Volume 8, Number 27
7 July 2008

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ADOLESCENT HEALTH RESEARCH

Ensuring a healthier tomorrow in Central America: Protecting the sexual and reproductive health of today's youth
(Report; Central America and the Caribbean)
New York, New York, Guttmacher Institute, 2008. 67 p.
Remez L | Prada E | Singh S | Bixby LR | Bankole A
Protecting the sexual and reproductive health of today's Central American youth is urgent. El Salvador, Guatemala, Honduras and Nicaragua have the highest rates of adolescent childbearing in all of Latin America. Moreover, current HIV prevalence has surpassed the 1% threshold for a generalized epidemic in Honduras and is nearing that magnitude in El Salvador and Guatemala. Preserving young people's health is not only important for youth themselves; it is also a vital development priority. This report, based on recent national surveys, presents key patterns and trends in the sexual and reproductive behavior of 15-24-year-olds in these four countries, and identifies important gaps and needs.

Effectiveness of web-based education on Kenyan and Brazilian adolescents' knowledge about HIV / AIDS, abortion law, and emergency contraception: Findings from TeenWeb
(Abstract; subscription needed for full text; South America | Sub-Saharan Africa)
Social Science and Medicine. 2008;:1-10.
Halpern CT | Mitchell EM | Farhat T | Bardsley P
Little evidence is available about the utility of web-based health education for students in low resource settings. This paper reports results from an evaluation of the TeenWeb project, a multi-year, web-based health education intervention implemented in two urban settings: Nairobi, Kenya (N = 1178 school students) and Rio de Janeiro, Brazil (N = 714 school students). A quasi-experimental, school-based pre-test/post-test design was implemented at each study site to determine if easy access to web-based reproductive health information, combined with intellectual 'priming' about reproductive health topics, would result in improved knowledge and attitudes about topics such as condom use, access to HIV testing, emergency contraception and abortion laws. Students in web-access schools completed one web-based module approximately every 6-8 weeks, and in return, had access to the Internet for at least 30 min after completing each module. Although students were encouraged to access project-supplied web-based health information, freedom of web navigation was an incentive, so they could choose to access other Internet content instead. Most measures showed statistically significant differences between students in 'web' and 'comparison' conditions at post-test, but only about half of the differences were in the hypothesized direction. Results of an embedded experiment employing more directed feedback tripled the likelihood of correctly reporting the duration of emergency contraception effectiveness. Review of URL logs suggests that the modest results were due to inadequate exposure to educational materials. Future intervention should focus on teen's purposeful searching for health information when they are in personal circumstances of unmet health needs.

Geographical variations and contextual effects on age of initiation of sexual intercourse among women in Nigeria: A multilevel and spatial analysis
(Research Article; Sub-Saharan Africa)
International Journal of Health Geographics. 2008 May 30;7(27):[12] p.
Uthman OA
The age of initiation of sexual intercourse is an increasingly important issue to study given that sexually active young women are at risk of multiple outcomes including early pregnancies, vesico-vaginal fistula, and sexually transmitted infections. Much research has focused on the demographic, familial, and social factors associated with sexual initiation and reasons adolescents begin having consensual intercourse. Less is known, however, about the geographical and contextual factors associated with age of initiation of sexual intercourse. Therefore, the purpose of this study was to examine the extent of regional and state disparities in age of initiation of sexual intercourse and to examine individual- and community-level predictors of early sexual debut. Multilevel logistic regression models were applied to data on 5531 ever or currently married women who had participated in 2003 Nigeria Demographic and Health Survey. Coital debut at 15 years or younger was used to define early sexual debut. Exploratory spatial data analysis methods were used to study geographic variation in age at first sexual intercourse. The median age at first sexual intercourse for all women included in the study was 15 years (range; 14 -19). North West and North East had the highest proportion of women who had reported early sexual debut (61% -78%). The spatial distribution of age of initiation of sexual intercourse was nonrandom and clustered with a Moran's I = 0.635 (p = .001). There was significant positive spatial relationship between median age of marriage and spatial lag of median age of sexual debut (Bivariate Moran's I = 0.646, (p = .001). After adjusting for both individual-level and contextual factors, the probability of starting sex at an earlier age was associated with respondents' current age, education attainment, ethnicity, region, and community median age of marriage. The study found that individual-level and community contextual characteristics were independently associated with early sexual debut, suggesting that interventions to reduce adolescent high-risk sexual behaviour should focus on high-risk places as well as high-risk groups of people.

FAMILY PLANNING RESEARCH

Contextual influences on contraceptive use in the Eastern Cape, South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health and Place. 2008 Dec;14(4):841-852.
Stephenson R | Beke A | Tshibangu D
This paper uses linked individual and health facility data from the 1998 South Africa Demographic and Health Survey and the 1998 Eastern Cape Facility Survey to explore community and health facility influences on modern contraceptive use. Several pathways of influence between the community and individual contraceptive adoption are identified, centering primarily on the community climate of female autonomy. Few significant effects of the health facility environment on contraceptive adoption are identified. The residual variation in contraceptive use highlights the deficits that exist in current datasets for capturing community influences on contraceptive behavior.

Three methods of estimating births averted nationally by contraception
(Abstract; subscription needed for full text; Global)
Population Studies. 2008;62(2):191-210.
Liu L | Becker S | Tsui A | Ahmed S
This paper compares the performance of three methods applicable to national-level demographic data of estimating births averted as a consequence of contraceptive practice. Two are based on the relationship between the general fertility rate (GFR) or total fertility (TFR) and contraceptive prevalence, while the third uses Bongaarts' proximate determinants (PD) model. Estimates of the number of births averted and the percentage by which the number would have increased in the absence of contraception are consistent between the GFR-based and TFR-based methods, but in general lower than the estimates generated by the PD-based method, except for a few high-contraceptive-prevalence countries. For 156 countries and areas around the world the estimated number of births that would have occurred in a recent year in the absence of contraception--the average of the estimates of the three methods--is approximately 230 million, which is more than the estimated 129 million births that actually occurred.

Male hormonal contraception: A double-blind placebo-controlled study
(Abstract; subscription needed for full text; Global)
Journal of Clinical Endocrinology and Metabolism. 2008 Apr 15;:[21] p..
Mommers E | Kersemaekers WM | Elliesen J | Kepers M | Apter D
This study was performed to assess spermatogenesis suppression and safety of a new combination of an etonogestrel (ENG) implant combined with testosterone undecanoate (TU) injections for male contraception. This is the first large placebo-controlled study for male hormonal contraception. In this double-blind, multicenter study, we randomly assigned 354 healthy men to receive either a low or high release ENG implant subcutaneously combined with intramuscular TU injections (750 mg every 10 or 12 weeks, or 1000 mg every 12 weeks), or placebo implant and injections. Treatment duration was 42 or 44 weeks and post-treatment follow up at least 24 weeks. Overall, spermatogenesis was suppressed to 1 million/ml or less at week 16 in 89% of men, with approximately 94% in two high release ENG groups. Suppression was maintained up to the end of the treatment period in 91% of men. For all men who completed the treatment period, 3% never achieved less than or = 1 million/ml. Median recovery time to a sperm concentration above 20 million/ml was 15 weeks (mean 17 weeks, 95% confidence interval 16 to 18 weeks). Treatment was well tolerated. As compared to the placebo group, more men in the active treatment groups reported adverse events such as weight gain, mood changes, acne, sweating or libido change. Both for spermatogenesis suppression and safety, differences were small between the active treatment groups. The combination of an ENG implant with TU injections is a well tolerated male hormonal method providing effective and reversible suppression of spermatogenesis. Although the results are good, there is still room for improvement, possibly by adjusting the dose regimen or changing the mode of application.

Association between contraceptive discontinuation and pregnancy intentions in Guatemala
(Abstract; subscription needed for full text; Central America and the Caribbean)
Revista Panamericana de Salud Publica / Pan American Journal of Public Health. 2008 Jun 30;23(6):410-417.
Barden-O'Fallon JL | Speizer IS | White JS
The objective of this study was to determine whether contraceptive discontinuation is associated with pregnancies that are conceived earlier than desired (mistimed) or are not wanted at the time of conception (unwanted). Data were obtained from the 2002 Guatemala National Maternal and Child Health Survey. Pregnancies within the three years prior to and at the time of the survey (April 1999-November 2002) were classified as either 'intended,' 'mistimed,' or 'unwanted.' The key independent variable was whether the woman had used contraception within 12 months of the pregnancy and, for those who had used it, the reason for discontinuation (either to get pregnant or for another reason). A multinomial logistic analysis was used to determine the degree of association of discontinuation with pregnancy intentions. One of every five mistimed pregnancies and one of every six unwanted pregnancies followed discontinuations that were for reasons other than to become pregnant (e.g., contraceptive failure, side effects, and health concerns). Discontinuations for reasons other than to become pregnant were shown to be positively and significantly associated with a reported mistimed pregnancy (coefficient = 2.15; standard error = 0.27) or unwanted pregnancy (2.68; 0.37) compared to an intended pregnancy. Pregnancies preceded by discontinuations for reasons other than to become pregnant were also more likely to be reported as mistimed or unwanted than pregnancies of women who were not using contraception during the year prior to pregnancy. There is a need to increase contraceptive continuation. Any program should include an increased effort to reduce contraceptive failure and better address the side effects and the health concerns that women have that can lead to discontinuation. Non-users who want to delay or limit births should also be identified and targeted for outreach in order to reduce unintended pregnancies.

GENDER and HEALTH RESEARCH

Gender based violence: Correlates of physical and sexual wife abuse in Kenya
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Family Violence. 2008 Jul;23(5):333-342.
Kimuna SR | Djamba YK
This study explored factors associated with physical and sexual wife abuse on a sample of 4,876 married women aged 15-49 years in the 2003 Kenya Demographic Health Survey. Results indicate that 40% of married women reported at least one type of violence; 36% were physical and 13% were sexual. Multivariate analysis showed that living in poorer households, being Christian, being in a polygamous marriage, having a husband who drinks alcohol, and being in sales, agricultural, or unskilled jobs significantly increased the wife's risk of physical and sexual abuse. Wife's education had significant effect on both physical and sexual abuse, but the relationships were not linear. Wife's age and number of children were significantly associated only with physical abuse; husband's education had a marginal but significant effect only on sexual abuse. Research implications are discussed.

A multilevel analysis of effect of neighbourhood and individual wealth status on sexual behaviour among women: Evidence from Nigeria 2003 Demographic and Health Survey
(Research Article; Sub-Saharan Africa)
BMC International Health and Human Rights. 2008 Jun 27;8(9):[18] p.
Uthman OA | Kongnyuy EJ
Nigeria is home to more people living with HIV than any other country in the world, except South Africa and India-where an estimated 2.9 million [1.7 million -4.2 million] people were living with the virus in 2005. Women bear the greatest burden of frequent high-risk pregnancies, raising large families, and increasingly, the AIDS epidemic. Thus, there is a need for better understanding of the determinants of high risk sexual behaviour among women. In this study, we examined factors associated with extra-marital sex among women in Nigeria and investigated how much variation in reported extra-marital sex can be attributed to individual-, and community-level factors. We analyzed data from 6362 sexually active women aged 15-49 years who participated in the Nigeria 2003 Demographic and Health Survey using multilevel logistic regression models. Results are presented as odds ratio with 95% confidence interval. Independent of other factors, compared to women aged 15-24 years, those 25-34 years (odds ratio [OR] 0.59; 95% CI: 0.44 -0.79) and 35 years or older (OR 0.36; 95% CI: 0.24 -0.54) were less likely to have reported multiple concurrent sex partners in the last 12 years. As expected, women currently or formerly married were less likely to have reported multiple concurrent sex partners than women never married. Women who drank alcohol in the last three months were more likely to have reported multiple concurrent sex partners. Compared to women from richest household, women from poorest and middle household were 83% and 51% more likely to multiple concurrent sex partners in the last 12 month respectively. After individual compositional and contextual factors, community wealth status was statistically significant with sexual behaviour. The study has demonstrated that individual and community wealth status are independent predictors of women's sexual behaviour, and that there is significant neighbourhood variation in odds of multiple concurrent sex partners, even after controlling for effects of both individual- and community-level characteristics. Scholars trying to understand variation individual high risk sexual behaviour should pay attention to the characteristics of both individuals and places of residence.

Prevalence of polycystic ovary syndrome in unselected women from southern China
(Abstract; subscription needed for full text; Asia)
European Journal of Obstetrics, Gynecology and Reproductive Biology. 2008 Jul;139(1):59-64.
Chen X | Yang D | Mo Y | Li L | Chen Y
The objective was to determine the prevalence and metabolic parameters of polycystic ovary syndrome (PCOS) in southern China. The study was observational with a parallel study. Participants were studied in a medical examination center. A population of 915 women of reproductive age was investigated at the time of their annual physical examination to determine the prevalence of PCOS in unselected women from southern China. Our results demonstrated a 2.2% (20/915) prevalence of PCOS. Women with PCOS had higher levels of luteinizing hormone and higher luteinizing hormone/follicle-stimulating hormone ratios than those in the other groups. Women with PCOS had higher fasting insulin levels and lower fasting glucose/fasting insulin ratios than women in any of the other groups. Some clinical and biochemical characteristics were apparent in PCOS patients in our population, and ethnic differences may be considered when studying the clinical and metabolic features of PCOS in China.

HIV/AIDS and STIs NEWS

Rwanda: Military to lead the way in male circumcision
(News Article; Sub-Saharan Africa)
7 Jul 2008
Integrated Regional Information Networks (IRIN)

HIV/AIDS and STIs RESEARCH

Quality of life, optimism / pessimism, and knowledge and attitudes toward HIV screening among pregnant women in Ghana
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Women's Health Issues. 2008 Jul-Aug;18(4):301-309.
Moyer CA | Ekpo G | Calhoun CL | Greene J | Naik S
We sought to explore optimism/pessimism, knowledge of HIV, and attitudes toward HIV screening and treatment among Ghanaian pregnant women. Pregnant women in Accra, Ghana, completed a self-administered questionnaire including the Life Orientation Test-Revised (LOT-R, an optimism/pessimism measure), an HIV knowledge and screening attitudes questionnaire, the Short Form 12 (SF-12, a measure of health-related quality of life [HRQOL]), and a demographic questionnaire. Data were analyzed using t-tests, ANOVA, correlations, and the x2 test. There were 101 participants; 28% were nulliparous. Mean age was 29.7 years, and mean week of gestation was 31.8. All women had heard of AIDS, 27.7% had been tested for HIV before this pregnancy, 46.5% had been tested during this pregnancy, and 59.4% of the sample had ever been tested for HIV. Of those not tested during this pregnancy, 64.2% were willing to be tested. Of all respondents, 89% said they would get tested if antiretroviral drugs (ARVs) were readily available and might prevent maternal-to-child transmission. Neither optimism/pessimism nor HRQOL was associated with attitudes toward HIV screening. Optimism was negatively correlated with HIV knowledge (p = .001) and was positively correlated with having never been tested before this pregnancy (p = .007). The relationship between optimism/pessimism and HIV knowledge and screening behavior is worthy of further study using larger samples and objective measures of testing beyond self-report.

Risk factors for bacterial vaginosis incidence in young adult Thai women
(Abstract; subscription needed for full text; Asia)
Sexually Transmitted Diseases. 2008 Jul;35(7):643-648.
Rugpao S | Sriplienchan S | Rungruengthanakit K | Lamlertkittikul S | Pinjareon S
The objective of this study was to determine risk factors for incident bacterial vaginosis (BV) in young Thai women. Prospective data from a cohort of 1522 women aged 18 to 35 years, who were enrolled in a study of hormonal contraception and HIV acquisition, were used to evaluate potential risk factors for BV, as diagnosed by Amsel criteria. The median prevalence of BV from 3 to 24 months of follow-up visits was 2.5%. The BV incidence was 10.0 per 100-woman years. Statistically significant factors in multivariable analysis were sex during menstruation [hazard ratio (HR), 1.80; 95% CI, 1.11-2.92], male partners having sex with other women (HR, 2.3; 95% CI, 1.45-2.98), cigarette smoking (HR, 1.79; 95% CI, 1.08 -2.98), and trichomoniasis (HR, 15.68; 95% CI, 4.95-49.68). Intravaginal practices were not associated with incident BV in unadjusted or adjusted analysis. This study supports the association between sexual behaviors and the incident BV. Failure to detect an association between intravaginal practices and incident BV warrants further studies in high-risk populations or in women with a higher prevalence of intravaginal practices.

The role of partnership dynamics in determining the acceptability of condoms and microbicides
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS Care. 2008 Jul;20(6):733-740.
Montgomery CM | Lees S | Stadler J | Morar NS | Ssali A
Microbicides are a class of substances under development that could reduce the sexual transmission of HIV and other sexually transmitted diseases when applied locally to genital mucosal surfaces. Microbicide acceptability research has largely focused on product characteristics, rather than processes of negotiation within relationships about use. Gender relations, decision-making power and communication within sexual relationships are recognised as important determinants of condom and contraceptive use, and are likely to determine microbicide use also. As part of social science research linked to the Microbicides Development Programme (MDP) we combine relationship-based theories with anthropological work conducted with women and men using a placebo gel. We explore communication and decision-making in gel and condom use, including constructions of risk and trust. During the MDP301 Phase III pilot study, in-depth interviews were conducted at sites in South Africa, Tanzania, Uganda and Zambia. Following four weeks of placebo gel use, women and their partners were asked about gel use and acceptability, partner involvement, sexual practices and condom use. Data from 45 couples at five sites were analysed using a grounded theory approach in NVivo. Participation in the study did not require women to inform their partners, yet our data shows women seeking permission from their partners, negotiating disclosure, exchanging information and persuading or motivating for gel use. Although gel was supposedly 'woman-controlled', men exercised considerable influence in determining whether and how it was used. Despite this, negotiations around use were largely successful, since the gel increased sexual pleasure and provided opportunities for intimate communication and the building of trust. Decisions about condom and microbicide use are made in a dyadic context and involve a complex negotiation of risk and trust. Whilst preferences relating to product characteristics are largely individual, use itself is dependent on partnership dynamics and the broader social context in which sexual risk management occurs.

Local gin (akpeteshie) and HIV / AIDS in the Upper West Region of Ghana: The need for preventive health policy
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health and Place. 2008 Dec;14(4):804-814.
Luginaah I
The paper describes a qualitative analysis of community perceptions of the relationship between locally brewed alcohol (akpeteshie) and the spread of HIV/AIDS in the Upper West Region of Ghana. A thematic analysis of focus group discussions show that akpeteshie consumption is on the rise among adults and young people, with severe impacts on women who are constantly living in poverty, frequently subjected to coercive sex and violence which exposes them to HIV, infectious, and other sexually transmitted diseases. The findings suggest that intervention programmes must focus on akpeteshie bars, 'places' which have become the 'daily spots' for drinking. Furthermore, control and prevention programmes must be linked to the economic empowerment of women and young people in the region.

New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: An analysis of survey and clinical data
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Lancet. 2008 Jun 28-Jul 4;371(9631):2183-2191.
Dunkle KL | Stephenson R | Karita E | Chomba E | Kayitenkore K
Sub-Saharan Africa has a high rate of HIV infection, most of which is attributable to heterosexual transmission. Few attempts have been made to assess the extent of HIV transmission within marriages, and HIV-prevention eff orts remain focused on abstinence and non-marital sex. We aimed to estimate the proportion of heterosexual transmission of HIV which occurs within married or cohabiting couples in urban Zambia and Rwanda each year. We used population-based data from Demographic and Health Surveys (DHS) on heterosexual behaviour in Zambia in 2001-02 and in Rwanda in 2005. We also used data on the HIV serostatus of married or cohabiting couples and non-cohabiting couples that was collected through a voluntary counselling and testing service for urban couples in Lusaka, in Zambia, and Kigali, in Rwanda. We estimated the probability that an individual would acquire an incident HIV infection from a cohabiting or non-cohabiting sexual partner, and then the proportion of total heterosexual HIV transmission which occurs within married or cohabiting couples in these settings each year. We analysed DHS data from 1739 Zambian women, 540 Zambian men, 1176 Rwandan women, and 606 Rwandan men. Under our base model, we estimated that 55 - 1% to 92 - 7% of new heterosexually acquired HIV infections among adults in urban Zambia and Rwanda occurred within serodiscordant marital or cohabiting relationships, depending on the sex of the index partner and on location. Under our extended model, which incorporated the higher rates of reported condom use that we found with non-cohabiting partners, we estimated that 60 - 3% to 94 - 2% of new heterosexually acquired infections occurred within marriage or cohabitation. We estimated that an intervention for couples which reduced transmission in serodiscordant urban cohabiting couples from 20% to 7% every year could avert 35 - 7% to 60 - 3% of heterosexually transmitted HIV infections that would otherwise occur. Since most heterosexual HIV transmission for both men and women in urban Zambia and Rwanda takes place within marriage or cohabitation, voluntary counselling and testing for couples should be promoted, as should other evidence-based interventions that target heterosexual couples.

Environmental support and HIV prevention behaviors among female sex workers in China
(Abstract; subscription needed for full text; Asia)
Sexually Transmitted Diseases. 2008 Jul;35(7):662-667.
Hong Y | Fang X | Li X | Liu Y | Li M
The objective of this study was to examine the influence of environmental support on HIV prevention behaviors (i.e., condom use behaviors, communication and intention, and HIV/STD testing) among female sex workers (FSWs) in China. A cross-sectional survey was administered among 310 FSWs recruited from entertainment establishments in Liuzhou City in Southwest China in 2006. Sex workers were asked about their demographic and working characteristics and their HIV prevention behaviors. Environmental support was measured by a scale consisting of 8 items regarding condom availability, managerial, and social support of HIV prevention (Cronbach alpha = 0.73). After adjusting for demographic and working characteristics, condom use self-efficacy and knowledge, environmental support was strongly associated with following HIV prevention behaviors: overall consistent condom use (aOR = 1.7, 95% CI = 1.3, 2.3), consistent condom use in the last 3 sexual acts (aOR = 1.5, 95% CI = 1.1, 2.0), intention to use condoms consistently (aOR = 1.6, 95% CI = 1.1, 2.2), and HIV testing (aOR = 1.6, 95% CI = 1.1, 2.2). Environmental support is a significant predictor of HIV prevention behaviors among establishment-based FSWs in China. The data underscore the importance of developing environmental/structural HIV/STD interventions for FSWs. Condoms need to be easily accessible in the establishments. Gatekeepers need to be educated to create a supportive environment for condom use and HIV prevention.

p24 as a predictor of mortality in a cohort of HIV-1-infected adults in rural Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Jul;48(3):345-349.
Erikstrup C | Kallestrup P | Zinyama-Gutsire RB | Gomo E | Luneborg-Nielsen M
Implementation of antiretroviral treatment in sub-Saharan Africa requires efficient tools to monitor HIV patients. p24 measurements have been proposed as an alternative to HIV-RNA because of the low cost of reagents and equipment needed. Here, we evaluate p24 as a prognostic marker in a cohort of HIV-1-infected individuals in Zimbabwe. Treatment-naive HIV-1-infected individuals (n = 198) from the Mupfure Schistosomiasis and HIV Cohort were followed until death or censoring (3-4.3 years). At baseline, p24, HIV-RNA, CD4 cell counts, and clinical staging (Centers for Disease Control and Prevention classification) were assessed. p24 correlated with HIV-RNA (P less than 0.0001, R2: 0.44). Ten percent of p24 but only 1% of HIV-RNA measurements was undetectable. p24 predicted Centers for Disease Control and Prevention category (P less than 0.001) stronger than CD4 count (P = 0.34) in multivariate logistic regression. p24 predicted mortality in univariate Cox analysis (P less than 0.0001) and in multivariate analysis, but it was inferior to HIV-RNA and CD4 count. This is the first study to evaluate the prognostic strength of p24 in an area with a predominance of HIV subtype C infections. p24 correlated with HIV-RNA and predicted clinical stage better than CD4 count. It predicted mortality in both univariate and multivariate analysis, but in multivariate analysis, it was inferior to HIV-RNA and CD4 count.

MATERNAL AND CHILD HEALTH RESEARCH

Prevention of mother-to-child transmission of HIV-1 through breast-feeding by treating infants prophylactically with lamivudine in Dar es Salaam, Tanzania: The Mitra Study
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Jul;48(3):315-323.
Kilewo C | Karlsson K | Massawe A | Lyamuya E | Swai A
The objective of this study was to investigate the possibility of reducing motherto- child transmission (MTCT) of HIV-1 through breast-feeding by prophylactic antiretroviral (ARV) treatment of the infant during the breast-feeding period. Design was an open-label, nonrandomized, prospective cohort study in Tanzania (Mitra). HIV-1-infected pregnant women were treated according to regimen A of the Petra trial with zidovudine (ZDV) and lamivudine (3TC) from week 36 to 1 week postpartum. Infants were treated with ZDVand 3TC from birth to 1 week of age (Petra arm A) and then with 3TC alone during breast-feeding (maximum of 6 months). Counseling emphasized exclusive breast-feeding. HIV transmission was analyzed using the Kaplan-Meier survival technique. Cox regression was used for comparison with the breast-feeding population in arm A of the Petra trial, taking CD4 cell count and other possible confounders into consideration. There were 398 infants included in the transmission analysis in the Mitra study. The estimated cumulative proportion of HIV-1-infected infants was 3.8% (95% confidence interval [CI]: 2.0 to 5.6) at week 6 after delivery and 4.9% (95% CI: 2.7 to 7.1) at month 6. The median time of breast-feeding was 18 weeks. High viral load and a low CD4 T-cell count at enrollment were associated with transmission. The Kaplan-Meier estimated risk of HIV-1 infection at 6 months in infants who were HIV-negative at 6 weeks was 1.2% (95% CI: 0.0 to 2.4). The cumulative HIV-1 infection or death rate at 6 months was 8.5% (95% CI: 5.7 to 11.4). No serious adverse events related to the ARV treatment of infants occurred. The HIV-1 transmission rate during breast-feeding in the Mitra study up to 6 months after delivery was more than 50% lower than in the breastfeeding population of Petra arm A (relative hazard = 2.61; P = 0.001; adjusted values). The difference in transmission up to 6 months was significant also in the subpopulation of mothers with CD4 counts greater than or equal to 200 cells/microliter. The rates of MTCT of HIV-1 in the Mitra study at 6 weeks and 6 months after delivery are among the lowest reported in a breast-feeding population in sub-Saharan Africa. Prophylactic 3TC treatment of infants to prevent MTCT of HIV during breast-feeding was well tolerated by the infants and could be a useful strategy to prevent breast milk transmission of HIV when mothers do not need ARV treatment for their own health.

The pervasive and persistent influence of caste on child mortality in India
(Abstract; subscription needed for full text; Asia)
Population Research and Policy Review. 2008 Aug;27(4):477-495.
Dommaraju P | Agadjanian V | Yabiku S
This study examines the effect of caste on child mortality and maternal health care utilization in rural India using data from the National Family Health Survey (NFHS-2) carried out during 1998-1999. Results from multilevel discrete time hazard models indicate that, net of individual-level and community-level controls, children belonging to low castes have higher risks of death and women belonging to low castes have lower rates of antenatal and delivery care utilization than children and women belonging to upper castes. At the same time, the controls account for most of the differences within the low castes. Further analysis shows that the mortality disadvantage of low castes is more pronounced in poorer districts. These results highlight the need to target low caste members in the provision of maternal and child health services.

The effects of pregnancy spacing on infant and child mortality in Matlab, Bangladesh: How they vary by the type of pregnancy outcome that began the interval
(Abstract; subscription needed for full text; Asia)
Population Studies. 2008;62(2):131-154.
DaVanzo J | Hale L | Razzaque A | Rahman M
Using high-quality longitudinal data on 125,720 singleton live births in Matlab, Bangladesh, we assessed the effects of duration of intervals between pregnancy outcomes on infant and child mortality and how these effects vary over subperiods of infancy and childhood and by the type of outcome that began the interval. Controlling for other correlates of infant and child mortality, we find that shorter intervals are associated with higher mortality. Interval effects are greater if the interval began with a live birth than with another pregnancy outcome. In the first week of the child's life, the effects of short intervals are greater if the sibling born at the beginning of the interval died; after the first month, the effects are greater if that sibling was still alive. Many relationships found are consistent with the maternal depletion hypothesis, and some with sibling competition. Some appear to be due to correlated risks among births to the same mother.

Knowledge of prenatal health care among Costa Rican and Panamanian women
(Abstract; subscription needed for full text; Central America and the Caribbean)
Revista Panamericana de Salud Publica / Pan American Journal of Public Health. 2008 Jun 30;23(6):369-376.
Guilford WH | Downs KE | Royce TJ
There is evidence that health care during pregnancy is a crucial component in ensuring a safe delivery. Because the infant mortality rate in Costa Rica is almost half the rate of Panama, the researchers tested the hypothesis that women in Costa Rica are more knowledgeable about prenatal health care than women in neighboring Panama. A multiple-choice survey was used to evaluate women's knowledge of prenatal care using WHO recommendations as the nominal standard. Oral surveys were administered to 320 women in Costa Rican and Panamanian health care clinics. The surveys consisted of multiple-choice questions designed to assess four specific domains of knowledge in prenatal care: nutrition, danger signs, threats from illness, and acceptable activities during pregnancy. Survey answers were scored, and significant factors in assessing women's knowledge of prenatal care were determined using analysis of variance and general linear models. Costa Rican women scored higher than Panamanian women in most domains of knowledge in prenatal health care. Only country of origin and educational level were significant factors in determining knowledge of prenatal care. However, country of origin was a stronger predictor of knowledge of prenatal care than was having completed high school. These data suggest that Costa Rican women are more knowledgeable about necessary prenatal care than Panamanian women, and that this difference is probably related to direct education about and promotion of prenatal care in Costa Rica. This suggests an influence of cultural health care awareness that extends beyond the previously established negative correlation between maternal educational level and infant mortality.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Reproduction in upheaval: Ethnic-specific fertility responses to societal turbulence in Kazakhstan
(Research Article; Asia)
Population Studies. 2008 Jul;62(2):211-233.
Agadjanian V | Dommaraju P | Glick JE
This study contributes to the literature on demographic adjustments to societal crises by examining ethnic-specific probabilities of having first, second, and third marital births in late-twentieth-century Kazakhstan. Discrete-time logit models, employing data from the 1995 and 1999 Kazakhstan Demographic and Health Surveys, are fitted. The results show that the probability of a first birth responded to societal cataclysms of the post-Soviet transition, but this response was most manifest and enduring in the ethnic group that had been most demographically advanced and that also found itself most politically and economically vulnerable. While ethnic differences in the probabilities of second and third births were generally more pronounced than in the probability of first birth, the pace of their post-Soviet decline was relatively uniform across all ethnic groups.

Marriage formation as a process intermediary between migration and childbearing
(Research Article; Asia)
Demographic Research. 2008 Jun 27;18(21):611-628.
Hoem JM | Nedoluzhko
In studies of differences in fertility between migrants and non-migrants, marriage interferes because migration can be motivated by an impending marriage or can entail entry into a marriage market with new opportunities. One would therefore expect elevated fertility after migration, although a competing theory states that on the contrary fertility ought to be reduced in the time around the move because migration temporarily disturbs the life of the migrant. In any case marriage appears as a process that is intermediary between migration and childbearing. To handle such issues it pays to have a technique that allows the analyst to separate any disruptive effects of migration from any boosting effects of marriage in studies of childbearing. The purposes of the present paper is (i) to remind us that such a technique is available, in fact is straightforward, and (ii) to apply the technique to further analyze a set of data on migration and first-time parenthood in Kyrgyzstan recently used by the second author and Gunnar Andersson. The technique has the neat feature that it allows us to operate with several "clocks" at the same time. In the analysis of first births we keep track of time since migration (for migrants) and time since marriage formation (for the married) beside the respondent's age (for women at childbearing ages); in other connections there may be more clocks. For such analyses we make use of a flexible graphical housekeeping device that allows the analyst to keep track of a feature like whether migration occurs before or after marriage, or at the same time. This is a half-century-old flow chart of statuses and transitions and is not much more complex that the famous Lexis diagram, which originated with Gustav Zeuner, as we now know. These reflections were first presented at a symposium dedicated to Professor Zeuner.

Fifty years of violent war deaths from Vietnam to Bosnia: Analysis of data from the world health survey programme
(Research Article; Global)
BMJ. British Medical Journal. 2008;336(7659):1482-1486.
Obermeyer Z | Murray CJ | Gakidou E
The objective of this study was to provide an accurate estimate of violent war deaths. The design was an analysis of survey data on mortality, adjusted for sampling bias and censoring, from nationally representative surveys designed to measure population health. Estimated deaths compared with estimates in database of passive reports. The setting was 2002-3 World health surveys, in which information was collected from one respondent per household about sibling deaths, including whether such deaths resulted from war injuries. The main outcome measure was estimated deaths from war injuries in 13 countries over 50 years. From 1955 to 2002, data from the surveys indicated an estimated 5.4 million violent war deaths (95% confidence interval 3.0 to 8.7 million) in 13 countries, ranging from 7000 in the Democratic Republic of Congo to 3.8 million in Vietnam. From 1995 to 2002 survey data indicate 36 000 war deaths annually (16 000 to 71 000) in the 13 countries studied. Data from passive surveillance, however, indicated a figure of only a third of this. On the basis of the relation between world health survey data and passive reports, we estimate 378000 global war deaths annually from 1985-94, the last years for which complete passive surveillance data were available. The use of data on sibling history from peacetime population surveys can retrospectively estimate mortality from war. War causes more deaths than previously estimated, and there is no evidence to support a recent decline in war deaths.

Albania: Trends and patterns, proximate determinants and policies of fertility change
(Research Article; Europe)
Demographic Research. 2008 Jul 1;19(11):261-292.
Gjonca A | Aassve A | Mencarini L
For a very long time, Albania has had one of the highest levels of fertility in Europe: in 2002 the total fertility rate of 2.2 children per woman was the highest in Europe. Although this current level is high, the country has experienced a rapid fertility reduction during the last 50 years: a TFR decline from 7 to 2.2. This reduction has occurred in the absence of modern contraception and abortion, which indicates the significance of investments in the social agenda during the communist regime that produced policies with indirect effects on fertility. Most significant of these were policies focused on education, in particular on female education. Social and demographic settings for a further fertility reduction in Albania have been present since 1990. Contraception and abortion have been legalized and available since the early 1990s, but knowledge of their use is still not widespread in the country, largely due to the interplay between traditional and modern norms of Albanian society. This chapter points out that future fertility levels will be determined not only by new policies that might be introduced, but predominantly by the balance of this interplay.

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Volume 8, Number 27 7 July 2008