Volume 8, Number 33
18 August 2008

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ADOLESCENT HEALTH RESEARCH

Adolescent and young adult women's knowledge of and attitudes toward the intrauterine device
(Abstract; subscription needed for full text; Global)
Contraception. 2008 Sep;78(3):211-217.
Whitaker AK | Johnson LM | Harwood B | Chiappetta L | Creinin MD
This study aimed to assess adolescent (aged 14-18 years) and young adult (aged 19-24 years) women's knowledge of and attitudes toward intrauterine devices (IUDs) before and after a brief educational intervention. We administered a 43-item survey to 144 women aged 14-24 years, with half in each age category. The survey assessed knowledge of and attitudes toward IUDs, and incorporated a 3-min educational intervention about IUDs. Predictors for knowledge of and attitudes toward the IUD were examined using logistic regression. Forty percent of participants had heard of the IUD. Having ever heard of the IUD was associated with age greater than 18 years [adjusted odds ratio (OR)=5.7; 95% confidence interval (95% CI)=2.1-15.7], a higher level of maternal education (adjusted OR=4.5; 95% CI=1.5-13.3) and a history of voluntary sexual intercourse (adjusted OR=4.9; 95% CI=1.0-23.5). Of those who had heard of the IUD previously, 37.5% reported a positive attitude toward the IUD before the intervention. After the educational intervention, 53.5% of all participants reported a positive attitude toward the IUD, with both adolescent and young adult women having similarly positive attitudes (51.4% vs. 55.6%, p=.62). This positive attitude was associated only with a history of voluntary sexual intercourse (adjusted OR=5.2; 95% CI=1.3-21.1). The characteristics of the IUD that the participants strongly liked and disliked were rated similarly by the two age groups. However, more adolescent women considered the privacy of the IUD and the ability to use the copper IUD for 10 years as positive characteristics. Most young women were unaware of IUDs but were likely to think positively about IUDs after being educated about them. Demographic and reproductive health history did not predict attitude; thus, all young women should be offered education about IUDs.

Condom use among sexually active Kenyan female adolescents at risk for HIV-1 infection
(Abstract; subscription needed for full text; Sub-Saharan Africa)
AIDS and Behavior. 2008;:[7] p.
Cherutich P | Brentlinger P | Nduati R | Kiarie JN | Farquhar C
High rates of unintended pregnancy and HIV infection occur in sub-Saharan Africa yet few Kenyan studies have defined correlates of condom use in sexually active female adolescents. Female adolescents receiving reproductive health care and aged 15-19 were interviewed. The prevalence of ever-use of condom was 21.4% and 52 (7.3%) subjects were infected with HIV-1. Older age, higher levels of education, ever-use of hormonal contraceptives and higher numbers of sexual partners, non-consensual sex and exchange of sex for favours, were independent correlates of condom use. Condom use should be promoted in this population. Further exploration is needed on the developmental and contextual factors predisposing female adolescents to increased risk of HIV.

FAMILY PLANNING RESEARCH

The relation between short-term oral contraceptive consumption and cerebrovascular, cardiovascular disorders in Iranian women attending Hajj
(Abstract; subscription needed for full text; Middle East)
Saudi Medical Journal. 2008 Jul;29(7):1024-1027.
Azarpazhooh MR | Rafi S | Etemadi MM | Khadem N | Fazlinejad A
The objective of this study was to evaluate the spectrum of probable vascular complications due to short-term oral contraceptives OC consumption. In this cohort study, selected Iranian female pilgrims from Razavi-Khorasan, Iran province less than 50 years old, attending Hajj in 2005 were evaluated. We reviewed their physical examinations, vascular risk factors and OC consumption before Hajj. Pilgrims were followed-up in terms of developing possible vascular complications during Hajj and the following year. This study included 896 individuals and completed follow-up was performed for 642. The results showed that 782 (87.3%) of pilgrims used OC. One person developed cerebral vein thrombosis, one myocardial infarction, and one deep vein thrombosis. Eighteen patients (2.8%) experienced transient hypertension. Ten patients (1.5%) had migraine exacerbations. The relationship between developed definite vascular complications and OC consumption was not statistically significant in this study p=0.365. Although vascular complications of long-term OC consumption have been analyzed and proved in several studies, few studies have determined short-term OC consumption effects on the vascular system. It seems that even short-term usage of OC may result in vascular complications, thus further studies with more samples is recommended to determine its safety and complications.

Ovulation inhibition with four variations of a four-phasic estradiol valerate / dienogest combined oral contraceptive: Results of two prospective, randomized, open-label studies
(Abstract; subscription needed for full text; Global)
Contraception. 2008 Sep;78(3):218-225.
Endrikat J | Parke S | Trummer D | Schmidt W | Duijkers I
Attempts to improve the tolerability of combined oral contraceptives (COCs) have included the substitution of ethinylestradiol (EE) with 17ß-estradiol (E2). However, this has proved unsatisfactory, specifically in terms of cycle control. To improve upon the poor cycle control seen previously, E2 [in the form of estradiol valerate (E2V); 1 mg of E2V contains 0.76 mg of E2] was combined with dienogest (DNG) in a novel four-phasic regimen. In the current studies, the ovulation-inhibition potency of four variations of this regimen was assessed. Two randomized, open-label, Phase II studies were performed. The first study compared two regimens (Regimens 1A and 2A) with similar dosages of DNG but different lengths of application. Having established in Study 1 that the length of application of Regimen 2A was most suitable, but that the dosages of DNG were too low for effective ovulation inhibition, a second study, which compared two regimens (Regimens 2B and 2C) with similar lengths of application but with increased dosages of DNG, was undertaken. The primary efficacy variable in both studies was the proportion of women with a Hoogland score of 5 or 6 during Cycle 2. The full analysis set comprised 192 and 203 women in Studies 1 and 2, respectively. In Study 1, 10 women (10.9%) in Regimen 1A and 6 women (6.4%) in Regimen 2A had a Hoogland score of 5 or 6. In Study 2, three women (3.1%) in Regimen 2B and one woman (1.0%) in Regimen 2C had a Hoogland score of 5 or 6. There were no safety concerns with any of the regimens. The results of these studies identified a four-phasic COC preparation comprising E2V/DNG that provides efficient ovulation inhibition. It is expected that this regimen will lead to an innovative COC containing E2 instead of EE.

GENDER and HEALTH RESEARCH

Sex trafficking in Nepal: Survivor characteristics and long-term outcomes
(Abstract; subscription needed for full text; Asia)
Violence Against Women. 2008 Aug;14(8):905-916.
Crawford M | Kaufman MR
There has been little systematic research on therapy, rehabilitation, and social reintegration of women formerly trafficked into prostitution. This study examines characteristics and outcomes of Nepali sex trafficking survivors. Twenty case files of survivors rehabilitated in the shelter of an anti-trafficking NGO were randomly selected. All individuals in the sample suffered somatic and behavioral sequelae. Three quarters of the survivors eventually returned to their villages to live. These results suggest that current rehabilitation and reintegration programs are producing positive results. However, there is need for more systematic diagnosis, record keeping, and outcome studies as well as education to reduce stigma and promote safe migration practices.

The politics of identity and sexual violence: A review of Bosnia and Rwanda
(Abstract; subscription needed for full text; Europe | Sub-Saharan Africa)
Human Rights Quarterly. 2008 Aug;30(3):561-578.
Weitsman PA
This article argues that particular assumptions about biology, ethnicity, genetics, and gender create a permissive environment for policies of sexual violence during war. It further asserts that the children born as a consequence of these policies become a prism for identity politics. The arguments regarding identity and war and the consequences on policies of sexual violence during wartime are illustrated through analyses of the Serbian militia's rape campaigns in Bosnia in the early 1990s and the mass rape and killing of Tutsis in Rwanda in 1994.

HIV/AIDS and STIs RESEARCH

Risk factors for recent HIV infection in Uganda
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAMA. Journal of the American Medical Association. 2008 Aug 6;300(5):540-549.
Mermin J | Musinguzi J | Opio A | Kirungi W | Ekwaru JP
Studies of factors associated with acquiring human immunodeficiency virus (HIV) are often based on prevalence data that might not reflect recent infections. The objective of this study was to determine demographic, biological, and behavioral factors for recent HIV infection in Uganda. A nationally representative household survey of cross-sectional design was conducted in Uganda from August 2004 through January 2005; data were analyzed until November 2007. There were 11 454 women and 9905 men aged 15 to 59 years who were eligible. Questionnaires were completed for 10 826 women (95%) and 8830 men (89%); of those interviewed, blood specimens were collected for 10 227 women (94%) and 8298 men (94%). Specimens seropositive for HIV were tested with the BED IgG capture-based enzyme immunosorbent assay to identify recent seroconversions (median, 155 days) using normalized optical density of 0.8 and adjustments. Of the 1023 HIV infections with BED results, 172 (17%) tested as recent. In multivariate analysis, risk factors associated with recent HIV infection included female sex (adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.1-5.2); current marital status (widowed vs never married, aOR, 6.1; 95% CI, 2.8-13.3; divorced vs never married, aOR, 3.0; 95% CI, 1.5-6.1); geographic region (north central Uganda vs central Uganda/Kampala, aOR, 2.6; 95% CI, 1.7-4.1); number of sex partners in past year (greater than or equal to 2 compared with none; aOR, 2.9; 95% CI, 1.6-5.5); herpes simplex virus type 2 infection (aOR, 3.9;95%CI, 2.6-5.8); report of a sexually transmitted disease in the past year (aOR, 1.7; 95% CI, 1.2-2.4); and being an uncircumcised man (aOR, 2.5; 95% CI, 1.1-5.3). Among married participants, recent HIV infection was associated with never using condoms with partners outside of marriage (aOR, 3.2; 95% CI, 1.7-6.1) compared with individuals having no outside partners. The risk of incident HIV infection for married individuals who used condoms with at least 1 outside partner was similar to that of those who did not have any partners outside of marriage (aOR, 1.0; 95% CI, 0.3-2.7). A survey of individuals in Uganda who were tested with an HIV assay used to establish recent infection identified risk factors, which offers opportunities for prevention initiatives.

Infant feeding intentions and practices of HIV-positive mothers in southwestern Nigeria
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Human Lactation. 2008;24(3):303-310.
Adejuyigbe E | Orji E | Onayade A | Makinde N | Anyabolu H
It has been shown that infant feeding pattern affects mother-to-child transmission of HIV. This study reports the infant feeding practices of HIV-positive mothers in southwestern Nigeria.

Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial
(Abstract; subscription needed for full text; Sub-Saharan Africa)
BMJ. British Medical Journal. 2008 Aug 7;337:a506.
Jewkes R | Nduna M | Levin J | Jama N | Dunkle K
The objective of this study was to assess the impact of Stepping Stones, a HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour. The design was a cluster randomised controlled trial, carried out in 70 villages (clusters) in the Eastern Cape province of South Africa. Stepping Stones, a 50 hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2. The primary outcome measure was incidence of HIV. Other outcomes included incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse. There was no evidence that Stepping Stones lowered the incidence of HIV (adjusted incidence rate ratio 0.95, 95% confidence interval 0.67 to 1.35). The programme was associated with a reduction of about 33% in the incidence of HSV-2 (0.67, 0.46 to 0.97; P=0.036)- that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1000 people exposed. Stepping Stones significantly improved a number of reported risk behaviours in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women desired behaviour changes were not reported and those in the Stepping Stones programme reported more transactional sex at 12 months. Stepping Stones did not reduce incidence of HIV but had an impact on several risk factors for HIV- notably, HSV-2 and perpetration of intimate partner violence.

Innovative program offers HIV therapy to internally displaced persons in Uganda
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAMA. Journal of the American Medical Association. 2008 Aug 6;300(5):493.
Hampton T
To study the feasibility of providing HIV/AIDS care in conflict settings, Edward Mills, PhD, of the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, Canada, along with other HIV/AIDS researchers and clinicians from a nongovernmental nongovernmental group in Uganda, The AIDS Support Organization (TASO), and the Ottawa Hospital in Canada set out to study a population of internally displaced persons and to document outcomes following antiretroviral therapy in the Gulu District of northern Uganda. Mills and his colleagues discovered that more than 92% of patients with complete follow-up data for more than 1 year had adherence to their antiretroviral regimen of 95% or greater, and only about 1% of these patients died during follow-up. The findings indicate that adults with HIV/AIDS receiving antiretroviral medications through this program have clinical outcomes comparable with those found in peaceful regions of Uganda and other low-income countries, Mills said.

MATERNAL AND CHILD HEALTH RESEARCH

How important are individual, household and commune characteristics in explaining utilization of maternal health services in Vietnam?
(Abstract; subscription needed for full text; Asia)
Social Science and Medicine. 2008 Sep 06;67(6):1009-1017.
Sepehri A | Sarma S | Simpson W | Moshiri S
Using Vietnam's latest National Household Survey data for 2001-2002 this paper assesses the influence of individual, household and commune-level characteristics on a woman's decision to seek prenatal care, on the number of prenatal visits, and on the choice between giving birth at a health facility or at home. The decision to use any care and the number of prenatal visits is modeled using a two-part model. A random intercept logistic model is used to capture the influence of unobserved commune-specific factors found in the data regarding a woman's decision to give birth at a health facility rather than at home. The results show that access to prenatal care and delivery assistance is limited by observed barriers such as low income, low education, ethnicity, geographical isolation and a high poverty rate in the community. More specifically, more prenatal visits increase the likelihood of giving birth at a health facility. Having compulsory health insurance increases the odds of giving birth at a health facility for middle and high income women. In contrast, health insurance for the poor increases the likelihood of having more prenatal visits but has little effect on the place of delivery. These results suggest that the existing safe motherhood programs should be linked with the objectives of social development programs such as poverty reduction, and that policy makers need to view both the individual and the commune as appropriate units for policy targeting.

Gains in awareness, ownership and use of insecticide-treated nets in Nigeria, Senegal, Uganda and Zambia
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Malaria Journal. 2008 Aug 7;:[27] p.
Baume CA | Marin MC
In April 2000, the Roll Back Malaria (RBM) "Abuja Summit" set a target of having at least 60% of pregnant women and children under five use insecticide-treated nets (ITNs). Thereafter, programmes were implemented to create demand, reduce taxes and tariffs, spur the commercial market, and reach vulnerable populations with free or subsidized ITNs. Using national ITN monitoring data from the USAID-sponsored AED/NetMark project, this article examines the extent to which these activities were successful in increasing awareness, ownership, and use of nets and ITNs. A series of surveys with standardized sampling and measurement methods was used to compare four countries at two points in time. Surveys were conducted in 2000 and again in 2004 (Nigeria, Senegal, Zambia) or 2006 (Uganda). They contained questions permitting classification of each net as untreated, ever-treated or currently-treated (an ITN). Household members as well as nets owned were enumerated so that households, household members, and nets could be used as units of analysis. Several measures of net/ITN ownership, plus RBM ITN use indicators, were calculated. The results show the impact of ITN activities before the launch of massive free net distribution programmes. In 2000, treated nets were just being introduced to the public, but four to six years later the awareness of ITNs was nearly universal in all countries but Nigeria, where awareness increased from 7% to 60%. By any measure, there were large increases in ownership of nets, especially treated nets, in all countries. All countries but Nigeria made commensurate gains in the proportion of under-fives sleeping under a net/ITN, and in all countries the proportion of pregnant women sleeping under a net/ITN increased greatly. A mix of demand creation, a strengthened commercial sector, reduced taxes and tariffs, and programmes making ITNs available at reduced prices resulted in impressive gains in awareness, ownership, and use of nets and ITNs in Nigeria, Senegal, Zambia, and Uganda between 2000 and 2004-2006. None of the countries reached the ambitious Abuja targets for ITN use, but they made substantial progress towards them.

Process indicators in the program for humanization of prenatal care and childbirth in Ceará state, Brazil: Analysis of a historical series (2001-2006)
(Research Article; South America)
Cadernos de Saúde Pública. 2008 Jul;24(7)
Passos AA | Moura E
This was a descriptive, exploratory, documental study of trends that aimed to analyze process indicators in the Program for Humanization of Prenatal Care and Childbirth in Ceará State, Brazil, from 2001 to 2006. The authors analyzed data from 312,507 pregnant women. In 2001, the year the program was implemented in the State, the system tabulated data for three of the seven process indicators; beginning in 2002, all indicators were tabulated. Total enrollment of pregnant women was the only indicator that increased every year until 2006, while the other indicators increased from 2002 until 2005, but declined from 2005 to 2006. When combining the completion of six prenatal visits with a postpartum visit, routine laboratory tests, or both, the percentages declined. Tetanus immunization reached the highest percentage in 2002 (68.34%), decreasing to 60.86% in 2006. The combination of six prenatal visits, a postpartum visit, laboratory tests, tetanus immunization, and HIV test was the indicator with the lowest percentage for the State (15.67%), although it was higher than the national average. Even considering flaws in the use of the Prenatal Care Information System, it is unacceptable that prenatal care still lacks complete coverage for such basic elements as routine laboratory tests and tetanus immunization.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Men gone wild? The politics of population control. [Book review of "Fatal MisConception: The Struggle to Control World Population" by Matthew Connelly]
(Review/Synthesis; Global)
Lancet. 2008 Aug 2;372(9636):363-364.
Gillespie D
Matthew Connelly considers his book the first "global history of population control", which, at various times and places, encompasses eugenics, infanticide, pronatalist schemes, restrictive immigration policies, genocide, and family planning. His archival research exhaustively spans the late 1800s through to the mid-1980s, after which his research becomes a bit thin. He includes a numbing number of cameo appearances by the famous, the infamous, and the unknown. Although an occasional nugget of interest can be found in the first part of the book, most readers will find Connelly's attention to minutiae a powerful narcotic.

Understanding the effects of siblings on child mortality: Evidence from India
(Abstract; subscription needed for full text; Asia)
Journal of Population Economics. 2008 Oct;21(4):877-902.
Makepeace G | Pal S
Given the intrinsically sequential nature of childbirth, timing of a child's birth has consequences not only for itself but also for its older and younger siblings. The paper argues that prior spacing and posterior spacing between consecutive siblings are thus important measures of intensity of sibling competition for limited parental resources. While the available estimates of child mortality tend to ignore the endogeneity of sibling composition, we use a correlated recursive model of prior and posterior spacing and child mortality to correct it. There is evidence that uncorrected estimates under-estimate the effects of prior and posterior spacing on child mortality.

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