Advancing Sexual and Reproductive Health and Rights
 
International Perspectives on Sexual and Reproductive Health
Volume 36, Number 4, December 2010
UPDATE


NEW ESTIMATE OF OFFICIAL DEVELOPMENT ASSISTANCE

Official development assistance—grants or loans given by donor nations or institutions to developing countries—for maternal, newborn and child health increased between 2003 and 2008, but did so in proportion to health assistance overall.1 According to an analysis of 2003–2008 distribution data from 31 donors of official development assistance (including the United States and United Kingdom, World Bank International Development Association and United Nations Population Fund), an estimated $4.7 billion was disbursed for maternal, newborn and child health activities in all developing countries in 2007 and $5.4 billion was disbursed in 2008. Of that funding, the 68 "priority countries"—those designated as having the highest rates of maternal and child mortality—received 72% in 2007 and 76% in 2008. Official development assistance for maternal, newborn and child health increased by 105% from 2003 to 2008; however, funding for the health sector overall also increased by 105% during that period, suggesting that maternal, newborn and child health was not prioritized. Assistance to the 68 priority countries increased by 120% between 2003 and 2008. The degree to which funding was targeted to the countries with the greatest need—those with high mortality rates and low income levels—increased in general over the period, although certain countries did persistently receive more or less assistance per person than other comparable countries.

1. Pitt C et al., Countdown to 2015: assessment of official development assistance to maternal, newborn, and child health, 2003–08, Lancet, 2010, 376(9751):1485–1496.

SPOUSAL ABUSE IN URBAN BANGLADESH

Comprehensive intervention programs are needed in Bangladesh to address the high prevalence of male-on-female intimate partner violence.1 According to self-reported 2006 survey data from 8,320 urban, currently married Bangladeshi men aged 15–49, 55% had ever perpetrated physical violence against their wife, and 23% had perpetrated physical violence against their wife in the past year. The most common form of physical abuse was slapping or arm-twisting, which 50% of men said they had ever done. Twenty percent of men reported ever sexual violence. In multivariate analyses, men's lifetime history of physical spousal abuse was positively associated with being older than 24, having a below-secondary education, being of low or middle household wealth status, recent drug or alcohol use, poor mental health and agreeing that wife-beating is justified (odds ratios, 1.6–2.8). Physical violence in the past year was linked with the same factors (1.4–2.3), but was negatively associated with living in a smaller urban area (vs. an urban nonslum) and being aged 40–49 (0.5–0.8). Ever having committed sexual violence was positively associated with living in a smaller urban area, Muslim religion, low or middle household wealth, recent drug or alcohol use, having had a recent STI and agreeing that wife-beating is justified (1.4–1.8). The authors comment that "the pervasiveness of [intimate partner violence] in this sample of men and the multitude of risk markers across different domains of men's social life strongly support the implementation of comprehensive strategies and culturally sensitive prevention programs to help men who have a higher likelihood of perpetrating spousal abuse in Bangladesh and elsewhere in South Asia become less violent toward their wives."

1. Sambisa W et al., Physical and sexual abuse of wives in urban Bangladesh: husbands' reports, Studies in Family Planning, 2010, 41(3):165–178.

BISEXUALITY AMONG MEN IN AFRICA

It is not uncommon for African men who have sex with men to have relationships with both males and females, sometimes concurrently, according to a study of 537 men in Malawi, Namibia and Botswana who reported in 2008 surveys ever having had anal sex with another man.1 The HIV prevalence among men in the sample was high, ranging from 12% in Namibia to 21% in Malawi. Overall, men reported having had an average of three male partners in the last six months; 15% had had five or more male partners during that time. More than half (54%) had had both a male and a female sexual partner in the last six months, and nearly one-fifth (16%) had concurrent male and female partners at the time of interview. Thirty-four percent of the men were married or had a stable female partner. In multivariate analyses, men who had had sexual partnerships with both men and women were more likely than those who had not to have used condoms consistently, to have used condoms consistently with casual or regular partners and to have received money for sex (odds ratios, 1.9–12.7). Concurrent partnerships with men and women were positively associated with consistent condom use with casual or regular partners, having received or paid money for sex and having been tested for HIV (1.7–4.8). The authors comment that "given the findings of high rates of bisexual partnerships, it is likely that sexual network analyses…have oversimplified the patterns which have driven HIV spread in the region."

1. Beyrer C et al., Bisexual concurrency, bisexual partnerships, and HIV among southern African men who have sex with men, Sexually Transmitted Infections, 2010, 86(4):323–327.

CHANGING CHINA'S CONTRACEPTIVE POLICY

An intervention launched by the Chinese government and the United Nations Population Fund that changed the contraceptive policy in 30 counties to allow local service providers to offer a wider range of contraceptives and individuals to make an informed choice of methods without coercion appears to have been successful in shifting away from the traditional "top-down" policy, under which service providers encouraged women to accept an IUD after first birth and sterilization after subsequent births.1 According to a study of baseline (2003) and endline (2005) survey data from 980 married parous women aged 15–49 who lived in one of the intervention counties and had initiated use of a contraceptive method in the prior two years, the proportion of women who chose a method traditionally encouraged by the government decreased over the study period: In 2003, 57% of women used a policy-driven method (i.e., the IUD for women with one child and sterilization for those with more), compared with 51% in 2005—a 12% reduction. The proportion of women using a policy-driven method who reported that a family planning worker motivated their choice decreased by 39%, from 15% in 2003 to 9% in 2005. In multivariate analyses, women in 2005 were less likely than those in 2003 to be using a policy-driven method (odds ratio, 0.6). In addition, compared with women who chose their method on their own, women who were motivated by a family planning worker had greater odds (1.9) of using a policy- driven method. The authors conclude that the intervention "was generally successful in weakening the top-down policy," but point out that "when the choice is influenced by the [family planning worker] it is likely to show a strong emphasis on the methods traditionally promoted by official family planning policy."

1. Brown JJ, Bohua L and Padmadas SS, A multilevel analysis of the effects of a reproductive health programme that encouraged informed choice of contraceptive method rather than use of officially preferred methods, China 2003–2005, 2010, 64(2):105–115.

GEL DOES NOT PREVENT HIV IN CLINICAL TRIAL

The microbicide gel PRO2000 is safe, but does not prevent the vaginal transmission of HIV, according to a clinical trial conducted between September 2005 and August 2008 among adult sexually active, HIV-negative women from 13 clinics in four Sub-Saharan African countries.1 Of the 9,385 women—2,734 of whom were randomly assigned to use a 2% gel formulation before intercourse, 3,326 to use a 0.5% gel and 3,325 to use a placebo—a mean of 89% reported at endpoint that they had used the gel at last sex; adherence to study protocols did not differ by gel group. The HIV incidence at endpoint did not differ by group (4.7 per 100 woman-years for the 2% group, 4.5 for the 0.5% group and 4.3 for the control group). No serious adverse events—such as death, cervical or profuse nonmenstrual bleeding—were attributed to the study gels; the incidence of such events did not differ by group (4.5% per 100 woman-years for the 2% group, 4.6 for the 0.5% group and 3.9 for the control group).

1. McCormack S et al., PRO2000 vaginal gel for prevention of HIV-1 infections (Microbicides Development Pro-gramme 301): a phase 3, randomized, double-blind, parallel-group trial, Lancet, 2010, 376(9749):1329–1337).

A LITTLE KNOWLEDGE IS A DANGEROUS THING

The information given to study participants as part of an informed consent process can affect their baseline knowledge and interfere with a subsequent intervention, according to a study conducted among two cohorts of adult couples attending clinics in Lusaka, Zambia—1,557 couples participating in a family planning knowledge intervention and 472 couples participating in an HIV transmission study.1 At baseline, there were no differences in terms of age, literacy, employment or other demographic characteristics between the family planning study couples—who were exposed to detailed information about specific contraceptive methods during their video-based informed consent process—and non–family planning study couples—whose informed consent video was virtually identical, but excluded any contraceptive information. However, at baseline (i.e., after informed consent, but before the intervention), greater proportions of females and males in the family planning group than of those in the non–family planning group had knowledge of the injectable, the implant and the IUD (73–99% vs. 28–96%). In addition, greater proportions of females and males in the family planning group expressed general concerns about contraception at baseline (48–53% vs. 41–47%). The researchers comment that informed consent content materials should "strike a balance between informing and educating the potential study participants."

1. Stephenson R et al., The influence of informed consent content on study participants' contraceptive knowledge and concerns, Studies in Family Planning, 2010, 4(3):217–224.

LEVONORGESTREL EC HAS NO EFFECT AFTER OVULATION

Emergency contraceptive pills containing levonorgestrel are not effective at preventing pregnancy if taken after ovulation, according to a study of 388 women aged 18–38 who requested emergency contraception at a Chilean Institute of Reproductive Medicine clinic in Santiago within 120 hours of unprotected sex.1 Researchers determined by blood hormone levels and transvaginal ultrasound that 122 of the women had had unprotected intercourse during one of the six fertile days of their menstrual cycle (the five days before ovulation and the day of ovulation); 87 received emergency contraception before ovulation and 35 after. Among women who received emergency contraception prior to ovulation, the researchers were able to verify ovulation for 71%. Emergency contraception prevented pregnancy among women who received it before ovulation: Of the 13 pregnancies that would have been expected among women in this group in the absence of emergency contraception, none actually occurred. However, among women who received emergency contraception after ovulation, the expected and observed numbers of pregnancies were similar (seven and six, respectively). The authors conclude that levonorgestrel "is very effective in preventing pregnancy when it is administered before ovulation, but it is ineffective in preventing pregnancy once fertilization has occurred."

1. Noé G et al., Contraceptive efficacy of emergency contraception with levonorgestrel given before or after ovulation, Contraception, 2010, 81(5):414– 420.