Advancing Sexual and Reproductive Health and Rights
International Perspectives on Sexual and Reproductive Health
Volume 38, Number 4, December 2012


Between 2000 and 2011, an estimated one-third of women between the ages of 20 and 24 in low- and middle-income countries (excluding China) were married by age 18, and one in eight were married by age 15, according to a new report by the United Nations Population Fund entitled Marrying Too Young: End Child Marriage.1 Regionally, child marriage is most common in South Asia and in West and Central Africa, where more than 40% of young women are married before age 18. Those who have no education, are in the lowest wealth quintile and live in rural areas are the most likely to experience child marriage. If the present trends continue, 142 million young women will be married by age 18 in the next decade, and 152 million more in the following decade. To discourage child marriage, the report identifies five core approaches: empowering girls by building their skills and enhancing their social assets, improving girls’ access to quality formal education, mobilizing communities to transform detrimental social norms, enhancing the economic situation of girls and their families, and generating an enabling legal and policy environment.

1. United Nations Population Fund (UNFPA), Marrying Too Young: End Child Marriage, New York: UNFPA, 2012,< documents/publications/2012/MarryingTooYoung.pdf>, accessed Oct. 16, 2012.


Nurses in low-resource settings can effectively determine the completeness of a medication abortion without using an ultrasound, according to a study of 718 women who received a medication abortion at five public hospitals in Maputo City, Mozambique, between May 2005 and December 2006.1 On the basis of findings from the physical examination of patients 4–6 days and 12–21 days after administration of misoprostol, and of patients’ reports of bleeding, pain and tissue passage, nurses trained to evaluate the completeness of a medication abortion determined that 83% of patients had had a complete abortion, 15% had had an incomplete abortion and 2% had an ongoing pregnancy. Gynecologists trained in abdominal ultrasound—and blinded to nurses’ assessments—evaluated the same women and determined that 80% had had a complete abortion, 17% had had an incomplete abortion and 3% had an ongoing pregnancy. Overall, nurses and gynecologists agreed in their diagnoses in 84% of cases. The authors comment that their findings “indicate the potential for successfully training midlevel providers to assess pregnancy expulsion following misoprostol abortions without the use of ultrasonography and thereby increasing the accessibility of safe, effective abortion services in decentralized health-care settings.”

1. Gebreselassie H et al., Clinical diagnosis of completeness of medical abortion by nurses: a reliability study in Mozambique, Contraception, 2012, 86(1):74–78.


A multifaceted intervention implemented in 2005 at one tertiary hospital in Yunnan Province was effective in reducing the facility’s rate of deliveries by cesarean section.1 In 2001–2004, the cesarean delivery rate at the hospital was 54–56% per year. After the intervention—which included such components as education of obstetrics staff and patients, implementation of international guidelines, removal of potential financial incentives for surgeons to perform cesareans and daily review of proper medical indications—the cesarean rate decreased to 42% in 2005 and to 36% in 2011. Overall, the average annual cesarean rate was lower in 2005–2011 than in 2001–2004 (40% vs. 55%). The incidence of obstetric complications increased after implementation of the intervention. In multivariate analyses, delivery by cesarean was associated with an increased risk of admission into the neonatal intensive care unit for treatment (odds ratio, 1.3). The authors comment that “the dramatic reduction in our primary caesarean section rate between 2001–2004 and 2005–2011, despite a progressive increase in complicated pregnancies, has put us on par with the United States of America, whose average caesarean section rate is 38%.”

1. Runmei M et al., Practice audits to reduce caesareans in a tertiary referral hospital in south-western China, Bulletin of the World Health Organization, 2012, 90(7):488–494.


Maternal obesity among women in Sub-Saharan Africa is associated with an elevated risk of neonatal mortality, according to an analysis of data from the most recent Demographic and Health Surveys of 27 Sub-Saharan African countries.1 Of the 81,126 women in the pooled sample, 65% had an optimum weight, 17% were underweight and 19% were overweight (including 5% who were considered obese). Of women’s most recent singleton live births within the five years prior to the survey, some 1,290 infants had died during the first 28 days of life. Compared with infants born to an optimum-weight mother, those born to an overweight mother had 20% higher odds of neonatal death (odds ratio, 1.2), and those born to an obese mother had 50% higher odds of neonatal death (1.5), after adjustment for covariates. In separate analyses by time elapsed since birth, having an overweight or obese mother was positively associated with mortality within the infant’s first two days (1.3 and 1.6, respectively); no associations were found at ages 2–6 days or 7–27 days. The authors comment that “rates of obesity in sub-Saharan Africa are currently low by global standards,” but are “projected to rise substantially…during the next two decades.” They conclude that if future research confirms a causal relationship between maternal obesity and neonatal deaths, “obese women should be strongly advised to deliver in a health facility capable of providing prompt emergency obstetric and neonatal care.”

1. Cresswell JA et al., Effect of maternal obesity on neonatal death in sub-Saharan Africa: multivariable analysis of 27 national datasets, Lancet, 2012, 380(9850):1325–1330.


Substantial progress has been made worldwide toward achieving Millennium Development Goal 4 (MDG 4), a two-thirds reduction in the under-five mortality rate between 1990 and 2015, according to the annual report by the United Nations Inter-Agency Group for Child Mortality Estimation.1 In 2011, an estimated 6.9 million children died around the world before reaching age five—far fewer than in 1990, when nearly 12 million such deaths occurred. The global child mortality rate decreased by 41% over the period, from 87 deaths per 1,000 live births in 1990 to 51 deaths per 1,000 live births in 2011. The annual rate of reduction in under-five mortality increased over the last two decades, from 1.8% per year in 1990–2000 to 3.2% per year in 2000–2011. The highest rates of child mortality continue to be in Sub-Saharan Africa, where one in nine children die before age five. However, progress is being made there: The annual rate of reduction in under-five mortality doubled in Sub-Saharan Africa, from 1.5% per year in 1990–2000 to 3.1% per year in 2000–2011. Despite the positive trends, the report concludes that more must be done to achieve MDG 4. The authors comment that “accelerating the reduction in under-five mortality is possible by expanding effective preventive and curative interventions that target the main causes of post-neonatal deaths (pneumonia, diarrhoea, malaria and undernutrition) and the most vulnerable newborn babies and children.”

1. United Nations Inter-Agency Group for Child Mortality Estimation, Levels & Trends in Child Mortality: Report 2012, New York: United Nations Children’s Fund (UNICEF), 2012, <>, accessed Nov. 6, 2012.


Researchers from the Imperial College in London have developed a diagnostic testing method purported to be both more sensitive and less expensive than any previously invented.1 The experimental method described in the journal Nature Nanotechnology uses gold nanoparticles to produce a color-specific result easily read with the naked eye, and could be configured to detect low concentrations of various proteins, such as those related to HIV, tuberculosis or even prostate cancer. And with the method being estimated to cost one-tenth as much as others, it could be particularly important in the developing world, where available diagnostic tests are often too expensive. The researchers plan to work with not-for-profit global health organizations to manufacture and distribute the test in low-resource settings.

1. Wickham C, New test to improve HIV testing in poor countries, Reuters, Oct. 28, 2012, <>, accessed Nov. 6, 2012.


The World Health Organization (WHO) in 2009 underestimated the cost of a universal “test and treat” strategy against HIV in South Africa, as well as the time it would take for such a strategy to achieve success, according to results of a mathematical model developed by researchers at the University of California, Los Angeles (UCLA).1 The WHO analysis predicted that universal “test and treat” (i.e., testing the entire adult population for HIV and providing immediate treatment for all those infected, regardless of their current need) would eliminate new HIV transmisssion in South Africa within 10 years, and would cost approximately $10 billion less overall than “universal access” (i.e., providing treatment to all adults living with HIV who have a current need). However, the UCLA model—a modification of the WHO model with additional factors to account for such things as the potential need for expensive, second-line drugs if HIV-resistant strains emerge—predicts that universal test and treat would take 40 years to eliminate new HIV transmission in South Africa and would cost approximately $12 billion more than universal access. The researchers conclude that “before implementing a universal [test and treat] strategy, …we recommend striving to achieve universal access to treatment,” which would “increase the life expectancy of millions of HIV-infected individuals.”

1. Wagner BG and Blower S, Universal access to HIV treatment versus universal ‘test and treat’: transmission, drug resistance & treatment costs, PLoS ONE, 2012, 7(9):e41212.


•The Henry J. Kaiser Family Foundation has released a report examining how countries are responding to the core principle of the U.S. Global Health Initiative of focusing on women, girls and gender equality. The report identifies nine central themes, one of which is that the women, girls and equality principle has reinforced existing efforts and added value to programming, but has had limited impact on the advancement of broader gender equality. It is available at <>.

•In Improving Maternal Mortality and Other Aspects of Women’s Health: The United States’ Global Role, Phillip Nieburg of the Center for Strategic & International Studies identifies key challenges to reducing pregnancy-related deaths and improving the general health of women in developing countries, and discusses related priorities of U.S. global health policy. He concludes by detailing three overarching recommendations: Proceed with a comprehensive plan for improving women’s health; improve quality, quantity and use of data; and further reduce maternal deaths through expanded family planning services. The report is available at < Nieburg_MaternalMortality_Web.pdf>.