Volume 8, Number 29
21 July 2008

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ADOLESCENT HEALTH RESEARCH

Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review
(Research Article; Global)
International Family Planning Perspectives. 2008 Jun;34(2):89-96.
Kim CR | Free C
Peer-led interventions have become a popular method of providing sexual health education to adolescents, but the efficacy of this approach and the methodological quality of recent trials have not been systematically reviewed. Electronic and hand searches were conducted to identify quasi-randomized and randomized controlled trials of peer-led adolescent sexual health education published from 1998 to 2005. Studies were eligible if they had an appropriate comparison group, provided preintervention and postintervention data,and reported all outcomes. Study results were summarized and, where appropriate, pooled; in addition, 10 aspects of studies' methodological quality were assessed. Thirteen articles met the inclusion criteria. Pooled, adjusted results from seven trials that examined the effects of peer-led interventions on condom use at last sex found no overall benefit (odds ratio, 1.0). None of the three trials that assessed consistent condom use found a benefit. One study reported a reduced risk of chlamydia (0.2), but another found no impact on STI incidence. One study found that young women (but not young men) who received peer-led education were more likely than nonrecipients to have never had sex. Most interventions produced improvements in knowledge, attitudes and intentions. Only three studies fulfilled all 10 of the assessed quality criteria; two others met nine criteria. Despite promising results in some trials, overall findings do not provide convincing evidence that peer-led education improves sexual outcomes among adolescents. Future trials should build on the successful trials conducted to date and should strive to fulfill existing quality criteria.

Neurobehavior of full-term small for gestational age newborn infants of adolescent mothers
(Abstract; subscription needed for full text; South America)
Jornal de Pediatria. 2008 May-Jun;84(3):217-223.
Barros MC | Guinsburg R | Mitsuhiro SS | Chalem E | Laranjeira RR
The objective of this study was to compare the neurobehavior of small (SGA) and adequate (AGA) for gestational age full-term neonates born to adolescent mothers. This prospective cross-sectional study included full-term newborn infants aged 24-72 hours, free from central nervous system malformations and born to adolescent mothers at a single center in Brazil. Infants were assessed with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) for: habituation, attention, arousal, regulation, handling, quality of movement, excitability, lethargy, nonoptimal reflexes, asymmetry, hypertonia, hypotonia, and stress/abstinence signals. The chi-square test and analysis of variance were used to compare SGA and AGA infants. Multivariate regression was used to analyze factors associated with the score of each NNNS variable. Of 3,685 infants born in the study hospital, 928 (25%) had adolescent mothers. Of these, 477 infants met the inclusion criteria: 419 (88%) were AGA and 58 (12%) were SGA. Univariate analysis did not show any differences between AGA and SGA neonates in terms of NNNS variables. Multivariate analysis showed that SGA neonates born by vaginal delivery had lower scores for quality of movements than those born by caesarean section. The SGA neonates born with local or without anesthesia had higher scores for excitability than those born with spinal anesthesia. Additionally, female SGA neonates had lower scores for stress/abstinence signals than males. SGA neonates born to adolescent mothers showed poorer quality of movements, more excitability and more signals of stress in association with sex of infant and variables related to delivery.

Lithuanian general practitioners' knowledge of confidentiality laws in adolescent sexual and reproductive healthcare: A cross-sectional study
(Abstract; subscription needed for full text; Europe)
Scandinavian Journal of Public Health. 2008 May;36(3):303-309.
Lazarus JV | Jaruseviciene L | Liljestrand J
In Lithuania, the legislation addressing confidentiality in adolescent healthcare is contradictory and vague. Previous studies have also revealed that medico-legal knowledge among physicians is poor, and attitudes play a correspondingly greater role than legal knowledge in ensuring the confidentiality of patients. The objective of this study was to survey the knowledge of Lithuanian general practitioner (GPs) of legal issues surrounding confidentiality for minors in sexual and reproductive healthcare. A 41-item questionnaire was sent to a random sample of 607 GPs. Their legal knowledge was evaluated with respect to the provisions of the Lithuanian Law on the Rights of Patients and Compensation for Health Damage. The analysis included descriptive statistics and binary logistic regression to estimate odds ratios for the eight independent variables (age, gender, type, location, ownership, size, frequency of consultations, and existence of a written office policy). The response rate was 73.5%. Of these respondents, 49.3% proved to be knowledgeable about legal standards protecting the confidentiality of adolescents in healthcare. Knowledgeability was found to be higher among GPs who had a written office policy that was based on the law. Respondents stated that the most important measure to improve confidentiality in adolescent healthcare would be the development of an explicit legal framework to address it. GPs' unfamiliarity with existing confidentiality regulations implies that there are ways to improve confidentiality in sexual and reproductive care beyond merely changing the law. This study suggests the need for a comprehensive strategy, including the development of professional guidelines and written office policies coupled with legal educational programmes directed at GPs.

Prevalence and correlates of condom use at last sexual intercourse among in-school adolescents in urban areas of Uganda
(Abstract; subscription needed for full text; Sub-Saharan Africa)
East African Journal of Public Health. 2008 Apr;5(1):22-25.
Twa-Twa JM | Oketcho S | Siziya S | Muula AS
Correct and consistent condom use remains an important public health intervention against the spread of Human Immunodeficiency Virus and other sexually transmitted infections. There is paucity of information on sexual behaviour of in-school adolescents in Uganda. We, therefore, used secondary data of the Uganda Global School-based Health Survey (UGSHS) conducted in 2003 to determine the prevalence and correlates of condom use at last sexual intercourse in urban areas of Uganda. A two-stage cluster sampling technique was used to obtain a representative sample. Altogether 1709 students participated in the survey in urban areas of whom 179 (14.9% of males, and 7.9% of females) had sexual intercourse within 12 months before the survey. Overall 77.3% (79.7% of male, and 72.3% of female) adolescents used a condom at last sexual intercourse. Adolescents who drank alcohol and used drugs were 64% (OR=1.64, 95%CI 1.54, 1.75) and 68% (OR=1.68, 95%CI 1.56, 1.81) more likely to have used a condom, respectively. Meanwhile, adolescents who ever got drunk, and who reported to ever had 2 or more sex partners were 55% (OR=0.45, 95%CI 0.42, 0.48) and 35% (OR=0.65, 95%CI 0.62, 0.68) less likely to have used a condom compared to those who had never got drunk, and who ever had 1 sex partner, respectively. Finally, adolescents who reported receiving no parental supervision were 45% (OR=0.55, 95%CI 0.53, 0.58) less likely to have used a condom compared to those who reported receiving parental supervision. Parental supervision may be effective in promoting condom use among adolescents. Furthermore, drinking alcohol was associated with condom use probably due to peer pressure and easy access of condoms in drinking places as condoms are not actively promoted in schools. There is need for further research on how in-school adolescents could access condoms.

Assessing acceptability of parents / guardians of adolescents towards introduction of sex and reproductive health education in schools at Kinondoni Municipal in Dar es Salaam city
(Abstract; subscription needed for full text; Sub-Saharan Africa)
East African Journal of Public Health. 2008 Apr;5(1):26-31.
Mbonile L | Kayombo EJ
The objective of this study was to assess acceptability of parents/guardians of adolescents towards the introduction of sex and reproductive health education in the community and schools. A multi-stage random sampling technique was used to get 150 participants for this study. A structured questionnaire was used to interview the sampled participants and was supplemented with guided focus group discussion in Kinondoni Municipality of Dar es Salaam, Tanzania. The analysis of the findings shows that there is a mixed feeling on the introduction of sex and reproductive health education in schools. Participants strongly supported that they should talk with their adolescents about sexuality and reproductive health (88.6%) but their culture prohibits them from doing so (76.7%). Also supported that condoms could protect against HIV/AIDS and sexually transmitted infections (82%), but strongly opposed the use of condoms to their adolescents because it would encourage promiscuity (78%). When the data were analysed by faith of the religions of the participants, 64% were in favour of introducing sex education and reproductive health, but were opposed to use of condoms to their adolescents. All participants were against vijiweni, which were recreation centres for the youths because they taught bad manners to their adolescents. The preferred source of information about sex education and reproductive health should be from the parents/guardians (86%), religious leaders (70%), media (62%), health workers (61%) and school teachers (59%). All in all the will of introduction of sex education and reproductive health in the community is there but the approach need to be worked out carefully by taking into account of the cultural and religious factors. Parents/guardians, religious leaders and traditional charismatic leaders should take part in designing the programme and even being involved in teaching it. The other option is to lump together sex education and reproductive health education in science especially in biology which is already in place in Tanzania education programmes.

FAMILY PLANNING RESEARCH

Vasectomy: Reaching out to new users
(Research Article; Global)
Population Reports. Series D: Male Sterilization. 2008 Jun;(6):1-23.
Kols A | Lande R
This issue of Population Reports can help managers of family planning and reproductive health programs to: Identify and address the barriers that discourage men from choosing vasectomy; Improve the quality of vasectomy services by adopting the safest and most effective surgical techniques; Select effective communication channels and design persuasive messages to promote vasectomy; Compare and assess different approaches to delivering vasectomy services; Develop training programs for providers who counsel clients on vasectomy and providers who perform the procedure; Plan how to introduce and scale up vasectomy services.

Profile of intrauterine contraceptive device acceptors at the University of Uyo Teaching Hospital, Uyo, Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Annals of African Medicine. 2008;7(1):1-5.
Abasiattai AM | Bassey EA | Udoma EJ
Use of modern contraceptive methods has been shown to reduce unwanted pregnancy, high parity and maternal mortality. Intrauterine contraceptive devices which are among the safest and most effective reversible contraceptives available, are particularly suitable for women in developing countries as they are affordable, convenient to use, do not require re-supply visits and are very costeffective. The aim of this study is to determine the socio-demographic characteristics of intrauterine contraceptive device acceptors, the pattern of insertions and complications at the University of Uyo Teaching hospital, Uyo. The record cards of all clients who had intrauterine contraceptive device inserted at the family planning clinic over a six-year period were reviewed. During the study period, there were 852 new contraceptive acceptors out of which 39.7% accepted the intrauterine contraceptive device. The modal age group of the clients was 25-29 years (32.5%). Acceptance of intrauterine contraceptive device was most common among multiparous clients (65.1%). Majority of the acceptors were married (90.0%), Christians (98.8%) and 72.8% had at least secondary school education. Clinic personnel (65.7%) and friends/relatives (21.3%) were the most common sources of information on contraception. Most (93.5%) of the clients had their intrauterine contraceptive devices inserted within 7 days of menstruation. Lower abdominal pain (5.5%) and vulval/vaginal itching (5.3%) were the most common complications. The acceptors of intrauterine contraceptive devices in our center were young, multiparous and educated women. Increasing mass media involvement in the dissemination of accurate information about intrauterine contraceptive devices to the general populace, the introduction of postpartum and post-abortal intrauterine contraceptive device insertions and the encouragement of our grandmultiparous women to accept intrauterine contraceptive device would lead to an increase in its acceptance and use.

'New bottle, but old wine': From family planning to HIV / AIDS in post-Doi Moi Vietnam
(Abstract; subscription needed for full text; Asia)
Global Public Health. 2008;3(S2):76-91.
Giang LM | Huong NT
This paper begins with an observation that during the past two decades HIV/AIDS has emerged as a new public health priority in Vietnam and has commanded increasing attention and resources from both the government and the donor community. By juxtaposing HIV/AIDS with family planning, another social and health priority that preceded, and overlapped with, HIV/AIDS for a large part of the 1990s, we show two major gaps that have undermined both programmes. One is the lack of a strong civil society, that could have served as advocates for change, especially outside the government and the donor community. The other is the desire for control of women's bodies and sexuality that has been driven by the ever shifting project of nation building. We argue that these two major gaps represent more continuity than discontinuity in the way sexual and reproductive health issues are approached in Vietnam despite the seeming shift in priority that the emergence of HIV/AIDS suggests.

Community and health facility influences on contraceptive method choice in the Eastern Cape, South Africa
(Research Article; Sub-Saharan Africa)
International Family Planning Perspectives. 2008 Jun;34(2):62-70.
Stephenson R | Beke A | Tshibangu D
Although a growing number of studies have examined how community factors influence contraceptive use, few have explored how such factors affect method choice. Data from the 1998 South Africa Demographic and Health Survey and the 1998 Eastern Cape Facility Survey were used to examine community and health facility influences on the method choices of 1,165 women aged 15-49 who lived in the Eastern Cape. Relative risk ratios from multilevel multinomial models assessed how method choice varied between communities. The likelihood of using the pill or a more permanent method rather than the injection rose with the proportion of women in a community who controlled their earnings (risk ratios, 3.2 and 3.8, respectively). In communities with higher proportions of females with only a primary education, women were less likely to use the pill instead of the injection (0.1). Higher doctor staffing levels were associated with a greater likelihood of using the pill or amore permanent method (1.5 and 1.4),and having more expired methods in stock was associated with increased use of amore permanent method (2.1). Several facility factors were associated with a decreased likelihood of using the pill rather than the injection: higher numbers of community healthworkers in an area and higher numbers of facility nurses who had received training on HIV/AIDS in the last year (0.9 for each). Yet a substantial amount of variation in method choice was not accounted for by these variables. Future research should emphasize the collection of community-level data on structural, behavioral and cultural factors to help explain the variation in method choice between communities.

The role of individual and community normative factors: A multilevel analysis of contraceptive use among women in union in Mali
(Research Article; Sub-Saharan Africa)
International Family Planning Perspectives. 2008 Jun;34(2):79-88.
Kaggwa EB | Diop N | Storey JD
Unlike in other African countries, the fertility rate in Mali has remained at a relatively high rate of 6.8 births per woman. Little research exists on the role that community norms play in use of family planning, particularly in low-prevalence countries. Data on 7,671 women in union from the 2001 Mali Demographic and Health Survey were analyzed using multilevel modeling techniques to assess the effects of individual and community factors on the adoption of modern contraceptive methods. Only 5% of women in union were using a modern contraceptive method in 2001. The odds of contraceptive use were elevated among women in the highest wealth quintile, women who approved and whose partner approved of family planning, those who had had recent discussions on family planning with their partner or others and those exposed to family planning messages (odds ratios, 1.4-2.7). At the community level, the odds of modern contraceptive use rose with the proportion of women who were exposed to family planning messages (5.5), and decreased as the mean number of births per woman rose (0.7). In the final model, which included both individual- and community-level factors, the community factors were no longer significant. Because approval of family planning and discussion of family planning with partners were shown to be the factors most strongly associated with modern contraceptive use in the multilevel model, programs that seek to increase individual approval and those that teach communication between partners could be particularly helpful to increasing contraceptive use in Mali.

GENDER and HEALTH RESEARCH

Factors associated with physical spousal abuse of women during pregnancy in Bangladesh
(Abstract; subscription needed for full text; Asia)
International Family Planning Perspectives. 2008 Jun;34(2):71-78.
Naved RT | Persson LA
Violence toward pregnant women is a gross violation of human rights with adverse health consequences for the woman and potentially for her fetus; however, few studies have examined factors associated with such abuse in developing countries or with population-based data. A sample of 2,553 ever-pregnant women aged 15-49 from one urban and one rural site in Bangladesh were surveyed in 2001 as part of a World Health Organization multicountry study. Multilevel logistic regression analysis was used to examine factors associated with physical spousal abuse of women during pregnancy. Urban and rural women whose mother or mother-in-law had experienced physical spousal abuse had increased odds of experiencing abuse during pregnancy (odds ratios,2.1-3.4); increased spousal communication was negatively associated with the outcome in both settings (0.6 and 0.7). Among urban women, being older than 19, having a husband with more than 10 years of education and being from certain higher income quartiles were negatively associated with abuse (0.2-0.5); living in a community highly concerned about crime was positively associated with abuse (1.1). Among rural women, being able to depend on natal family support in a crisis was negatively associated with abuse (0.5); being in a marriage that involved dowry demands and being Muslim were positively associated with abuse (1.8 and 3.6, respectively). The message that a family history of spousal violence increases a daughter's risk of such abuse should be widely communicated. Further research is needed to determine whether increased couple communication reduces the likelihood of violence or whether absence of violence leads to increased couple communication.

New drugs in development for the treatment of endometriosis
(Abstract; subscription needed for full text; Global)
Expert Opinion on Investigational Drugs. 2008 Aug;17(8):1187-1202.
Fedele L | Somigliana E | Frontino G | Benaglia L | Vigano P
Endometriosis is a common and enigmatic disease causing pelvic pain and infertility. Current treatment is mainly based on the use of surgery and ovarian suppressive agents. There is in particular the need for new therapeutic options able to allow a normal menstrual cycle to occur and also consent pregnancy. In the present review, we aimed to give a concise and practical overview in order to allow the clinician to clearly understand the level of development of these drugs. We have presented only treatments supported by in vivo researches with a special attention to studies in humans. Results show appealing new possibilities are emerging from agents counteracting the endometriosis-associated inflammation. Recent data also suggests that there is still the opportunity to refine the use of already available agents.

HIV/AIDS and STIs RESEARCH

HIV-1 persists in breast milk cells despite antiretroviral treatment to prevent mother-to-child transmission
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS. 2008 Jul;22(12):1475-1485.
Lehman DA | Chung MH | John-Stewart GC | Richardson BA | Kiarie J
The effects of short-course antiretrovirals given to reduce mother-to-child transmission (MTCT) on temporal patterns of cell-associated HIV-1 RNA and DNA in breast milk are not well defined. Women in Kenya received short-course zidovudine (ZDV), single-dose nevirapine (sdNVP), combination ZDV/sdNVP or short-course highly active antiretroviral therapy (HAART). Breast milk samples were collected two to three times weekly for 4-6 weeks. HIV-1 DNA was quantified by real-time PCR. Cell-free and cellassociated RNA levels were quantified by the Gen-Probe HIV-1 viral load assay. Cell-free HIV-1 RNA levels in breast milk were significantly suppressed by sdNVP, ZDV/sdNVP or HAART therapy compared with ZDV between day 3 and week 4 postpartum (P less than or = 0.03). Breast milk HIV-1 DNA levels (infected cell levels) were not significantly different between treatment arms at any timepoint during the 4-6-week follow-up. At 3 weeks postpartum, when the difference in cell-free RNA levels was the greatest comparing HAART directly with ZDV (P=0.0001), median log10 HIV-1 DNA copies per 1_106 cells were 2.78, 2.54, 2.69, and 2.31 in the ZDV, sdNVP, ZDV/sdNVP and HAART arms, respectively (P=0.23). Cell-associated HIV-1 RNA levels were modestly suppressed in HAART versus ZDV/sdNVP during week 3 (3.37 versus 4.02, P=0.04), as well as over time according to a linear mixed-effects model. Cell-free and, to a lesser extent, cell-associated HIV-1 RNA levels in breast milk were suppressed by antiretroviral regimens used to prevent MTCT. However, even with HAART, there was no significant reduction in the reservoir of infected cells, which could contribute to breast milk HIV-1 transmission.

The social construction of ARVs in South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Global Public Health. 2008;3(S2):58-75.
Sember R
An estimated 5.5 million people are currently living with HIV/AIDS in South Africa, 4.9 million of them between the ages of 15-49, 18.8% of the total population in that age bracket (Department of Health, Republic of South Africa 2006). The potential medical and social benefits of anti-retroviral drugs (ARVs) would be substantial, but South Africa's leaders have faulted in their response to AIDS from the very beginning, particularly President Thabo Mbeki, who, in concert with the Minister of Health, has questioned the basic science of AIDS, and has condemned ARVs as poisonous. President Mbeki has created a false distinction between social causes and disease agents in his analysis that it is poverty, rather than HIV, that causes AIDS. He has made his arguments using post-colonial rhetoric to condemn pharmaceutical imperialism and medical experimentation on African populations. Opponents, most notably the pro-treatment social movement group, Treatment Action Campaign, claim that because poverty increases the risk of infection, illness and death due to HIV access to anti-retroviral medication is a social justice issue--justice demands the medications be available at all government clinics at no cost. In 2003 a government-sponsored treatment programme was launched, and by mid-2006 it was treating 140,000 persons with HIV/AIDS, less than 25% of the number estimated to require treatment. Treatment access, for all who need it in South Africa, is an ambitious but achievable goal. A new president will be elected in 2008, and many hope that this will result in a national treatment programme unshackled from the "AIDS denialism" of the current leaders. Former deputy president, Jacob Zuma, is likely to be the next president. His record on AIDS, and his patriarchal attitudes towards women, are troubling, however. One can only hope that the provincial health systems, which operate with a fair level of autonomy from the national Department of Health, will not be further hampered in their work by the politics of the central government.

Tackling HIV in India: Evidence-based priority setting and programming
(Abstract; subscription needed for full text; Asia)
Health Affairs. 2008;27(4):1091-1102.
Claeson M | Alexander A
In the wake of a downward revision of the number of HIV-infected people, India is launching an ambitious US$2.5 billion, five-year HIV plan. Responding to new data on HIV prevalence and risk behavior, India has earmarked almost 70 percent of the budget for prevention; one-third focuses on prevention activities for those at highest risk of HIV, and the remainder addresses HIV testing expansion and services for pregnant women. About 20 percent of the total budget is for care and treatment. Although the size and scope of the proposed HIV response pose challenges, the world has much to learn from India's data-informed approach to policy and priority setting.

Rapid antiretroviral therapy scale-up in Hubei Province, China
(Abstract; subscription needed for full text; Asia)
Health Affairs. 2008;27(4):1140-1147.
Sherer R | Gui X | Zhan F | Teter C | Ping DL
In 2003, physicians in China were unprepared to care for people with AIDS. Project HOPE partnered with Hubei Province health authorities to train and mentor doctors and build capacity for HIV care. From 2004 to 2006, seventy-eight Chinese "master trainers" were trained, who then trained and mentored 8,759 health workers. During this period, as the free antiretroviral therapy period began, measures of physician competence in HIV care improved significantly, and annual mortality from AIDS fell from 49 percent to 8.8 percent. This international partnership created a sustainable capacity for effective HIV prevention and care that could be replicable in other settings.

Patterns of individual and population-level adherence to antiretroviral therapy and risk factors for poor adherence in the first year of the DART trial in Uganda and Zimbabwe
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Aug 1;48(4):468-475.
Muyingo SK | Walker AS | Reid A | Munderi P | Gibb DM
Good adherence is essential for successful antiretroviral therapy (ART) provision, but simple measures have rarely been validated in Africa. This was an observational analysis of an open multicenter randomized HIV/AIDS management trial in Uganda and Zimbabwe. At 4-weekly clinic visits, ART drugs were provided and adherence measured through pill usage and questionnaire. Viral load response was assessed in a subset of patients. Drug possession ratio (percentage of drugs taken between visits) defined complete (100%) and good ($95%) adherence. In 2957 patients, 90% had pill counts at every visit. Good adherence increased from 87%, 4 weeks after ART initiation, to 94% at 48 weeks, but only 1454 (49%) patients achieved good adherence at every visit in the first year. Complete adherence was associated with 0.32 greater reduction in log10 viral load (95% confidence interval 0.05, 0.60 P = 0.02) and was independently associated with higher baseline CD4 count, starting ART later in the trial, reporting a single regular sexual partner, clinical center, and time on ART. Population level adherence improved over time suggesting an association with clinical experience. Most patients had at least one visit in the year on which they reported not having good adherence, showing the need for continued adherence interventions.

MATERNAL AND CHILD HEALTH RESEARCH

Determinants of neonatal mortality in Indonesia
(Research Article; Asia)
BMC Public Health. 2008 Jul 9;8(232):[38] p.
Titaley CR | Dibley MJ | Agho K | Roberts CL | Hall J
Neonatal mortality accounts for almost 40 per cent of under-five child mortality, globally. An understanding of the factors related to neonatal mortality is important to guide the development of focused and evidence-based health interventions to prevent neonatal deaths. This study aimed to identify the determinants of neonatal mortality in Indonesia, for a nationally representative sample of births from 1997 to 2002. The data source for the analysis was the 2002-2003 Indonesia Demographic and Health Survey from which survival information of 15,952 singleton live-born infants born between 1997 and 2002 was examined. Multilevel logistic regression using a hierarchical approach was performed to analyze the factors associated with neonatal deaths, using community, socio-economic status and proximate determinants. At the community level, the odds of neonatal death was significantly higher for infants from East Java (OR = 5.01, p = 0.00), and for North, Central and Southeast Sulawesi and Gorontalo combined (OR = 3.17, p = 0.03) compared to the lowest neonatal mortality regions of Bali, South Sulawesi and Jambi provinces. A progressive reduction in the odds was found as the percentage of deliveries assisted by trained delivery attendants in the cluster increased. The odds of neonatal death were higher for infants born to both mother and father who were employed (OR = 1.84, p = 0.00) and for infants born to fathers who were unemployed (OR = 2.99, p = 0.02). The odds were also higher for higher rank infants with a short birth interval (OR = 2.82, p = 0.00), male infants (OR = 1.49, p = 0.01), smaller than average-sized infants (OR = 2.80, p = 0.00), and infants whose mother had a history of delivery complications (OR = 1.81, p = 0.00). Infants receiving any postnatal care were significantly protected from neonatal death (OR = 0.63, p = 0.03). Public health interventions directed at reducing neonatal death should address community, household and individual level factors which significantly influence neonatal mortality in Indonesia. Low birth weight and short birth interval infants as well as perinatal health services factors, such as the availability of skilled birth attendance and postnatal care utilization should be taken into account when planning the interventions to reduce neonatal mortality in Indonesia.

Safe motherhood in Pakistan
(Abstract; subscription needed for full text; Asia)
International Journal of Gynecology and Obstetrics. 2008 Aug;102(2):179-185.
Jafarey S | Kamal I | Qureshi AF | Fikree F
The maternal mortality ratio in Pakistan remains high at between 350 and 500 per 100000 live births, while the neonatal mortality ratio is 50 per 1000 live births. This paper examines the trends in maternal and neonatal mortality in Pakistan and looks at why slow progress has been made in attempts to achieve safe motherhood. Despite numerous initiatives, it is uncertain whether Pakistan will achieve Millennium Development Goals 4 and 5 by 2015.

Use of evidence-based practices in pregnancy and childbirth: South East Asia Optimising Reproductive and Child Health in Developing Countries project
(Research Article; Asia)
PLoS One. 2008 Jul;3(7):[7] p.
The burden of mortality and morbidity related to pregnancy and childbirth remains concentrated in developing countries. SEA-ORCHID (South East Asia Optimising Reproductive and Child Health In Developing countries) is evaluating whether a multifaceted intervention to strengthen capacity for research synthesis, evidence-based care and knowledge implementation improves adoption of best clinical practice recommendations leading to better health for mothers and babies. In this study we assessed current practices in perinatal health care in four South East Asian countries and determined whether they were aligned with best practice recommendations. We completed an audit of 9550 medical records of women and their 9665 infants at nine hospitals; two in each of Indonesia, Malaysia and The Philippines, and three in Thailand between January- December 2005. We compared actual clinical practices with best practice recommendations selected from the Cochrane Library and the World Health Organization Reproductive Health Library. Evidence-based components of the active management of the third stage of labour and appropriately treating eclampsia with magnesium sulphate were universally practiced in all hospitals. Appropriate antibiotic prophylaxis for caesarean section, a beneficial form of care, was practiced in less than 5% of cases in most hospitals. Use of the unnecessary practices of enema in labour ranged from 1% to 61% and rates of episiotomy for vaginal birth ranged from 31% to 95%. Other appropriate practices were commonly performed to varying degrees between countries and also between hospitals within the same country. Whilst some perinatal health care practices audited were consistent with best available evidence, several were not. We conclude that recording of clinical practices should be an essential step to improve quality of care. Based on these findings, the SEA-ORCHID project team has been developing and implementing interventions aimed at increasing compliance with evidence-based clinical practice recommendations to improve perinatal practice in South East Asia.

The tip of the iceberg: Evidence of seasonality in institutional maternal mortality and implications for health resources management in Burkina Faso
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Scandinavian Journal of Public Health. 2008 May;36(3):310-317.
Hounton SH | Sombie I | Townend J | Ouedraogo T | Meda N
The aims of this study were to investigate seasonal patterns of institutional maternal deaths and complications, and to test for an association with malaria seasons, rainfall, and household income. A systematic case review of hospital records in the Boucle du Mouhoun health region (Burkina Faso) was conducted over a 2-year period. A statistical smoothing procedure (T4253H) and Freedman's test were used to investigate seasonality and association with malaria, rainfall or household income variations. The data consistently showed the greatest rates of maternal deaths, eclampsia and haemorrhage cases during the dry season, which is the low malaria transmission season, and the period of the year when households have most money available and the lowest opportunity cost of travelling to seek medical attention, suggesting that financial and geographical barriers may be major underlying factors. The management both of health resources in hospital and of referral systems should accommodate cyclical variations in the presentation of maternal complications. Effective mechanisms are needed to help reduce the significant barriers to uptake faced by women and their families at particular times of the year.

A risk assessment for pregnancy using the World Health Organization classifying form in primary health-care facilities in Enugu, Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Tropical Doctor. 2008 Jul;38(3):135-137.
Aniebue UU | Aniebue PN
We present a cross-sectional survey of the pattern of high-risk pregnancies in randomly selected primary health-care facilities in Enugu, Nigeria, using the World Health Organization's classifying form. None of the 10 maternity homes studied had a standard risk screening tool. The age of the 299 women studied ranged from 16 to 42 years with a mean of 27.8 + 6.7 years. Eighty-eight (29.4%) of them were nulliparous, 160 (53.5%) were multiparous and 51 (17.1%) grandmultiparous. One hundred and twenty (40.1%) respondents were in the high-risk category. Rhesus D-negative blood group parturients (42, 35.0%), previous perinatal deaths (29.2%) and multiple pregnancies (9.2%) were the most common risk factors. The prevalence of high-risk pregnancies significantly increased with maternal age and parity and was not influenced by an improved maternal educational attainment. The institution of screening for high-risk pregnancies is vital at the primary health-care level and must be emphasized and must be regularly audited.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Population policy implementation in Nigeria, 1988-2003
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Population Review. 2008;47(1):[48] p.
Adegbola O
The first Nigerian Population Policy was written in 1988 to reduce population growth as a collaboration between the Federal Ministry of Health and the World Bank. Whether this policy was successful is in contention. Some schools of thought argue that it was unsuccessful due to cultural, religious and financial factors in play. However, a positive demographic change was noticed statistically after the policy was implemented. Achievement of policy goals was limited due to flaws in the implementation strategy adopted for the National Population Program as well as due to a cultural aversion to family planning in Northern Nigeria, among other factors. The success of the policy was greatest in Southern Nigeria where social advancement also played an integral role. This paper shows that the attitudes towards population growth differ between these two very important regions of one country. This paper also addresses, in great detail, the obstacles to the implementation of the 1988 policy, and analyzes why the policy was successful in a part of the country, but not in another. With a new Population Policy having been implemented in 2006, identifying the problems of the 1988 program implementation has limited value unless the learned lessons result in a greater determination by the upper echelons of government, the bureaucracy and the political class in the nation to reprogram efforts for the future. While the Federal Government has recently instituted reform agenda that cover economic, social and administrative reforms, the population sector, together with the political governance that will address the role of population size in allocation of resources and power, needs to be included in the reform agenda.

Towards smaller family size in Egypt, Morocco and Turkey: Overall change over time or socio-economic compositional effect?
(Abstract; subscription needed for full text; North Africa | Europe)
Population Review. 2008;47(1):[14] p.
D'Addato AV | Vignoli D | Yavuz S
The whole region of the South and East Mediterranean exhibits a profound fertility transition with marked differences in the pace of fertility declines among the countries. The authors choose three representative countries: Egypt, Morocco and Turkey. Determinants of the propensity towards smaller family size are investigated as scrutinizing the development in the pattern of third births, which represents the critical step in the transitional process for these countries. The authors are particularly interested in verifying whether the decline of higher-order births is significantly driven by an overall societal change over time or by compositional change over different socio-economic segments of the female population. Evidence is found that overall societal changes have mainly driven the decline in large family size, though, to a much lesser extent, compositional changes are important too.

Hotspots and coldspots: Household and village-level variation in orphanhood prevalence in rural Malawi
(Research Article; Sub-Saharan Africa)
Demographic Research. 2008 Jul 15;19(32):1217-1248.
Weinreb A | Gerland P | Fleming P
We explore the characteristics of households and villages in which orphans are resident in two areas of Malawi. We first review pertinent themes in qualitative data collected in our research sites. Then, using spatial analysis, we show how positive and negative clusters of orphans -which we term orphanhood "hotspots" and "coldspots" -can be found at the village and sub-village levels. In the third and longest section of the paper, and using multilevel analyses with both simple and complex variance structures, we evaluate the relationship between the presence of orphans and a range of individual, household and village-level characteristics, including households' spatial relationship to each other and to other local sites of significance. This series of analyses shows that the most important covariates of orphan presence are household size, wealth, and religious characteristics, with all measured simultaneously at both household and village-level. In addition, most of these have heterogenous effects across villages. We conclude by reviewing some difficulties in explaining causal mechanisms underlying these observed relationships, and discuss conceptual, theoretical and programmatic implications.

A rural Ethiopian population undergoing epidemiological transition over a generation: Butajira from 1987 to 2004
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Scandinavian Journal of Public Health. 2008 Jun;36(4):436-441.
Berhane Y | Wall S | Fantahun M | Emmelin A | Mekonnen W
The objective of this study was to describe the epidemiological development of a rural Ethiopian population from 1987 to 2004 in terms of mortality and associated sociodemographic factors. A rural population comprising 10 communities was defined in 1987 and has since been followed by means of regular household visits. After an initial census, births, deaths and migration events were recorded, together with key background factors, on an open cohort basis. Over 97,000 individuals were observed during a total of over 700,000 person years. The initial population of 28,614 increased by an average of 3.64% annually to 54,426 from 1987 to 2004, and also grew older on average. Birth and mortality rates fell, but were still subject to short-term variation due to external factors. Overall mortality was 13.5 per 1000 person years. Increasing mortality in some adult age groups was consistent with increasing AIDS-related deaths, but a new local hospital in 2002 may have contributed to later falls in overall mortality. Sex, age group, time period, literacy, water source, house ownership and distance to town were all significantly associated with mortality differentials. This population has undergone a complex epidemiological transition during a generation. Detailed long-term surveillance of this kind is essential for describing such processes. Many factors that significantly affect mortality cannot be directly controlled by the health sector and will only improve with general development.

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