The proportion of women delivering by cesarean section has risen substantially in southeastern China since the mid-1990s, with almost all of the increase occurring because of women’s request for the procedure. 1 According to an analysis of maternal and child health surveillance data from 1.1 million singleton births in in two provinces in southeast China, the overall proportion of deliveries by cesarean section increased from 22% in 1994 to 60% in 2003, and then decreased slightly to 56% by 2006; the rate of cesarean delivery on maternal request per 100 all deliveries rose dramatically, from 0.8% to 22% between 1994 and 2003, before falling slightly to 20% by 2006. In fact, after 1998, the rise in the overall cesarean rate was almost entirely due to maternal request, as opposed to other indications such as having had a previous cesarean delivery, and breech presentation. In multivariate analysis, cesarean delivery on maternal request in 1994–1995 was positively associated with mothers’ being older than 22, not having had any previous children, having education beyond primary school and not being a farmer, as well as giving birth in a county hospital (versus a provincial hospital) and delivering a baby that weighed 4,000g or more at birth (odds ratios, 1.3–3.8);. however, most of these associations were attenuated (1.0–1.4) or disappeared for procedures between 2004 and 2006. The authors comment that “the reasons for the very high overall cesarean delivery rate and [cesarean delivery on maternal request] in China are complex,” but suggest that they are largely social and cultural.

1. Zhang J et al., Cesarean delivery onmaternal request in southeast China, Obstetrics & Gynecology, 2008, 111(5):1077–1082.


The prevalence of female genital cutting in Egypt appears to have decreased, according to a national study of female students conducted between March and May 2005.1 Among the 38,816 females aged 10–18 surveyed in schools in nine Egyptian governates, the overall prevalence of genital cutting was 50%— substantially less than the 97% among married women estimated by the 2000 Egyptian Demographic Health Survey. The prevalence of cutting differed by parental education: Twenty percent of young women whose father had attended a university and 22% of young women whose mother had attended a university had been circumsized, compared with 65% of those whose mother or father was illiterate. The prevalence of cutting also differed by type of school (9% in private urban schools, 46% in public urban schools and 62%in rural schools) and by governate (ranging from 18%in Port Said to 86%in Luxor city). Two thirds of young women reported that mothers are mainly responsible for deciding to have their daughters circumcised. The authors comment that “[female genital cutting] is an issue that demands a collaborative approach involving health professionals, religious leaders, educationalists, and nongovernmental organizations.” And in light of their finding that mothers are the main decision maker in regard to genital cutting, they recommend concentrating on “changing the attitude of mothers and grandmothers towards the prevention of this violence against girls.”

1. Tag-Eldin MA et al., Prevalence of female genital cutting among Egyptian girls, Bulletin of the World Health Organization, 2008, 86(4):269–274.'


Treatment of herpes simplex 2 (HSV-2) with acyclovir does not affect HIV acquisition, according to a study among a sample of HIV seronegative women infected with HSV-2 who worked in food and recreational facilities in northwestern Tanzania.1 Of the 821 women aged 16–35 enrolled in the study between January 2004 and May 2006, half were randomly assigned to the intervention group to receive 400mg of acyclovir twice daily, and half were assigned to the control group to receive a placebo. All participants were followed for 12–30 months and attended mobile clinics every three months for HIV testing; women in the intervention group were followed for an average of 1.5 years and women in the control group for an average of 1.6 years. Over the study period, 27 women in the intervention group and 28 women in the control group became infected with HIV, corresponding to HIV incidence of 4.4 per 100 person-years and 4.1 per 100 person-years, respectively; however, no association was found between treatment with acyclovir and HIV acquisition. The authors comment that although it is possible that the hypothesis that infection with HSV increases HIV acquisition is false, “this seems unlikely, given the strong biologic and epidemiologic evidence for a synergistic effect between HIV and HSV-2.” They conclude that “the lack of effect of suppressive therapy on HIV acquisition suggests that renewed attention should be given to new strategies of HSV-2 prevention and control to prevent HIV infection.”

1. Watson-Jones D et al., Effects of herpes simplex suppression on incidence of HIV among women in Tanzania, New England Journal of Medicine, 2008, 358(15):1560–1571.


Children born to women given multiple micronutrients during pregnancy show positive effects in terms of weight and size through early childhood, according to a follow-up conducted between December 2005 and 2006 of children whose mothers had participated in a double-blind trial 2–3 years before in Dhanusha district,Nepal.1 In the original study, the infants of women who had taken a supplement consisting of 15 vitamins and minerals during their second and third trimesters of pregnancy weighed more, on average at birth than the infants of women who had taken only iron and folic acid.When researchers reassessed 917 of the 1,077 children at am ean age of 2.6 years, children in the intervention group weighed an average of 204g more than those in the control group—a difference of 127g more than at birth. There was no difference between groups in mean height; however, the circumference of the intervention children’s heads, chests and hips were all significantly larger than those of the control children (mean differences, 2.4mm, 3.2m and 4.0mm, respectively). Furthermore, the systolic blood pressure of children in the intervention group was significantly lower than that of children in the control group (mean difference, 2.5mmHg). The authors comment, “We are only beginning to unravel the longer-term effects of increasing body mass. Its distal effects on health—cognitive performance, childhood illness and mortality, and later blood pressure— might be beneficial, but we need further follow-up and larger studies to confirmour findings.”

1. Vaidya A et al., Effects of antenatal multiple micronutrient supplementation on children’s weight and size at 2 years of age in Nepal; follow-up of a double- blind randomized controlled trial, Lancet, 2008, 371(9611):492–499.


Methods used to prevent transmission of HIV should also be effective in preventing herpes simplex 2 (HSV-2).1 As part of a randomized controlled trial of male circumcision to reduce HIV acquisition in Kisumu, Kenya, 2,771 uncircumcised HIV-negative men aged 18–24 were interviewed and underwent medical examination and testing for HSV-2 between February 2002 and September 2005. The overall seroprevalence of HSV-2 in the sample was 28%. In multivariate analyses, HSV-2 infection was positively associated with having a preference for dry sex (odds ratio, 1.4) and having had two or more sex partners (1.7–2.0), and negatively associated with not using a condom at last sex (0.8). The authors comment that their analyses identified “modifiable behaviors—preference for dry sex, inconsistent condom use and multiple sex partners—[as targets] for HSV-2 prevention.” They suggest that “the same behavioural interventions used currently for HIV prevention— abstinence, reducing the number of sex partners and increasing condom use— should be effective for HSV-2 prevention.”

1. Mehta SD et al.,Herpes simplex virus type 2 infection among young uncircumcised men in Kisumu, Kenya, Sexually Transmitted Infections, 2008, 84(1):42–48.


HIV-positive women who receive prophylactic antiobiotics during labor have a reduced risk of endometritis (infection of the endometrial lining of the uterus) after vaginal delivery. 1 As part of a double-blind trial conducted between February 2003 and May 2005 in two hospitals in Durban, South Africa, half of a sample of 424 HIV-positive pregnant women for whom vaginal delivery was anticipated were randomly selected to receive a single intravenous dose of the antibiotic cefoxitin during labor, and half were selected to receive a placebo. Two weeks after delivery, the overall rate of sepsis was 17% among women in the antibiotic group and 19% among controls; for both groups,most infections occurred within one week after delivery. In analyses by type of infection, women who had received antibiotics had a significantly lower risk of endometritis than those who had received the placebo (risk ratio, 0.5). There were no significant differences between groups in the rates of neonatal sepsis and perinatal mortality.

1. Sebitloane HM, Moodley J and Esterhuizen TM, Prophylactic antibiotics for the prevention of postpartum infectious morbidity in women infected with human immunodeficiency virus: a randomized controlled trial, American Journal of Obstetrics&Gynecology, 2008, 198(2):189.e1–189.e6.


Men’s knowledge of HIV prevention methods is positively associated with their having had sex with commercial sex workers, according to an analysis of data from the 2003 Kenyan Demographic and Health Survey.1 Of the 2,895 sexually active men aged 15–49 included in the study, 15% reported ever having had sex with a commercial sex worker. Sixteen percent of men who knew all three methods of preventing HIV—abstinence, being faithful with only one sexual partner and always using condoms when having sex—had ever had sex with a sex worker; the proportion among men who knew two or fewer of those prevention methods was 11%. In multivariate analyses controlling for social and demographic characteristics, knowledge of all three HIV prevention methods was positively associated with sex with a sex worker (odds ratio, 1.6). The authors comment that the positive association between men’s knowledge of HIV prevention methods and their experience with commercial sex workers “could be bidirectional or reverse causality,” yet “indicates that knowledge in HIV/AIDS prevention has not been translated to change in behavior.” They add that “this change may require time and continuous efforts including assertive campaigns on safe practices and behaviors.”

1. Hong R, Behavior, knowledge, attitude, and other characteristics of men who had sex with female commercial sex workers in Kenya, American Journal of Men’s Health, 2008, 2(1):17–24.


•In its 2007 AIDS Epidemic Update, UNAIDS provides the most recent estimates of the AIDS epidemic and explores new findings and trends in the epidemic’s evolution. The report, which estimates that 33.2 million people worldwide are living with HIV and that 2.5 million new infections occurred in 2007, can be downloaded in English, French, Spanish or Russian at .

•UNICEF has released State of the World’s Children Report 2008, which assesses the current state of child survival and of primary health care formothers, newborns and children. The full report is available at ; regional editions for Africa, Asia, and Latin America and the Caribbean are forthcoming.