global rate of maternal mortality declined substantially over the past three decades, although decreases did not occur in all regions or countries, according to an analysis of pregnancy-related deaths among women aged 15–49 from 181 countries.1 This analysis, based on data from vital registration systems, censuses and surveys, indicates that the estimated number of maternal deaths worldwide decreased from 526,200 in 1980 to 342,900 in 2008—an annual rate of decline of 1.5%. The global maternal mortality ratio decreased from 422 per 100,000 live births in 1980 to 251 per 100,000 in 2008—an annual rate of decline of 1.8%. The proportion of the world's maternal deaths that occurred in Sub-Saharan Africa more than doubled over the period—from 23% to 52%—because of increased maternal mortality in that region since the early 1990s, as well as decreases in Asia. Regionally, South Asia and all regions of Sub-Saharan Africa continue to have the highest maternal mortality, with 2008 ratios above 280. Individual country rates ranged widely in 2008, from a low of four in Italy to a high of 1,575 in Afghanistan. However, maternal mortality tends to be concentrated: More than 50% of all pregnancy-related deaths in 2008 occurred in only six countries— Afghanistan, Ethiopia, India, Nigeria, Pakistan and the Democratic Republic of the Congo. Twenty-three countries are on track to achieve the fifth Millennium Development Goal of reducing their 1990 level of maternal mortality by 75% by 2015. The authors suggest that the global decrease in maternal mortality is most likely due to "four powerful drivers": decreased fertility, and increased per capita income, longer and more widespread schooling of women and greater use of skilled birth attendants.

1. Hogan MC et al., Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5, Lancet, 2010, DOI:10.1016/S0140-6736 (10)60518-1.

FINANCIAL PLANNING MAY HELP YOUTH TO AVOID SEXUAL RISK

Economic empowerment of orphaned adolescents can reduce the proportion who intend to participate in risky sexual behaviors, according to a study conducted in 15 primary schools in Rakai, Uganda, between 2005 and 2008.1 Of the 286 orphaned youth—half of whom were randomly assigned to receive financial planning education, future-planning mentorship and a savings account (the intervention group), and half who were assigned to the control group—260 (127 intervention youth and 133 controls) completed the baseline and 10-month follow-up interviews. At baseline, the intervention group had a mean score of 8.6 on a 10-point scale gauging youth's intentions of engaging in risky sexual behavior; controls had a mean score of 6.8. At follow-up, however, the intervention group's mean sexual risk-taking intention score (7.7) was lower than at baseline, whereas the control group's intention score (9.8) was higher. In multivariate analyses, intervention participation was negatively associated with sexual risk-taking intention, whereas age and male gender were positively associated with sexual risk-taking intention. The authors suggest that participation in the financial planning intervention "may provide adolescents with a sense of tangible hope for the future, which in turn may encourage adolescents to make careful decisions concerning their future."

1. Ssewamala FM et al., Effect of economic assets on sexual risk-taking intentions among orphaned adolescents in Uganda, America Journal of Public Health, 2010, 100(3):483–488.

ANOTHER EFFECTIVE METHOD OF EMERGENCY CONTRACEPTION

Gestrinone, a medication most commonly used to treat endometriosis, is as effective an emergency contraceptive method as mifepristone, according to a study of women at five Chinese clinics who sought emergency contraception within 72 hours of an act of unprotected inter-course.1 Between October 2001 and March 2003, 498 women seeking emergency contraception were selected to receive 10mg of gestrinone, of whom 12 became pregnant—equaling a pregnancy prevention effectiveness rate of 68%; among the 498 women selected to receive 10mg of mifepristone, nine pregnancies occurred—equaling an effectiveness rate of 76%. The two methods' effectiveness rates were not significantly different. Women in both groups were asked to keep a menstrual diary, and more than half (56–58%) menstruated within two days of the expected date of their next period. However, gestrinone seemed to shorten women's menstrual cycle (7% of gestrinone users had their period seven days before it was expected, compared with 3% of mifepristone users), whereas mifepristone seemed to lengthen their menstrual cycle (20% of mifepristone users had their period 3–7 days after it was expected, compared with 14% of gestrinone users). Bleeding or spotting was the most commonly reported side effect in both groups (16% of gestrinone users and 15% of mifepristone users); side effects did not differ significantly by group. The authors comment that "gestrinone is safe to use for emergency contraception; how-ever, larger studies are needed to assess…how it may compare with the more widely available levo-norgestrel regimen."

1. Wu S et al., Gestrinone compared with mifepristone for emergency contraception, Obstetrics & Gynecology, 2010, 115(4):740–744.

WOMEN ACCEPT LONG-TERM USE OF VAGINAL RING

Extended use of the vaginal contraceptive ring is an effective birth control method that is well-tolerated by women and offers noncontraceptive benefits, according to a prospective cohort study conducted between April 2004 and March 2005 in Sao Paulo, Brazil.1 Of the 75 women aged 18–37 who initiated a contraceptive regimen of using four consecutive 21-day contraceptive vaginal rings followed by a seven-day ring-free period, 13 stopped using the method in less than one year—equaling a discontinuation rate of 17%. The main clinical reason for women's discontinuation was irregular bleeding. No woman who used the regimen experienced a pregnancy during the study period. In addition, the frequency of certain premenstrual symptoms decreased with use of the ring: Before initiating the extended ring regimen, 56% of women reported menstrual pain and 25% reported irritability; at the one-year follow-up, those proportions were 20% and 5%, respectively. However, over the study period, ring users experienced an increase in mean body weight (from 64.1kg to 65.1kg) and body mass index (from 25.1kg/m2 to 25.9 kg/m2); blood pressure remained unchanged among women using the extended ring regimen.

1. Barreiros FA et al., Extended regimens of the contraceptive vaginal ring: evaluation of clinical aspects, Contraception, 2010, 81(3):223–225.

SOME YOUTH DO NOT TELL THE TRUTH ABOUT SEX

Adolescents with certain characteristics tend to be more reliable survey respondents than others, according to a longitudinal study conducted in two slum and two nonslum settlements in Nairobi, Kenya.1 Of the 2,324 adolescents aged 12–19 interviewed between June and September 2005 (Wave 1) and again between August and October 2006 (Wave 2), 20% gave inconsistent responses on whether they had ever had sex or on the timing of their first sex. In multivariate analyses, inconsistent reporting was positively associated with being male and attending school at Wave 1 (1.4 and 1.9, respectively), and was marginally associated with living in a slum and older age (1.5 and 1.1, respectively). Adolescents who lived in a slum, those who had ever tried smoking, drugs or alcohol and those who had a secondary education were more likely to make inconsistent reports about being sexually experienced than about the timing of their first sexual experience (2.8–4.8); older adolescents were more likely to report inconsistently about the timing of their first sex than about being sexually experienced (0.8). The authors recommend that "Researchers should account for biases stemming from misreporting of sensitive information among young people and, in particular, should be cognizant of how reporting quality may vary across demographic groups."

1. Beguy D et al., Inconsistencies in self-reporting of sexual activity among young people in Nairobi, Kenya, Journal of Adolescent Health, 2009, 45(6):595–601.

RAPID UPTAKE OF MODERN BIRTH CONTROL IN AFGHANISTAN

Acceptance of modern contraceptive methods in conservative rural areas can occur quickly when community leaders are educated about method safety and are involved in program messaging, according to a contraceptive use intervention conducted among 3,708 households with one woman of reproductive age in three Afghan provinces between fall 2005 and spring 2006.1 As part of the program, 65 community health workers developed intervention messages with community leaders, religious leaders and clinic staff; these messages addressed misconceptions about contraception; promoted the effectiveness and safety of family planning; and aligned contraceptive use, breast-feeding and birth-spacing with Islamic teachings (e.g., the Quran promotes two years of breast-feeding). While spreading these messages to women and men throughout the community, the health workers provided contraceptive methods, including—for the first time—the injectable. Over the eight-month study period, contraceptive prevalence increased by 24–27 percentage points, depending on province (from 9% to 34% in Farza, from 20% to 44% in Islam Qala and from 24% to 51% in Tormay). Uptake of the injectable contributed most of the increase in overall contraceptive use; in addition, pill use increased in Tormay and Farza, and condom use increased in Tormay. The authors acknowledge that lack of a formal control group was a limitation of their study, but comment that given that there were no other local promotional efforts, "changes can be attributed to the [intervention]."

1. Huber D, Saeedi N and Samadi AK, Achieving success with family planning in rural Afghanistan, Bulletin of the World Health Organization, 2010, 88(3): 227–231.