Volume 8, Number 32
11 August 2008

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ADOLESCENT HEALTH RESEARCH

Triple jeopardy: Female adolescence, sexual violence, and HIV / AIDS
(Report; Global)
New York, New York, IWHC, 2008 Jun. 6 p. (On Health and Rights)
Pervasive gender inequalities mean that girls especially face numerous violations to their sexual and reproductive health and rights, including sexual initiation before they are physically or emotionally ready. Girls who live in extreme poverty, among marginalized populations, without family support, or in situations of conflict and displacement are particularly vulnerable to coerced sexual encounters and abuse.

One Foot Wet and One Foot Dry: Transition Into Motherhood Among Married Adolescent Women in Rural Vietnam
(Abstract; subscription needed for full text; Asia)
Journal of Transcultural Nursing. 2008 Jul;19(3)
Klingberg-Allvin M | Binh N | Johansson A | Berggren V
This study explores married Vietnamese adolescents’ perceptions and experiences related to transition into motherhood and their encounter with health care service. In-depth interviews were conducted with 22 women younger than 20 who were either pregnant or had newly delivered. It emerged from the narratives that young women experienced ambivalence in the transition to motherhood in that they felt too young but also happy to be able to please their husband and the extended family. Patterns were shown indicating that the participants experienced lacking power with regard to decisions in relation to pregnancy, delivery, and contraceptive usage. Feelings of being patronized and ignored in the encounter with health care providers were seen in the narratives. Findings might be used for reproductive health care providers, social workers, and educators in their contact with young mothers to empower them to make their own decisions with regard to marriage, childbearing, and contraception.

FAMILY PLANNING RESEARCH

Population growth and climate change. Universal access to family planning should be the priority [editorial]
(Editorial; Global)
BMJ. British Medical Journal. 2008 Aug 2;337(7664):247-248.
Guillebaud J | Hayes P
The world's population now exceeds 6700 million, and humankind's consumption of fossil fuels, fresh water, crops, fish, and forests exceeds supply. These facts are connected. The annual increase in population of about 79 million means that every week an extra 1.5 million people need food and somewhere to live. Every person born adds to greenhouse gas emissions, and escaping poverty is impossible without these emissions increasing. Resourcing contraception therefore helps to combat climate change, although it is not a substitute for high emitters reducing their per capita emissions. As doctors, we must help to eradicate the many myths and non-evidence based medical rules that often deny women access to family planning. We should advocate for it to be supplied only wisely and compassionately, and for increased investment, which is currently just 10% of that recommended at the UN's Population Conference in Cairo. We must not put pressure on people, but by providing information on population and the environment, and appropriate contraception for everyone (and by their own example), doctors should help to bring family size into the arena of environmental ethics, analogous to avoiding patio heaters and high carbon cars.

Colon penetration by a copper intrauterine device: A case report with literature review
(Abstract; subscription needed for full text; Global)
Archives of Gynecology and Obstetrics. 2008 Jul 1;:[3] p.
Arslan A | Kanat-Pektas M | Yesilyurt H | Bilge U
The present case report describes colon injury subsequent to uterine penetration which is associated with the use of an intrauterine device (IUD). A 29-year-old multiparous woman, who presented with vague abdominal pain, had a TCu 380A inserted at her postpartum third month visit. The T-shaped segment of the IUD was found to be lodged within the lumen of a colon segment which was 60 cm far from the ileocecal valve. The vertical copper-bearing limb of the IUD extruded from the colon wall beyond the mesenteric edge and partially penetrated the fundal wall. After the aVected colon segment was resected, an end-to-end anastomosis was made. Recovery period was uneventful. The incidence of uterine penetration is aVected by the IUD type, the timing of insertion related to pregnancy termination, the position of uterus, insertion technique, the experience of the operator and the follow-up period. The location of missing IUDs can be determined by ultrasonography, X-ray or computed tomography imaging.

Assessing attitudes about emergency contraception among urban, minority adolescent girls: A in-depth interview study
(Abstract; subscription needed for full text; North America)
Pediatrics. 2008 Aug;122(2):e395-e401.
Mollen CJ | Barg FK | Hayes KL | Gotcsik M | Blades NM
The purpose of this work was to explore the knowledge, attitudes, and beliefs of urban, minority adolescent girls about intention to use emergency contraception pills and to identify barriers to emergency contraception pill use. We conducted an in-depth, semistructured interview study of healthy, urban-dwelling, English-speaking 15- to 19-year-old black adolescents seeking care in a children's hospital emergency department. Purposive sampling was used to recruit sexually active and nonsexually active adolescents and those with and without a history of pregnancy. Enrollment continued until saturation of key themes was achieved. Participants returned after their emergency department visit for a 1-hour interview. The interview consisted of semistructured questions based on the theory of planned behavior constructs: attitudes (including knowledge), subjective norms, and perceived behavioral control, as well as demographic data collection. Interviews were recorded and transcribed. Transcripts were coded by 2 members of the study team by using a modified grounded-theory method. Thirty interviews were required for saturation. Mean participant age was 16.4 years; 53% reported being sexually active, and 17% reported a history of pregnancy. Specific knowledge gaps exist about emergency contraception pills, including misconceptions about the recommended time frame for taking the medication. Several major themes were noted for each of the constructs. Intention to use emergency contraception pills is affected by the conflicting attitudes that the emergency contraception pill works faster than birth control pills and that those who use emergency contraception pills are irresponsible; family and friends are important influences and have uninformed but generally supportive opinions; and adolescents have a perception of limited behavioral control because of their young age and concerns about confidentiality. Urban, minority adolescent girls have misconceptions about emergency contraception pills, are affected by the opinions of those close to them, and express concern about specific barriers. These findings can inform specific interventions aimed at addressing the barriers to emergency contraception pill use that are of most importance to this population of young women.

GENDER and HEALTH RESEARCH

Health-sector responses to intimate partner violence in low- and middle-income settings: A review of current models, challenges and opportunities
(Research Article; Global)
Bulletin of the World Health Organization. 2008 Aug;86(8):635-642.
Colombini M | Mayhew S | Watts C
There is growing recognition of the public-health burden of intimate partner violence (IPV) and the potential for the health sector to identify and support abused women. Drawing upon models of health-sector integration, this paper reviews current initiatives to integrate responses to IPV into the health sector in low- and middle-income settings. We present a broad framework for the opportunities for integration and associated service and referral needs, and then summarize current promising initiatives. The findings suggest that a few models of integration are being replicated in many settings. These often focus on service provision at a secondary or tertiary level through accident and emergency or women's health services, or at a primary level through reproductive or family-planning health services. Challenges to integration still exist at all levels, from individual service providers' attitudes and lack of knowledge about violence to managerial and health systems' challenges such as insufficient staff training, no clear policies on IPV, and lack of coordination among various actors and departments involved in planning integrated services. Furthermore, given the variety of locations where women may present and the range and potential severity of presenting health problems, there is an urgent need for coherent, effective referral within the health sector, and the need for strong local partnership to facilitate effective referral to external, non-health services.

Emergency peripartum hysterectomy in a tertiary Istanbul hospital
(Abstract; subscription needed for full text; Europe)
Archives of Gynecology and Obstetrics. 2008 Sept;:[6] p.
Kayabasoglu F | Guzin K | Aydogdu S | Sezginsoy S | Turkgeldi L | Gunduz G
Objective is to evaluate the incidence, risk factors, indications, outcomes and complications of emergency peripartum hysterectomy performed after cesarean and vaginal
deliveries. We analyzed retrospectively 28 cases of emergency peripartum hysterectomy operations performed
between February 2001 and February 2007 at the Istanbul
Goztepe Training and Research Hospital, which is a teaching
hospital operating under the Turkish Ministry of
Health. The indications, risk factors and the associated
complications were compared with control groups. Statistical
analysis was performed using the STATA version 7.0
statistical package (Stata Corporation, College Station, TX,
USA). The overall incidence of emergency peripartum
hysterectomy at our hospital is 0,37 in 1,000 deliveries.
Abnormal placental adherence and uterine atony comprised
85% of the indications for peripartum hysterectomy. Postoperative maternal morbidity occurred in 15 cases (54%).
Most had a febrile morbidity and depression. Seven
patients underwent postpartum histerectomy due to consumptive coagulopathy. There was one maternal mortality
(4%) and Wve perinatal mortalities (18%). The maternal
death was due to consumptive coagulopathy after placental
abruption. All patients had to receive blood transfusions.
The median number of postoperative hospitalization days
was 7. Peripartum hysterectomy is still a dramatic
life-saving operation with high risks. The most common
reason for abnormal placental adherence is previous uterine
procedures.

HIV/AIDS and STIs RESEARCH

The outcomes and outpatient costs of different models of antiretroviral treatment delivery in South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Tropical Medicine and International Health. 2008 Aug;13(8):1005-1015.
Rosen S | Long L | Sanne I
The objective of this study was to estimate the average outpatient cost per patient in care and responding to treatment 1 year after initiation of antiretroviral therapy (ART) under different models of treatment delivery in South Africa. At each site, medical records for a sample patients of were reviewed 1 year after ART initiation. Each subject was assigned to one outcome category: in care and responding (IC); in care but not responding (NR); or no longer in care at study site (NIC). Average cost per outcomes category was estimated based on resource utilisation. Site 1 was an urban public hospital; Site 2 a programme that contracts private general practitioners; Site 3 a rural non-governmental (NGO) AIDS clinic; and Site 4 a peri-urban NGO primary care clinic. At month 12, IC, NR and NIC rates were 67%, 7% and 26% (Site 1); 52%, 3%, and 45% (Site 2); 63%, 9% and 28% (Site 3); and 76%, 11%, and 13% (Site 4). The average outpatient cost per patient initiated was $756 (Site 1), $896 (Site 2), $932 (Site 3) and $1,126 (Site 4). When all costs and all outcomes were taken into account, the average cost to produce an IC patient was $1,128 (Site 1), $1,723 (Site 2), $1,480 (Site 3), and $1,482 (Site 4). If all ART patients remain in care and responding, total costs will increase but the average cost to produce an IC patient will fall. The cost per ART patient treated varies moderately among sites. Cost differences increase markedly when patient outcomes are taken into account.

Non-puerperal induced lactation: An infant feeding option in paediatric HIV / AIDS in tropical Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Child Health Care. 2008 Sep;12(3):241-248.
Ogunlesi TA | Adekanmbi FA | Fetuga BM | Ogundeyi MM
A major problem in the management of infants exposed to HIV is the issue of feeding, which stems from the need to avoid transmission of the virus via breast milk. Other important issues in the nutrition of infants exposed to the virus include severe maternal illness, which makes suckling extremely difficult, and feeding orphans. Wet nursing is one of the recommended steps in addressing the feeding problems of such infants but for reasons of sociocultural disapproval, it appears not to be popular in traditional African settings. Non-puerperal induced lactation or re-lactation of a close relation, usually a grandmother, which hitherto has been used to rehabilitate severely malnourished motherless infants, may be equally useful. The procedure of re-lactation and the limitations of the method are highlighted. Also, the need to employ information, education and communication in improving the sociocultural acceptability of this veritable infant feeding method in tropical Africa is discussed.

Incidence of sexually transmitted infections among HIV-infected women using depot medroxyprogesterone acetate contraception
(Abstract; subscription needed for full text; Global)
Contraception. 2008 Aug;78(2):125-130.
Overton ET | Shacham E | Singhatiraj E | Nurutdinova D
Previous studies suggest that depot medroxyprogesterone acetate (DMPA) is associated with an increased risk of sexually transmitted infection (STI) acquisition. The primary aim of this study was to characterize the potential association between DMPA use and risk of STI acquisition among HIV-infected women. This is a retrospective cohort study among HIV-infected women followed at a university clinic from 1997 to 2005. Medical records were reviewed for demographic data, HIV parameters, self-reported condom use, substance use, duration of follow-up and incident cases of gonorrhea, chlamydial infection and trichomoniasis. Of 304 HIV-infected women identified, 82 received DMPA and 222 did not. Overall incidence rates of trichomoniasis, chlamydial infection and gonorrhea were 8.4, 4.0 and 3.1 cases per 100 person-years, respectively, with no significant differences between the women receiving or not receiving DMPA. In this HIV-infected cohort, STI rates were higher than the general population, yet DMPA use did not appear to enhance the risk of STI acquisition. This latter finding suggests that the concern for STI acquisition should not be a limiting factor in the use of DMPA in HIV-infected women. The implementation of additional secondary prevention strategies remains an important focus in the HIV epidemic.

Hematologic and hepatic toxicities associated with antenatal and postnatal exposure to maternal highly active antiretroviral therapy among infants
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS. 2008 Aug 20;22(13):1633-1640.
Bae WH | Wester C | Smeaton LM | Shapiro RL | Lockman S
The objective of this study was to assess hematologic and hepatic toxicities associated with in utero and breastfeeding exposure to maternal highly active antiretroviral therapy (HAART) among infants in Botswana. The design of the study was a nested cohort study within a randomized clinical trial (the Mashi Study). Laboratory toxicities among infants born to women who initiated HAART before delivery were compared with toxicities among those born to women who received zidovudine and a single dose of nevirapine or placebo in labor. Infants were randomized to breastfeed with extended zidovudine or to formula-feed. Hemoglobin concentrations, absolute neutrophil and platelet counts, and alanine aminotransferase and aspartate aminotransferase levels were recorded from birth to 7 months of age in infants. Grade 3 and 4 toxicities were compared by infant antiretroviral exposure status. In-utero exposure to maternal HAART was associated with increased risk for neutropenia in infants up to 1 month of age; 21.7% of HAART-exposed infants were neutropenic, compared with 5.5% of the infants exposed to zidovudine (P less than 0.01). However, neutropenia was no longer associated with antenatal exposure to HAART after 1 month of age. Postnatal exposure to HAART was not associated with hematologic or hepatic toxicities. Laboratory toxicities were clinically asymptomatic in all but one infant. Exposure to maternal HAART in utero may increase the risk for infant neutropenia, particularly among breastfed infants, but the clinical significance of this finding is uncertain. The lack of association between exposure to HAART through breastfeeding and long-term toxicities in infants is reassuring but deserves study in larger cohorts.

MATERNAL AND CHILD HEALTH RESEARCH

Maternal periodontal status and preterm low birth weight delivery: A case-control study
(Abstract; subscription needed for full text; Middle East)
Archives of Gynecology and Obstetrics. 2008 Jun 4;:[5] p.
Khader Y | Al-shishani L | Obeidat B | Khassawneh M | Burgan S
The objective of this study was to assess the association between severity and extent of maternal periodontal disease and preterm birth/ low birth weight (PLBW) among women in the north of Jordan. A total of 148 woman who gave preterm birth/ low birth weight birth and 438 women with uncomplicated full term vaginal delivery were included in this study. Socio-demographic characteristics, antenatal history, medical history, and family medical history were collected through personal interview or abstracted from maternal records. The oral hygiene status, and periodontal and dental parameters were assessed for all women. The average of probing pocket depth (PPD) and average of clinical attachment level (CAL) were significantly higher among women who gave PLBW babies. The mean gingival recession was not significantly different between the two groups. The percentages of sites with PPD greater than or = 3 mm and CAL greater than or = 3 mm were significantly higher among women who gave PLBW babies. Number of decayed teeth, number of filled teeth, and number of missing teeth showed no significant association with PLBW delivery. The extent and severity of periodontal diseases appeared to be associated with increased odds of PLBW delivery. Nevertheless, more and larger intervention trials are needed before it can be fully accepted that periodontal infection is a true risk factor for PLBW.

Aetiology of stillbirths and neonatal deaths in rural Ghana: Implications for health programming in developing countries
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Paediatric and Perinatal Epidemiology. 2008 Sep;22(5):430-437.
Edmond KM | Quigley MA | Zandoh C | Danso S | Hurt C
In developing countries many stillbirths and neonatal deaths occur at home and cause of death is not recorded by national health information systems. A community-level verbal autopsy tool was used to obtain data on the aetiology of stillbirths and neonatal deaths in rural Ghana. Objectives were to describe the timing and distribution of causes of stillbirths and neonatal deaths according to site of death (health facility or home). Data were collected from 1 January 2003 to 30 June 2004; 20 317 deliveries, 696 stillbirths and 623 neonatal deaths occurred over that time. Most deaths occurred in the antepartum period (28 weeks gestation to the onset of labour) (33.0%). However, the highest risk periods were during labour and delivery (intrapartum period) and the first day of life. Infections were a major cause of death in the antepartum (10.1%) and neonatal (40.3%) periods. The most important cause of intrapartum death was obstetric complications (59.3%). There were significantly fewer neonatal deaths resulting from birth asphyxia in the home than in the health facilities and more deaths from infection. Only 59 (20.7%) mothers of neonates who died at home reported that they sought care from an appropriate health care provider (doctor, nurse or health facility) during their baby's illness. The results from this study highlight the importance of studying community-level data in developing countries and the high risk of intrapartum stillbirths and infectious diseases in the rural African mother and neonate. Community-level interventions are urgently needed, especially interventions that reduce intrapartum deaths and infection rates in the mother and infant.

A systematic review of pediatric adherence to antiretroviral therapy in low- and middle-income countries
(Abstract; subscription needed for full text; Global)
Pediatric Infectious Disease Journal. 2008 Aug;27(8):686-691.
Vreeman RC | Wiehe SE | Pearce EC | Nyandiko WM
Sustaining antiretroviral therapy (ART) adherence requires accurate, consistent monitoring, a particular challenge for low-income countries. The optimal strategy to measure pediatric adherence remains unclear. The objective of this study was to conduct a systematic review of pediatric ART adherence measurement techniques, adherence estimates, and clinical correlates in low- and middle-income countries to inform ART adherence monitoring. We searched online bibliographic databases, including MEDLINE and EMBASE, using systematic criteria. Two reviewers selected all descriptive or interventional studies involving nonpregnant, HIV-positive individuals less than or = 18 years old that measured ART adherence in low- or middle-income countries as defined by World Bank criteria. Data were extracted regarding sample characteristics, study setting, measurement strategy, adherence estimate, and adherence correlates. The search yielded 1566 titles, of which 17 met selection criteria. Adherence measurement strategies included self- or proxy-report measures (14 studies), pill counts (4 studies), pharmacy records, drug levels, clinic adherence, and directly observed therapy (1 study each). The self- or proxy-report measures were heterogeneous, and few employed validation strategies. Caregiver-reported adherence was generally higher than self-report estimates. Pill counts revealed lower adherence estimates. Estimates of ART adherence ranged from 49% to 100%, with 76% of articles reporting greater than 75% adherence. Factors related to family structure, socioeconomic status, disclosure, and medication regimen were all significantly associated with ART adherence. Pediatric HIV care programs in low- and middle-income countries use heterogeneous methods to measure ART adherence. Adherence estimates vary substantially, but most studies from low- and middle-income countries report greater than 75% adherence, whereas most studies from high-income countries report less than 75% adherence.

Utilization of insecticide-treated nets by under-five children in Nigeria: Assessing progress towards the Abuja targets
(Research Article; Sub-Saharan Africa)
Malaria Journal. 2008 Jul 30;7(145):[45] p..
Oresanya OB | Hoshen M | Sofola OT
The Abuja target of increasing the proportion of people sleeping under insecticide-treated nets (ITNs) to 60% by the year 2005, as one of the measures for malaria control in Africa, has generated an influx of resources for malaria control in several countries in the region. A national household survey conducted in 2005 by the Malaria Control Programme in Nigeria assessed the progress made with respect to ITN ownership and use among pregnant women and children under five years of age since 2000. The survey was the first nationally representative study of ITN use assessing progress towards the Abuja target amongst vulnerable groups. A cross-sectional survey was taken of a sample of 7,200 households, selected by a multistage stratified sampling technique from 12 randomly selected states from the six geopolitical zones of the country. Data collection was done during the malarious rainy season (October 2005) using a modified WHO Malaria Indicator Survey structured questionnaire about household ownership and utilization of mosquito nets (treated or untreated) from household heads. Household ownership of any net was 23.9% (95% CI, 22.8%-25.1%) and 10.1% for ITNs (95% CI, 9.2%-10.9%). Education, wealth index, presence of an under-five child in the household, family size, residence, and region by residence were predictive of ownership of any net. The presence of an under-five child in the household, family size, education, presence of health facility in the community, gender of household head, region by residence and wealth index by education predicted ITN ownership. Utilization of any net by children under-five was 11.5% (95% CI, 10.4%-12.6%) and 1.7% (95% CI, 1.3%-2.2%) for ITN. Predictors of use of any net among under-five children were fever in the previous two weeks, presence of health facility in the community, caregiver's education, residence, and wealth index by caregiver's education; while religion, presence of health facility and wealth index by caregiver's education predicted the use of ITN among this group. This study demonstrated that the substantial increase in ITN utilization among children under five years of age in Nigeria is still far from the Abuja targets.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Adult mortality in a rural area of Senegal: Non-communicable diseases have a large impact in Mlomp
(Research Article; Sub-Saharan Africa)
Demographic Research. 2008 Aug 1;19(37):1419-1448.
Duthe G | Pison G
This study provides original estimates of adult mortality in Mlomp, a rural population of Senegal which has been monitored for twenty years. Causes of death are assessed through verbal autopsies which are completed by medical information. Between ages 15 and 60, male mortality is much higher than female mortality. Globally, AIDS mortality does not have the tragic impact observed in other regions of Africa, and maternal mortality is relatively low for a rural area, unlike injuries which are common among men. In Mlomp, non-communicable diseases, especially cancers, are predominant. In addition to behavioural factors, infectious diseases may contribute to this situation.

Determinants of self rated health and mortality in Russia -- Are they the same?
(Research Article; Asia)
International Journal for Equity in Health. 2008 Jul 25;7(19):[24] p.
Perlman F | Bobak M
Research into Russia's health crisis during the 1990s includes studies of both mortality and self-rated health, assuming that the determinants of the two are the same. In this paper, we tested this assumption, using data from a single study on both outcomes and socioeconomic, lifestyle and psychological predictor variables. We analysed data from 7 rounds (1994-2001) of the Russia Longitudinal Monitoring Survey, a panel study of a general population sample (11,482 adults aged over 18 living in households of 2 or more people). Self-rated health was measured on a 5 point scale and dichotomised by combining responses "very poor" and "poor" into poor health. Deaths (n=782) during a mean follow up of 4.1 years were reported by another household member. Associations between several predictor variables and poor or very poor self-rated health and mortality were measured using logistic regression and Cox proportional hazards analysis respectively. Poor self-rated health was significantly associated with mortality; hazard ratios, compared with very good, good or average health, were 1.69 (1.36-2.10) men and 1.74 (1.38- 2.20) in women. Low education predicted both mortality and poor self-rated health. Income was a better predictor of mortality than of self-rated health. Smoking doubled the risk of death but was not related to subjective wellbeing. Frequent drinkers reported better health but had increased mortality, compared with occasional drinkers. Greater life satisfaction was related to self-rated health but not to mortality. Although subjective health predicted mortality, the predictors of these two outcomes differed. Influences on subjective health other than serious disease and risk factors for relatively sudden deaths in apparently well people may be important, but require further research. Meanwhile, caution is required when using findings studies of self-rated health in Russia to understand the determinants of mortality.

Economic, social and spatial dimensions of India's excess child masculinity
(Abstract; subscription needed for full text; Asia)
Population-E. 2008;63(1):91-118.
Guilmoto CZ
The Indian subcontinent is a region characterized by a large diversity of populations, languages, cultures and faiths. Based on structure of castes whose practices and attitudes are changing, the Indian population is adopting new demographic behaviours whose diffusion and extent can be analysed spatially. In this article, Christophe Z. Guilmoto proposes a spatialized analysis of the recent aggravation of the gender imbalance in the child population, using data from the 2001 census for the 591 districts in India. This approach takes account of the spatial diffusion of behaviour, identifies more clearly the specific effects of the social and economic factors at work and proposes possible interpretations of the phenomenon.

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