Randomised trial of alternative malaria chemoprophylaxis strategies among pregnant women in Kigoma, Tanzania: I. Rationale and design

OBJECTIVE

The objective of the study was to assess the effectiveness of alternative strategies of malaria chemoprophylaxis on the reduction of malaria episodes and prevalence of parasitaemia among pregnant women in Kigoma urban district in western Tanzania.

DESIGN

Randomised antimalarial prophylactic trial.

SETTING

The study was conducted in an urban maternal and child health (MCH) clinic in Kigoma town.

SUBJECTS

All pregnant women attending antenatal care services at Kigoma urban MCH clinic were eligible. Informed consent was sought from each pregnant woman for participation in the study. INTERVENTION MEASURES: The intervention measures were intermittent and continuous malaria chemoprophylaxis using chloroquine and proguanil.

MAIN OUTCOME MEASURES

Reduction of malaria episodes and parasitaemia and haemoglobin levels among participating pregnant women in Kigoma urban district.

RESULTS

Baseline data indicates that the overall mean haemoglobin concentrations among the primigravidae and multigravidae women were similar within the intervention and comparison groups (F-test (df = 5, N = 701) = 1.27, P = 0.27). Similarly, no significant difference was observed in the prevalence of malaria parasitaemia within the primigravidae intervention and comparison groups (chi 2 test (df = 5, N = 701) = 5.4, P = 0.4). Hence, the process of randomisation produced comparable intervention and comparison groups with balanced characteristics. Specific results of the baseline studies are presented in the companion paper.

CONCLUSION

We conclude that the process of randomisation resulted in comparable intervention and comparison groups. As malaria is a common cause of considerable morbidity and mortality among pregnant women in Tanzania, the present study provided useful data for improving reproductive health in Kigoma region, western Tanzania.

Norplant use among urban minority women in the United States

The aim of this study was to develop a profile of urban American women who chose Norplant(R), determine factors associated with retention and early termination of implants, and to determine reasons for early removal. A total of 197 adult black and Hispanic women who had Norplant inserted were followed prospectively for up to 5 years. Interval and cumulative termination rates were calculated. Data were stratified by race and analyzed to include lost-to-follow-up (LTFU) subjects. Multivariate survival analysis was used to determine variables independently associated with termination. Cumulative continuation rates were 68% after year 1 and 13% after year 4. Significant predictors of retention included black race and lower parity. Probability of early termination increased with higher parity and Hispanic race. For black subjects, recent use of hormonal contraception was a predictor of retention. Menstrual changes and weight concerns were common reasons for removal. The Norplant 1-year continuation rate is lower than previously reported, but is higher than reported for oral contraceptives and Depo-Provera(R). Future studies should stratify by age, race, and parity, and use standardized terminology to report intervals of use.

Randomised trial of alternative malaria chemoprophylaxis strategies among pregnant women in Kigoma, Tanzania: II. Results from baseline studies

OBJECTIVE

To determine baseline data among pregnant women consenting to participate in a randomised trial of alternative strategies of malaria chemoprophylaxis in Kigoma urban district, western Tanzania.

DESIGN

Cross-sectional study.

SETTING

The study was conducted in an urban MCH clinic in Kigoma town in western Tanzania.

SUBJECTS

All consenting pregnant women who fulfilled entry criteria were recruited into the study. BASELINE STUDIES: Baseline data were collected prior to randomisation of women to antimalarial prophylactic regimens. Baseline measurements included examination for blood depleting parasitic infections (stool and urine examinations), haemoglobin levels, haematocrit, sickling test, and blood slide for malaria parasites.

RESULTS

A total of 728 pregnant women consented to participate in the interview and of these 705 participated in baseline studies constituting a participation rate of 96.8%. The age of participating women ranged from 14 to 45 years with a mean age of 23.7 years (standard deviation [SD] = 5.4) while the mean number of pregnancies ranged from 1 to 13 with a mean of 3.2 (SD = 2.2). The prevalence of malaria parasitaemia among the pregnant women examined was 9.4% (N = 705) while the prevalence of anaemia (defined as Hb < 8.5 gdl-1) was 12.4% (N = 579). No significant difference was observed in prevalence proportions of malaria parasitaemia in relation to age, parity, marital status and use of mosquito bednets. However the prevalence of anaemia among women in the age group 31-45 years was significantly lower than that observed among women in the age group 14-20 years (2.9% versus 18.9%; crude odds ratio [OR] = 0.13; 95% confidence interval [CI], 0.02-0.55). Sickle cell disease (HbAS) was found in 2.3% (N = 564) of the pregnant women examined.

CONCLUSION

It is concluded that the prevalence of malaria parasitaemia and anaemia was very high in this population suggesting the need for interventions directed at controlling these major causes of maternal morbidity and mortality in Tanzania.

The role of son preference in reproductive behaviour in Pakistan

The sex of surviving children is an important determinant of reproductive behaviour in South Asia in general and Pakistan in particular. This cohort study evaluates the role of the sex of children on reproductive intentions and subsequent behaviour of women in urban slums of Karachi, Pakistan. The analysis is based on two rounds of surveys conducted in 1990-91 and 1995 of a cohort of married women aged 15-49 years. The results show that pregnancies became increasingly unwanted as the number of surviving sons increased. The sex of surviving children was strongly correlated with subsequent fertility and contraceptive behaviour. However, rather than an exclusive son preference, couples strove for one or more sons and at least one surviving daughter. The policy implications of the link between overt son preference and low status of women are discussed.

Abortion services in rural Washington State, 1983-1984 to 1993-1994: availability and outcomes

CONTEXT

Fewer rural health providers offer abortion services than a decade ago. It is unknown how the reduction in service availability has affected women's pregnancy outcomes, the extent to which they must travel to obtain an abortion or whether abortions are delayed as a result.

METHODS

Population, birth and fetal death data, as well as pregnancy termination reports, obtained from Washington State were used to calculate abortion rates and ratios and birthrates for Washington residents in 1983-1984 and in 1993-1994. Residence of abortion patients was classified by county only, and location of providers was recorded as large urban county, small urban county, large rural county or small rural county. Distances that women traveled to obtain an abortion were calculated. Chi-square tests were used to compare urban and rural rates and ratios within time periods, and to compare changes that occurred between time periods.

RESULTS

Birthrates and abortion rates decreased for both rural and urban Washington women between 1983-1984 and 1993-1994, but the magnitude of the decrease was greater for rural women. The rural abortion rate fell 27%, from 14.9 abortions per 1,000 women to 10.9 per 1,000, while the urban rate dropped 17%, from 21.8 to 18.2 per 1,000. The decline in the abortion rate was larger for adolescents than it was for other age-groups. In rural areas, the abortion rate decreased from 16.5 per 1,000 adolescents aged 10-19 in 1983-1984 to 10.8 per 1,000 in 1993-1994, while it declined from 23.3 per 1,000 to 16.9 per 1,000 in urban areas. From the earlier to the later time period, rural women traveled on average 12 miles farther each way to obtain an abortion, and the proportion who obtained the procedure in a rural county decreased from 25% to 3%. In the earlier time period, 62% of rural women traveled 50 miles or more to obtain an abortion, compared with 73% in 1993-1994. From 1983-1984 to 1993-1994, the proportion of rural women who traveled out of state for an abortion increased from 8% to 14%. The proportion of rural women terminating their pregnancy after the first trimester increased from 8% in 1983-1984 to 15% in 1993-1994.

CONCLUSION

Rural Washington women are traveling farther and more often to urban and out-of-state locations for abortion services, and are obtaining their abortions at a later gestational age, which is associated with a decade-long decline in the number of abortion providers.

Predictors and impact of losses to follow-up in an HIV-1 perinatal transmission cohort in Malawi

BACKGROUND

Large simple trials which aim to study therapeutic interventions and epidemiological associations of human immunodeficiency virus (HIV) infection, including perinatal transmission, in Africa may have substantial rates of loss to follow-up. A better understanding of the characteristics and the impact of women and children lost to follow-up is needed.

METHODS

We studied predictors and the impact of losses to follow-up of infants born in a large cohort of delivering women in urban Malawi. The cohort was established as part of a trial of vaginal cleansing with chlorhexidine during delivery to prevent mother-to-infant transmission of HIV.

RESULTS

The HIV infection status could not be determined for 797 (36.9%) of 2156 infants born to HIV-infected mothers; 144 (6.7%) with missing status because of various sample problems and 653 (30.3%) because they never returned to the clinic. Notably, the observed rates of perinatal transmission were significantly lower in infants who returned later for determination of their infection status (odds ratio = 0.94 per month, P = 0.03), even though these infants must have had an additional risk of infection from breastfeeding. In multivariate models, infants of lower birthweight (P = 0.003) and, marginally, singletons (P = 0.09) were less likely to return for follow-up. The parents of infants lost to follow-up tended to be less educated (P < 0.001) and more likely to be in farming occupations, although one educated group, teachers and students, were also significantly less likely to return. Of these variables, infant birthweight, twins versus singletons, and maternal education were also associated with significant variation in the observed risk of perinatal transmission among infants of known HIV status.

CONCLUSIONS

Several predictors of loss to follow-up were identified in this large HIV perinatal cohort. Losses to follow-up can impact the observed transmission rate and the risk associations in different studies.

Declining syphilis prevalence in pregnant women in Nairobi since 1995: another success story in the STD field?

Untreated maternal syphilis during pregnancy will cause adverse pregnancy outcomes in more than 60% of the infected women. In Nairobi, Kenya, the prevalence of syphilis in pregnant women of 2.9% in 1989, showed a rise to 6.5% in 1993, parallel to an increase of HIV-1 prevalence rates. Since the early 1990s, decentralized STD/HIV prevention and control programmes, including a specific syphilis control programme, were developed in the public health facilities of Nairobi. Since 1992 the prevalence of syphilis in pregnant women has been monitored. This paper reports the findings of 81,311 pregnant women between 1994 and 1997. A total of 4244 women (5.3%) tested positive with prevalence rates of 7.2% (95% CI: 6.7-7.7) in 1994, 7.3% (95% CI: 6.9-7.7) in 1995, 4.5% (95% CI: 4.3-4.8) in 1996 and 3.8% (95% CI: 3.6-4.0) in 1997. In conclusion, a marked decline in syphilis seroprevalence in pregnant women in Nairobi was observed since 1995-96 (P<0.0001, Chi-square test for trend) in contrast to upward trends reported between 1990 and 1994-95 in the same population.

Pregnant adolescents in chemical dependency treatment. Description and outcomes

This study examines the treatment, maternal and infant outcomes of pregnant adolescents (16-19 years) enrolled in an adult perinatal chemical dependency treatment program. Twenty-one adolescent subjects were compared to 323 adult women (mean age, 27.4 years) after enrollment into a randomized treatment trial consisting of intensive outpatient or short-term residential conditions. The results show a similar treatment retention rate. Adolescents differed from adult women on marital status, drugs of choice (alcohol, marijuana vs. opiates and cocaine) and method of administration, with no injection drug users in the adolescent cohort. Tobacco use was high (> 85%) in both groups. Obstetric, maternal, and infant outcomes to 1 year were comparable. Older adolescents who are chemically dependent and pregnant have treatment needs similar to adult women and can benefit from programs designed to treat older women. Recruitment difficulties for adolescents in need of treatment is discussed.

Female circumcision: the prevalence and nature of the ritual in Eritrea

This study evaluates the prevalence, complications, and attitudes concerning the practice of female circumcision among the women of Eritrea. Four hundred thirty-six Eritrean women from rural and urban environments were questioned about their perceptions and beliefs concerning female circumcision. Eighty-eight percent of those interviewed had undergone some form of female circumcision. Those who favored the continuation of the practice were more likely to be rural dwellers with little formal education, and they did so primarily out of tradition or cultural conformity. The direct and indirect consequences of this practice to the health of women and infants are considerable and as complex as the social, religious, and traditional factors that have led to its preservation.

Effects of the status of women on the first-birth interval in Indian urban society

The status of women, which is relative and multidimensional, has an important bearing on any long-term reduction in fertility. In Indian society, where cohabitation and childbearing are socially sanctioned only after marriage, the length of the first-birth interval affects the completed family size by influencing the spacing and childbearing pattern of a family. This study examines the influence of certain aspects of the status of married women--education, employment, role in family decision making, and age at marriage--along with three socioeconomic variables--per capita income of the family, social position of the household, and the caste system--on the duration of the first-birth interval in an urban Hindu society of the north-east Indian state of Assam. The data were analysed by applying life table and hazard regression techniques. The results indicate that a female's age at marriage, education, current age, role in decision making, and the per capita income of the household are the main covariates that strongly influence the length of the first-birth interval of Hindu females of urban Assam. Of all the covariates studied, a female's education appears to be a key mediating factor, through its influence on her probability of employment outside the home and thereby an earned income and on her role in family decision making. Unlike other Indian communities, the effect of the caste system does not have a significant effect on first-birth timing in this urban Hindu society.

The relevance of ethnic monitoring in the experience of Haringey Healthcare NHS trust community family planning clinics

Ethnic monitoring of all new and first attenders in the year to community family planning clinics was carried out by means of an anonymous questionnaire during April to June 1997 inclusive to ascertain whether ethnic minority women attend family planning clinics. A 73 per cent response rate (2664 questionnaires) was obtained. The results showed that women came from a wide variety of ethnic groups and from almost every country in the world. Those of UK European origin were underrepresented. For 28 per cent of women, English was not their first language. A total of 66 languages were recorded. Sixty two per cent (1673) of all the women were between 20 and 34 years. Overall half of all the women attending did not have children. Though in some ethnic groups most women were parous, less than 20 per cent of Caribbean (born Caribbean) West African and Turkish Cypriot women and only six per cent of Turkish/Kurdish women born in Turkey had not had children. Thirty three per cent of women admitted to having had one or more terminations although there was only a 90 per cent response rate to this question. While between 20 and 25 per cent of United Kingdom, EEC and non EEC European and black British women had had one or more abortions, 49 per cent of West African, 43 per cent of Kurdish and 40 per cent of Turkish Cypriot women had had one or more abortions. The lowest percentage of women admitting to a termination were Irish (12 per cent). The majority of women did choose a method or methods of contraception. The oral contraceptive pill and the condom were the most popular methods, often being used together The method used was influenced by age and ethnicity. Younger women opted for 'the pill' while older women chose the intrauterine device. The combined pill and condom were relatively equally popular with UK, Irish, EEC European, Caribbean (born Caribbean, born UK) and 'other' groups of women; while the intrauterine device was the favoured method of Kurdish/Turkish women born in Turkey. Depo-Provera was used principally by UK, European, Caribbean (born Caribbean, born UK) and African (West and East) women. Twelve per cent of women were recorded as not using a method. These women might have attended for a pregnancy test, cervical smear, advice about general health, gynaecological problems, though this was not specifically recorded. These women featured in all age groups. While a third were UK European, two thirds were of other ethnic groups. This would appear to illustrate that those women do seem to be aware that family planning clinics can provide services in addition to supplying contraceptive methods. It was noted that the Kurdish/Turkish women favoured one particular clinic sited in the ante natal department of the local hospital (the North Middlesex) where linkworkers are available. They accounted for 34 per cent of those who attended (128 out of 371). However at all but one of the clinic sites, which are spread around the borough, the UK European group was in a minority ranging from 20 to 47 per cent in attendance, compared to other ethnic groups. It is proposed that ethnic monitoring will be routinely recorded from April 1998 for new and first time attenders. It is also planned to work more closely with various ethnic minority groups in the community.

Assessment of maternal mortality and late maternal mortality among a cohort of pregnant women in Bamako, Mali

OBJECTIVE

Few prospective studies have been undertaken of maternal mortality in sub-Saharan Africa. National statistics are inadequate, and data from hospitals are often the only source of information available. Reported maternal mortality ratios may therefore show large variations within the same country, as in Mali. This study was designed to produce an estimate of the maternal mortality ratio for the population of Bamako.

DESIGN

Prospective cohort study.

SETTING

Bankoni (population 59,000), a district of Bamako (population 700,000).

POPULATION

5782 pregnant women identified during quarterly household visits.

METHODS

After enrolment, two follow up visits, at six weeks and one year after delivery, were performed to collect information on the pregnancy, its outcome, the method of delivery, the puerperium and the first year after birth. Detailed inquiries on deaths were undertaken in the community, the maternity units and the reference hospital.

MAIN OUTCOME MEASURES

Maternal mortality ratio, late maternal mortality, likely cause of death.

RESULTS

Complete data at follow up were available on 4717 women (82%) (4653 single and 64 twin pregnancies). Most of the women had antenatal care were and delivered in a district maternity hospital. There were 4580 live births (96%). Fifteen maternal deaths were recorded, yielding an overall maternal mortality ratio of 327 per 100,000 live births. Hypertensive disorders and haemorrhage were the main causes of death. Five more deaths occurred within 42 days or one year after delivery.

CONCLUSIONS

This study gave an estimate of the maternal mortality ratio for the population of Bamako, and stressed the need of better emergency obstetric care and the importance of late maternal mortality.

HIV infection and disturbances of vaginal flora during pregnancy

Disturbances of vaginal flora are common among women of reproductive age. In areas of sub-Saharan Africa where the prevalence of HIV is high, the frequency of bacterial vaginosis (BV) is also high. In this study, we assessed the association of BV and other disturbances of vaginal flora with prevalent HIV infection in two cross-sectional studies among pregnant women in urban Malawi. The prevalence of HIV-1 was 23% in 1990 and 30% in 1993. Overall, 30% of the women had BV, 59% had mild or moderate disturbance of vaginal flora, and only 11% had normal vaginal flora. Increasing prevalence of HIV was significantly associated with increasing severity of disturbance of vaginal flora (p < .00001, chi2 trend test). This trend of increased prevalence persisted after controlling for concurrent sexually transmitted diseases (STDs), sexual activity, and socioeconomic factors. After multivariate adjustment for potential confounders, the odds ratio for the association of BV with prevalent HIV infection was 3.0 (95% confidence interval [CI], 2.4-3.8), that of moderate vaginal disturbance with HIV infection was 2.2 (95% CI, 1.7-2.8), and that of mild vaginal disturbance with HIV infection was 1.6 (95% CI, 1.3-2.1). Among women with BV, HIV infection was higher among younger women than older, implying more recent infection. Although these studies were cross-sectional, our data suggest that BV could be associated with increased susceptibility to HIV infection.

Natural growth of the population of Plovdiv, Bulgaria for the period 1895-1995

A study of the natural growth rate of the population using female cohorts by birth year has been carried out for the first time in our country. The study comprises 14 cohorts. The following characteristics are recorded: birth year, social group, educational level, number of live births, age of marriage, infant mortality rate, proto- and intergenetic intervals. Our report presents the key indicators of natural growth of population in the studied cohorts. A consistent trend of decreasing the number of livebirths is established. In the first studied cohort (1895-1899) the average number of offspring per woman is 3.94, reaching a level of 1.77 in the 1960-1964 cohort. The indicators for natural growth of population exhibit a similar trend. The summary fertility rate in the reference period decreases with more than 2 points--from 4.47 in 1895-1899 to 1.73 in 1960-1964. Likewise, the total reproduction rate goes down from 2.54 to 0.78 for the same period. Considerable changes have occurred in the indicators total period fertility rate and marriage fertility rate of women. For a period of 110 years the former has decreased 3.5 times, the latter--8 times. The drastic drop of the indicators of natural growth of the population is accounted for by an intricate complex of social, economic, psychological and biological factors. The marked aging of the population and the decrease of the percentage of women in active fertility age play a certain role in this process. The ascertained changes in the reproductive behavior and age structure of the female population are factors intensifying the unfavorable trends in the natural growth rate of the population in our country.

Genital chlamydial disease in an urban, primarily Hispanic, family planning clinic

BACKGROUND AND OBJECTIVES

Although chlamydia is a well-studied disease, little is known about the rates of genital chlamydial disease among female Hispanics in urban family planning clinics.

GOALS

To determine the prevalence of women with chlamydia in two clinic populations during 1994. We also sought to describe previously identified and novel risk factors for chlamydial disease in this unique population.

STUDY DESIGN

We conducted a retrospective case-control analysis in two community clinics in the Washington Heights section of New York City.

RESULTS

In 1994, 4,190 screening tests were done for Chlamydia trachomatis in these clinics, and the prevalence of positive tests was 5.4% (227/4,190). The mean age of the women screened was 19.2 years and most were of Hispanic origin (76%), students (51%), and received Medicaid (61%). Risk factors found to be associated with C. trachomatis infection included young age; earlier age at first coitus; pregnancy at the time of chlamydia screening; concurrent gonorrheal infection; and the clinical findings of cervical abnormalities, vaginal discharge, and adnexal tenderness. Hormonal contraception appeared to be protective against chlamydial infection (odds ratio, 0.36%; confidence interval, 0.17-0.77).

CONCLUSION

Sexually transmitted diseases were common in our population because 5.4% of the women screened had chlamydial infection and 1.5% had concurrent gonorrheal infection. Our study confirmed risk factors established in other populations. These data support the need for enhanced screening efforts for chlamydia to decrease the prevalence of disease in our population.

Understanding barriers to condom usage among HIV-infected African American women

Drawing on focus group discussions with adolescent and adult HIV-infected women between the ages of 16 and 45, this study explores the barriers to condom use among women infected with HIV. Although most of the participants were comfortable discussing condoms and sexuality, there was little, if any, negotiation of condom use with their male partners. Most of the participants used condoms inconsistently or not at all. Reasons for nonuse included a lack of trust in the reliability of condoms to protect them, a lack of desire for pregnancy prevention, and the male partner's refusal to use condoms. Women in discordant relationships explained their uninfected partner's refusal to use condoms as denial of the risk of contracting HIV or as a way of expressing their love for the infected partner. Women also had great difficulty in disclosing their HIV status to both family and partners. Prevention efforts to increase condom use among HIV-infected women should target both men and women and focus on negotiation and communication skills.

School importance and dropout among pregnant adolescents

PURPOSE

This study examined the relationship of psychological well-being, social support, and demographic variables to school importance and school dropout among pregnant teens.

METHOD

Fifty-one Caucasians and 68 African-Americans (mean age = 16.7 years, mean weeks pregnant = 23) were recruited from two Baltimore area prenatal teen clinics. The adolescents completed questionnaires measuring depression, self-esteem, mastery, parental and friend support, demographic characteristics (i.e., age, marital status, ethnicity, socioeconomic status), school importance, and status.

RESULTS

Most adolescents were enrolled in school or had graduated (69.7%), were receiving at least passing grades (78.7%), and perceived finishing high school as very important (76.7%). Blacks were more likely to say school was important (p < 0.001), were less likely to drop out (p < 0.01), and received higher grades (p < 0.01) than whites. Dropouts had lower family incomes than current school attenders and graduates (p < 0.05). One measure of psychological well-being (mastery, p < 0.01) was positively correlated with school importance. Social support did not correlate with school importance or dropout.

CONCLUSIONS

These findings suggest that dropping out of school among pregnant teens may be more strongly related to sociocultural factors than to individual characteristics such as emotional support and psychological well-being. Overall, this study reveals a positive picture of educational continuation and performance during pregnancy, with most adolescents recognizing the importance of education and remaining in school.

Patterns of induced abortion in urban area of southeastern region, Brazil

OBJECTIVE

To assess the behavior of induced abortion as a function of certain demographic variables, for the population of fertile women (15 to 49 years old) residing in the Vila Madalena subdistrict S. Paulo (Brazil).

MATERIAL AND METHOD

Two population samples were selected. One sample, with 996 women, investigated the incidence of induced abortions during 1987, using the RRT. In the other, involving 1,004 women, the same information was detected through a conventional approach. In both samples, the induced abortion occurring during the reproductive life was recorded in direct fashion. Though this analysis refers only to information about past abortions, that is by 2,000 women-, it should be noted that it is exactly the RRT that lends credibility to the found or results given results.

CONCLUSION

The analysis furnishes evidence showing that single women, young women between the ages of 15 and 19, women who have not had live births, women who have a number of children below the expected ideal, women who use contraceptive methods (especially inefficient ones) and women who do not have any restrictions as to abortion constitute the categories most inclined to resort to induced abortion. This grouping suggests the existence of interrelationships between categories, that is, each of these categories is probably composed primarily of the same women, those who are at the beginning of their reproductive lives.

Low birth weight and associated maternal factors in an urban area

OBJECTIVE

To study the prevalence of low birth weight (LBW) and its association with maternal factors.

DESIGN

Cohort study.

SETTING

Urban community.

SUBJECTS

Cohort of 210 pregnant women.

RESULTS

The LBW prevalence was 30.3%. On multivariate analyses the maternal factors significantly associated with LBW were anemia (OR-4.81), low socioeconomic status (OR-3.96), short birth interval (OR-3.84), tobacco exposure (OR-3.14), height (OR-2.78), maternal age (OR-2.68), body mass index (OR-2.02), and primiparity (OR 1.58).

CONCLUSIONS

Anemia, low socioeconomic status, short stature, short birth interval. Tobacco exposure, low maternal age, low body mass index, and primiparity are significantly risk factors for LBW.

Change in sexual behaviour and decline in HIV infection among young pregnant women in urban Uganda

OBJECTIVE

To describe sexual behaviour that may partly explain a decline in HIV seroprevalence in pregnant women in urban settings in Uganda, East Africa.

SETTINGS

Two major urban districts in Uganda.

METHODS

Repeated population-based behavioural surveys in 1989 and 1995, and repeated HIV serological surveys in consecutive pregnant women attending antenatal clinics from 1989 to 1995.

RESULTS

During the study period, a 2-year delay in the onset of sexual intercourse among youths aged 15-24 years and a 9% decrease in casual sex in the past year in male youths aged 15-24 years were reported. Men and women reported a 40% and 30% increase in experience of condom use, respectively. In the same study area, over the same period, there was an overall 40% decline in the rates of HIV seroprevalence among pregnant women attending antenatal clinics. It can be hypothesized that the observed declining trends in HIV correspond to a change in sexual behaviour and condom use, especially among youths.

CONCLUSIONS

This is the first report of a change over a period of 6 years in male and female sexual behaviour, assessed at the population level, that may partly explain the observed decline in HIV seroprevalence in young pregnant women in urban Uganda. This result should encourage AIDS control programmes to pursue their prevention activities.

Prevalence of chlamydial infection in females attending antenatal and family planning clinics in Karachi Pakistan

A prospective study was undertaken to investigate the relative prevalence of Chlamydia trachomatis in asymptomatic pregnant women of 2 socioeconomic groups and those attending the family planning clinics. Group 1 consisted of women attending the antenatal clinics of the Aga Khan University Hospital which caters to the affluent strata of our society (n = 100). Group 2 comprised women attending the antenatal clinics of Lady Dufferin Hospital which provides free obstetric care to women belonging to the lower socioeconomic groups of Karachi (n = 100). Group 3 consisted of sexually active women attending the family planning clinics of Lady Dufferin Hospital (n = 100). Endocervical swabs were taken from women assigned to each group. Chlamydiazyme, an enzyme linked immunoassay, was used to detect chlamydia antigen. The positive samples were retested by using the direct fluorescent monoclonal antibody technique. Chlamydia positive patients and their sexual partners were treated with Erythromycin stearate 500 mg 8-hourly for 7 days. These patients were retested after antibiotic therapy to assess the efficacy of the therapy. In groups 1 and 2, 2% and in Group 3, 12% of the females tested positive. Selective screening of sexually active women for chlamydial infection is advocated as a cost-effective public health measure.

Maternal menstrual history and small-for-gestational-age births in a population-based Chinese birth cohort

The relationship between maternal menstrual history and small-for-gestational-age (SGA) births is examined in a population-based birth cohort of 5291 mothers with singleton births and 28 completed gestational weeks in Qingdao, China, in 1992. Multivariate analyses suggest that the length of the menstrual cycle and age at menarche had independent effects on SGA after controlling for sex of the infant, physical size of the mother, blood pressure at the first antenatal visit, parity, gestational week at the first antenatal visit, number of antenatal visits, number of previous spontaneous abortions and maternal educational attainment and occupation. The relative risk (RR) of SGA among thin mothers (BMI < = 21) is 1.63 (95% confidence interval (CI) 1.16-2.29) if the mother's menarche started after 14 years (reference to < = 14 years), 1.75 (95% CI 0.96-3.20) if the mother's menstrual cycle was 29-30 days and 2.92 (95% CI 1.42-6.03) if the menstrual cycle > = 31 days ( < = 28 as a reference category for both). Among normal weight mothers (BMI 21-24), only a menstrual cycle equal or longer than 31 days still had a significant effect on SGA (RR 2.17, 95% CI 1.18-4.08), and among fat mothers no significant effects were observed. The results encourage further evaluation of the association between maternal menstrual background and fetal development among other ethnic populations and exploration of the possible biological mechanisms behind this relationship.

Late postnatal transmission of human immunodeficiency virus type 1 infection from mothers to infants in Dar es Salaam, Tanzania

OBJECTIVE

To study late postnatal transmission of human immunodeficiency virus type 1 in a cohort of children born to HIV-1-seropositive mothers who delivered at Muhimbili Medical Centre in Dar es Salaam, Tanzania.

MATERIALS AND METHODS

Since 1991 a prospective cohort study of mother-to-child transmission of HIV-1 has been conducted at Muhimbili Medical Centre in Dar es Salaam. HIV-1-seropositive mothers and age-matched seronegative controls were recruited into the cohort at delivery together with their newborns. Diagnosis of HIV-1 infection in children was based on polymerase chain reaction, HIV-1 p24 antigen tests and HIV antibody tests. Late postnatal transmission was defined as HIV-1 infection occurring after 6 months of age in a child who was uninfected at 6 months of age and who had an HIV-1-seropositive mother. Children born to HIV-seronegative mothers were used as controls. Breast-feeding was universal in this cohort. CD4 and CD8 T lymphocytes were assayed by flow cytometry in the mothers.

RESULTS

Among 139 children born to HIV-1-seropositive mothers and known to be HIV-uninfected at 6 months of age, 8 children became HIV-1-infected at the end of their first year of life or later. No conversions were observed in children younger than 11 months. The 8 conversions were observed during a follow-up covering 1555 child months between 6 and 27 months of age corresponding to a conversion rate of 6.2 per 100 child years. Among 260 children with HIV-seronegative mothers no child became HIV-infected during the follow-up. The percentage of CD4 T lymphocytes was similar in mothers with early and late transmission but was significantly lower in transmitting than in nontransmitting mothers.

CONCLUSION

Because no HIV-1 infection occurred in children with HIV-seronegative mothers, we conclude that the observed infections at the end of the first year of life or later among children born to HIV-seropositive women were caused by late transmission from mother to child, most likely through breast-feeding.

Family planning in Isparta, Turkey

Family planning practices were reported by 491 married women, aged 15-49, who applied to the Family Planning Centre in Isparta, Turkey. Eighty-four percent of the women used contraception, the IUD being used most frequently. Almost half of the women married before age 18 years.

Dominican, Mexican, and Puerto Rican prostitutes: drug use and sexual behaviors

Although Hispanics are overrepresented in AIDS cases in the United States, little information is available to help understand differences in drug and sex risk behaviors in Hispanic subgroups, needed to develop appropriate prevention programs. This study reports on HIV-related risk behaviors in three groups of Hispanic prostitutes recruited in the United States: Dominican (77), recruited in Washington Heights, NY, Mexican (151), recruited in El Paso, 7X; and Puerto Rican (48), recruited in East Harlem, NY Ethnographic interviews were conducted with a subsample of subjects to examine cultural meaning of risk behaviors; structured interviews were conducted with subjects to describe demographic characteristics and summarize levels of risk behaviors. Results indicated that the labels Hispanic and prostitute obfuscated important differences related to geographic and cultural factors. To be effective for diverse Hispanic groups, HIV prevention efforts and interventions must be based on knowledge of these differences.

Short stay surgery for breast cancer: an audit of an experience in a regional cancer centre in northern India

At the Institute Rotary Cancer Hospital, AIIMS, New Delhi, 246 patients of breast cancer were operated on from June 1993 to June 1996; 82 suitable patients were discharged within 48 h (short stay surgery, SSS) after surgery and 164 were discharged after 48 h (conventional stay surgery, CSS). After discharge, patients of both groups were followed in the outpatient clinic until the removal of sutures and drains. There was no mortality or readmission for a complication in either group. Mean post-operative hospital stay was 1.5 days in the SSS group, and 3.3 days in the CSS group. There was no statistically significant difference in the incidence of post-operative complications like wound infection (4.8% vs 4.2%), flap necrosis (6% vs 5.4%), seroma (14% vs 19%), and the average number of hospital visits (3.42 vs 3.2) in SSS and CSS groups, respectively. Patient acceptance of early discharge was good except in the day care group. The study supports the safety and feasibility of short stay surgery for breast cancer in certain circumstances for properly selected patients.

Self-reported factors influencing condom use among clinic attendees

Data were collected from a convenience sample of 231 urban women seeking health care at a Midwestern women's health care center at a city medical center. Participants responded to 53 items, most taken from the Family Health Center Survey, which was designed to elicit descriptive data related to three major categories: background factors, factors that might influence the decision to use a condom, and knowledge and attitudes that might predict condom acquisition. Knowledge of HIV transmission and safer sex was not a predictor of condom use. Through education and demonstrations of proper condom usage, nurses and other health care providers were influential in persuading adolescents and young adults to use condoms.

Urban adolescent females' views on the implant and contraceptive decision-making: a double paradox

Focus groups and in-depth interviews were used to explore the decline in popularity of the contraceptive implant in a clinic-based sample of 41 ethnically diverse, urban, sexually active adolescents. While these teenagers' socioeconomic status and patterns of inconsistent contraceptive use made them potentially ideal implant recipients, they were unlikely to select this method. Negative media reports about the method were less influential than social conditions such as peer perspectives and gender relations. Oral networks that propagated misinformation went unchallenged because of the silence of satisfied users. Personal factors such as future orientation, autonomous decision-making and value of control also influenced contraceptive decision-making.