The risk of perinatal mortality following short inter-pregnancy intervals-insights from 692 402 pregnancies in 113 Demographic and Health Surveys from 46 countries: a population-based analysis

BACKGROUND

Inter-pregnancy interval has been identified as a potentially modifiable risk factor to improve perinatal outcomes. We examined the WHO recommended interval of at least 24 months after a livebirth to next pregnancy, and its recommendation of waiting for at least 6 months after a pregnancy loss to improve subsequent pregnancy outcomes. We aimed to estimate the association between inter-pregnancy interval and perinatal mortality using the Demographic and Health Survey reproductive and contraceptive calendar.

METHODS

For this population-based analysis, we extracted data for pregnancies with gestational age and pregnancy outcomes from 113 publicly available Demographic and Health Surveys conducted between 2000 and 2022 in 46 countries that included a reproductive or contraceptive calendar module. The primary outcome was perinatal mortality (stillbirth and early neonatal death) while the inter-pregnancy interval was the exposure of interest, grouped into categories of less than 6 months, 6-11 months, 12-17 months, 18-23 months, and 24-59 months. The analysis was stratified by preceding pregnancy outcome (livebirths, stillbirths, or abortions). The Kaplan-Meier method and Cox proportional hazard model were used to calculate the cumulative probability of perinatal mortality and the hazard ratios (HRs).

FINDINGS

The analysis sample comprised of 692 402 pregnancies contributed by 570 145 women with a mean age of 28·4 years (SD 5·96). The overall HR of perinatal death was 2·72 (95% CI 2·52-2·93) times higher for an inter-pregnancy interval of less than 6 months compared with the WHO recommended optimal waiting time of 18-23 months following a livebirth. Overall HRs followed a context-related pattern, with the highest ratio of 2·95 (95% CI 2·67-3·25) in sub-Saharan Africa and the lowest of 1·98 (1·47-2·66) in north Africa, west Asia, and Europe. Inter-pregnancy intervals of less than 3 months, 6 months, and 12 months following stillbirth or abortion (spontaneous or induced) do not pose a higher risk for perinatal death in subsequent pregnancy.

INTERPRETATION

Our study reaffirms the WHO recommendation on optimal interval between the last livebirth and the next pregnancy of at least 24 months and avoiding pregnancy before 18 months. However, our analysis does not support the WHO recommendation of delaying the next pregnancy for at least 6 months after a pregnancy loss for improved perinatal survival.

FUNDING

None.

Integrating postpartum IUD counselling and insertion into routine maternity care in Nepal: Assessing trends over time

To meet the postpartum family planning (PPFP) needs of women in Nepal, an intervention was launched to integrate PPFP counselling and postpartum IUD (PPIUD) insertion into maternity care. Women delivering in study hospitals over a period of 18 months were interviewed at the time of delivery and at 15 months following the end of the study enrollment period to assess if the impact of the intervention observed at the end of the study was maintained. Data were collected prior to the intervention, at the middle month of the intervention roll out, at the end of the enrollment period and 15 months after the end of the enrollment period. We compared PPFP counselling and insertion rates before, during, at the end of and after the intervention study period, using cross-tabulation and chi-square tests. Overall, PPFP counselling rates increased from 11% at the baseline month to 45% at the end of the enrollment in February 2017 and remained the same 15 months later in July 2018. PPIUD uptake, however, rose from a negligible 0.1% at the baseline to 4.3% in February 2017, but declined to 3.4% in July 2018. PPIUD uptake among women who were counselled showed a similar trend, increasing from 1.9% at the baseline to 9.6% in February 2017 and declining to 6.0% in July 2018. The intervention had an appreciable continued impact on PPIUD counselling rates and although PPIUD uptake rose during the intervention, this trend was not observed in the 15 months post-study follow up. The impact of the intervention was greater and persistent in hospitals that had a longer period of exposure to intervention. The results suggest that counselling was well integrated with the maternity care, though uptake of PPIUD dropped after intervention activities such as active monitoring, technical supervision, provision of IUDs and training were withdrawn.

Trial registration: This study has been registered with Clinical Trial.gov. The registration number is NCT 02718222. Details about the study design have been published by Canning et al, 2016.

Does family planning counseling reduce unmet need for modern contraception among postpartum women: Evidence from a stepped-wedge cluster randomized trial in Nepal

Background

Postpartum women have high rates of unmet need for modern contraception in the two years following birth in Nepal. We assessed whether providing contraceptive counseling during pregnancy and/or prior to discharge from the hospital for birth or after discharge from the hospital for birth was associated with reduced postpartum unmet need in Nepal.

Methods

We used data from a larger a stepped-wedge, cluster randomized trial, including contraceptive counselling in six tertiary hospitals. Group 1 hospitals (three hospitals) initiated the intervention after three months of baseline data collection, while Group 2 hospitals (three hospitals) initiated the same intervention after nine months. We have enrolled 21,280 women in the baseline interviews and conducted two follow-up interviews with them, one and two years after they had delivered in one of our study hospitals. We estimated the effect of counseling and its timing (pre-discharge, post- discharge, both, or neither) on unmet need for modern contraception in the postpartum period, using random-effects logistic regressions.

Results

Unmet need for modern contraception was high (54% at one year and 50% at two years). Women counseled in either the pre-discharge period (Odds ratio [OR] 0·86; 95% CI: 0·80, 0·93) or in the post-discharge period (OR 0·86; 95% CI: 0·79, 0·93) were less likely to have an unmet need in the postpartum period compared to women with no counseling. However, women who received counseling in both the pre- and post-discharge period were 27% less likely than women who had not received counseling to have unmet need (OR 0.73; 95% CI: 0·67, 0·80).

Conclusions

Counseling women either before or after discharge reduces unmet need for postpartum contraception but counseling in both periods is most effective.

Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up

Background

Health service providers play a key role in addressing women’s need for postpartum pregnancy prevention. Yet, in Nepal, little is known about providers’ knowledge, attitudes, and practice (KAP) on providing postpartum family planning (PPFP), particularly the immediate postpartum intrauterine device (PPIUD). This paper assesses providers KAP towards the provision of PPIUDs in Nepal prior to a PPIUD intervention to gain a baseline insight and analyzes whether their KAP changes both 6 and 24 months after the start of the intervention.

Methods

Data come from a randomized trial assessing the impact of a PPIUD intervention in Nepal between 2015 and 2017. We interviewed 96 providers working in six study hospitals who completed a baseline interview and follow-up interviews at 6 and 24 months. We used descriptive analysis, McNemar’s test and the Wilcoxon signed-rank test to assess KAP of providers over 2 years.

Results

The PPIUD KAP scores improved significantly between the baseline and 6-month follow-up. Knowledge scores increased from 2.9 out of 4 to 3.5, attitude scores increased from 4 out of 7 to 5.3, and practice scores increased from 0.9 out of 3 to 2.8. There was a significant increase in positive attitude and practice between 6 and 24 months. Knowledge on a women’s chance of getting pregnant while using an IUD was poor. Attitudes on recommending a PPIUD to different women significantly improved, however, attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Practice of PPIUD counseling and insertion improved significantly from baseline to 24 months, from 10.4 and 9.4% to 99% respectively.

Conclusions

Although KAP improved significantly among providers during the PPIUD intervention, providers’ knowledge on a women’s chance of getting pregnant while using an IUD and attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Provider KAP could be improved further through ongoing and more in-depth training to maintain providers’ knowledge, reduce provider bias and misconceptions about PPIUD eligibility, and to ensure providers understand the importance of birth spacing.

Provider and Women Characteristics as Risk Factors for Postpartum Copper IUD Expulsion and Discontinuation in Nepal

CONTEXT

Providers' and women's characteristics are associated with postpartum copper IUD (PPIUD) outcomes, but the relationship between providers' level of experience and PPIUD expulsion and discontinuation has not been established.

METHODS

Data on 1,232 women and 118 providers who took part in a randomized trial of a PPIUD counselling and provision intervention in Nepal between 2015 and 2017 were used to identify associations between providers' and women's characteristics and PPIUD outcomes. Multinomial logistic regression models were used to estimate PPIUD expulsion and discontinuation risks at two years after insertion.

RESULTS

Thirteen percent of women had had partial or complete expulsions and 29% had discontinued PPIUD use by two years. Having a provider who had done at least 10 previous insertions was associated with lower risk of expulsion rather than continuation (relative risk ratio, 0.5) relative to having a less-experienced provider. Women had a higher risk of both expulsion and discontinuation relative to continuation if they were younger than 21 rather than aged 26-30 (2.4 and 1.7, respectively) or if they belonged to the Dalit rather than Brahmin caste (2.2 and 1.9, respectively). Women whose husbands did not live at home also had elevated discontinuation risks.

CONCLUSION

The findings highlight the need for increased training and supervision of providers during their first 10 PPIUD insertions. Counselling on risk of expulsion may especially benefit younger and Dalit women, and should include partners and other family members to avoid any stigma surrounding PPIUD use by women whose partner is away from home for a prolonged period.

Exploring reasons for discontinuing use of immediate post-partum intrauterine device in Nepal: a qualitative study

BACKGROUND

Postpartum intrauterine device (PPIUD) use remains very low in Nepal despite high levels of unmet need for postpartum family planning and the national government's efforts to promote its use. This study investigates reasons for continuing or discontinuing PPIUD use among Nepali women.

METHODS

We conducted in-depth interviews (IDIs) with 13 women who had discontinued PPIUD use and 12 women who were continuing to use the method 9 months or longer following the insertion. All interviews were audio recorded, transcribed, translated into English, and analyzed using a thematic approach.

RESULTS

Women discontinued PPIUD for several reasons: 1) side effects such as excessive bleeding during menstruation, nausea, back and abdominal pain; 2) poor quality of counselling and, relatedly, mismatched expectations in terms of device use; and 3) lack of family support from husbands and in-laws. In contrast, women who were continuing to use the method at the time of the study stated that they had not experienced side-effects, had received appropriate information during counselling sessions, and had the backing of their family members in terms of using PPIUD.

CONCLUSION

Experiencing side-effects or complications following PPIUD insertion and poor quality of family planning counselling were the two main reasons for discontinuation. Family members appeared to play a major role in influencing a woman's decision to continue or discontinue PPIUD suggesting that counseling may need to be expanded to them as well. Improving quality of counselling by providing complete and balanced information of family planning methods as well as ensuring sufficient time for counselling and extending PPIUD service availability at lower level clinics/health posts will potentially increase the uptake and continued use of postpartum family planning, including PPIUD, in Nepal.

Investigating the quality of family planning counselling as part of routine antenatal care and its effect on intended postpartum contraceptive method choice among women in Nepal

Background

Though modern contraceptive use among married women in Nepal has increased from 26% in 1996 to 43% in 2016, it remains low among postpartum women. Integration of counselling on family planning (FP) at the time of antenatal care (ANC) and delivery has the potential to increase post-partum contraceptive use. This study investigates the quality of FP counselling services provided during ANC visits and women’s perceptions of its effectiveness in assisting them to make a post-partum family planning (PPFP) decision.

Methods

In-depth interviews (IDIs) were conducted with 24 pregnant women who had attended at least two ANC visits in one of the six public hospitals that had received an intervention that sought to integrate FP counselling in maternity care services and introduce postpartum intrauterine device insertion in the immediate postpartum period. IDIs data were collected as part of a process evaluation of this intervention. Women were selected using maximum variation sampling to represent different socio-demographic characteristics. IDIs were audio recorded, transcribed verbatim in Nepali, and translated into English. Data were organized using Bruce-Jain quality of care framework and analyzed thematically.

Results

Overall, the quality of FP counselling during ANC was unsatisfactory based on patient expectations and experience of interactions with providers, as well as FP methods offered. Despite their interest, most women reported that they did not receive thorough information about FP, and about a third of them said that they did not receive any counselling services on PPFP. Reasons for dissatisfaction with counselling services included very crowded environment, short time with the provider, non-availability of provider, long waiting times, limited number of days for ANC services, and lack of comprehensive FP-related information, education and counselling (IEC) materials. Women visiting hospitals with a dedicated FP counselor reported higher quality of FP counselling.

Conclusions

There is an urgent need to re-visit the format of counselling on PPFP during ANC visits, corresponding IEC materials, counselling setting, and to strengthen availability and interaction with providers in order to improve quality, experience and satisfaction with FP counselling during ANC visits. Improvements in infrastructure and human resources are also needed to adequately meet women’s needs.

Integrating postpartum contraceptive counseling and IUD insertion services into maternity care in Nepal: results from stepped-wedge randomized controlled trial

BACKGROUND

In Nepal, 54% of women have an unmet need for family planning within the 2 years following a birth. Provision of a long-acting and reversible contraceptive method at the time of birth in health facilities could improve access to postpartum family planning for women who want to space or limit their births. This paper examines the impact of an intervention that introduced postpartum contraceptive counseling in antenatal care and immediate postpartum intra-uterine device (PPIUD) insertion services following institutional delivery, with the intent to eventually integrate PPIUD counseling and insertion services as part of routine maternity care in Nepal.

METHODS

This study took place in six large tertiary hospitals. All women who gave birth in these hospitals in the 18-month period between September 2015 and March 2017 were asked to participate. A total of 75,587 women (99.6% consent rate) gave consent to be interviewed while in postnatal ward after delivery and before discharge from hospital. We use a stepped-wedge cluster randomized design with randomization of the intervention timing at the hospital level. The baseline data collection began prior to the intervention in all hospitals and the intervention was introduced into the hospitals in two steps, with first group of three hospitals implementing the intervention 3 months after the baseline had begun, and second group of three hospitals implementing the intervention 9 months after the baseline had begun. We estimate the overall effect using a linear regression with a wild bootstrap to estimate valid standard errors given the cluster randomized design. We also estimate the effect of being counseled on PPIUD uptake.

RESULTS

Our Intent-to-Treat analysis shows that being exposed to the intervention increased PPIUD counseling among women by 25 percentage points (pp) [95% CI: 14-40 pp], and PPIUD uptake by four percentage points [95% CI: 3-6 pp]. Our adherence-adjusted estimate shows that, on average, being counseled due to the intervention increased PPIUD uptake by about 17 percentage points [95% CI: 14-40 pp].

CONCLUSIONS

The intervention increased PPIUD counseling rates and PPIUD uptake among women in the six study hospitals. If counseling had covered all women in the sample, PPIUD uptake would have been higher. Our results suggest that providing high quality counseling and insertion services generates higher demand for PPIUD services and could reduce unmet need.

TRIAL REGISTRATION

Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Delivering postpartum family planning services in Nepal: are providers supportive?

Background

Health service providers play a key role in addressing women’s need for pregnancy prevention, especially during the postpartum period. Yet, in Nepal, little is known about their views on providing postpartum family planning (PPFP) services and postpartum contraceptive methods such as immediate postpartum intra-uterine devices (PPIUD). This paper explores the perspectives of different types of providers on PPFP including PPIUD, their confidence in providing PPFP services, and their willingness to share their knowledge and skills with colleagues after receiving PPFP and PPIUD training.

Methods

In-depth interviews were conducted with 14 obstetricians/gynecologists and nurses from six tertiary level public hospitals in Nepal after they received PPFP and PPIUD training as part of an intervention aimed at integrating PPFP counseling and insertion into routine maternity care services. The interviews were audio recorded, transcribed, and analyzed using a thematic approach.

Results

Providers identified several advantages of PPFP, supported the provision of such services, and were willing to transfer their newly acquired skills to colleagues in other facilities who had not received PPFP and PPIUD training. However, many providers identified several supply-side and training-related barriers to providing high quality PPFP services, such as, (i) lack of adequate human resources, particularly a FP counselor; (ii) work overload; (iii) lack of private space for counseling; (iv) lack of IUDs and information, education and counseling materials; and (v) lack of support from hospital management.

Conclusions

Providers appeared to be motivated to deliver quality PPFP services and transfer their knowledge to colleagues but identified several barriers which prevented them from doing so. Future efforts to improve provision of quality PPFP services should address the barriers identified by providers.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3777-3) contains supplementary material, which is available to authorized users.

Gender role attitudes, awareness and experiences of non-consensual sex among university students in Shanghai, China

BACKGROUND

Non-consensual sex (NCS) among young people, an important subject with public health and human rights implications, was less studied in China. This study is to investigate the NCS awareness and victimization of university students in Shanghai, China and whether they were associated with adolescent gender-role attitudes.

METHODS

Gender-role attitudes, awareness and victimization of different forms of NCS were examined among 1099 undergraduates (430 males and 669 females) in four universities in Shanghai using computer-assisted self-interview approach.

RESULTS

University students held relatively egalitarian attitude to gender roles. Gender difference existed that girls desired to be more equal in social status and resource sharing while more endorsed the submissiveness for women in sexual interaction than boys. They held low vigilance on the risk of various forms of NCS, with the mean score on perception of NCS among boys (5.67) lower than that among girls (6.37). Boys who adhered to traditional gender norms were less likely to aware the nature of NCS (β = - 0.6107, p = 0.0389). Compared with boys, higher proportion of girls had been the victims of verbal harassment, unwanted touch, fondling, and penetrative sexual intercourse. Multivariable analysis revealed that girls who held more traditional gender-role attitudes were more vulnerable to physical NCS (OR = 1.41, p = 0.0558).

CONCLUSIONS

The weakening but still existing traditional gender norms had contributions in explaining the gender difference on the low vigilance of NCS and higher prevalence of victimization among university students in Shanghai, China. Interventions should be taken to challenge the traditional gender norms in individual and structural level, and promote the society to understand the nature of NCS better as well as enhance negotiation skills of adolescents and young people that prevent them from potentially risky situations or relationships.

Comparative satisfaction of receiving medical abortion service from nurses and auxiliary nurse-midwives or doctors in Nepal: results of a randomized trial

Background

Early first-trimester medical abortion (MA) service (≤ 63 days) has been provided by doctors and nurses under doctors’ supervision since 2009 in Nepal. This paper assesses whether MA services provided by specifically trained and certified nurses and auxiliary nurse-midwives independently from doctors’ supervision, is considered as satisfactory by women as those provided by doctors.

Methods

The data come from a multi-center, randomized, controlled equivalence trial conducted between April 2009 and March 2010 in five district hospitals in Nepal. Women seeking MA were randomly assigned to doctors or nurses and auxiliary nurse-midwives(ANMs).Eligible women were administered 200 mg mifepristone orally followed by 800 μg misoprostol vaginally two days later by their assigned providers and followed up 10–14 days later. At the follow-up visit women’s reported satisfaction with MA service they received was measured.

Results

Of 1295 women screened for eligibility, 535 were randomly assigned to a doctor and 542 to a nurse or ANM. Nineteen women were lost-to-follow up in the former group and 27 were lost-to-follow up or did not complete the acceptability interview in the latter group. This study is, therefore, based on516womenin the doctor’s group and 515 women in the nurse or ANM group. All women in the nurse or ANM group reported being satisfied or highly satisfied by MA compared to 99% in the doctor’s group. Satisfaction was similar regardless of the type of provider; 38% among nurse or ANM and 35% among the doctor group were “highly satisfied”, and 62% and 64%, respectively, were “satisfied”. Women’s experiences such as ‘less than expected amount or duration of bleeding following MA’, ‘shorter than expected duration of the abortion process’, and ‘able to manage symptoms’, were found to be associated with women’s higher satisfaction with MA. Counseling and information on the method, potential complications of MA and post-abortion contraception was nearly universal. No statistically significant differences were found in the level of satisfaction by age, parity, marital status, education or occupation of women.

Conclusions

Women’s satisfaction with MA service provided by trained nurses or auxiliary nurse-midwives was similar to that provided by doctors. The findings, therefore, provide support for extending safe and accessible medical abortion services by government-trained nurses and auxiliary nurse midwives to women seeking early first trimester pregnancy termination.

Trial registration

The trial was retrospectively registered with ClinicalTrials.gov (identifier: NCT01186302). Registered August 20, 2010.

Location and content of counselling and acceptance of postpartum IUD in Sri Lanka

BACKGROUND

The immediate postpartum IUD (PPIUD) is a long-acting, reversible method of contraception that can be used safely and effectively following a birth. To appropriately facilitate the immediate postpartum insertion of IUDs, women must be informed of the method's availability and must be counselled on its benefits and risks prior to entering the delivery room. We examine the relationship between the location and quality of antenatal counselling and women's acceptance of immediate postpartum IUD (PPIUD) in four hospitals in Sri Lanka.

METHODS

Data were collected between January 2015 and May 2015. Modified Poisson regressions with robust standard errors are used to assess the relationships between place of counselling, indicators of counselling quality, and PPIUD uptake following delivery.

RESULTS

We find that women who were counselled in hospital antenatal clinics and admission wards were much more likely to have a PPIUD inserted than women who were counselled in field clinics or during home visits. Hospital-based counselling had higher quality indicators for providing information on PPIUD, and women were more likely to receive PPIUD information leaflets in hospital locations than in lower-tiered clinics or during home visits. Women who were counselled at hospital locations also reported a higher level of satisfaction with the counselling that they received. Receipt of hospital-based counselling was also linked to higher PPIUD uptake, in spite of the fact that women were more likely to be given information about the risks and alternatives to PPIUD in hospitals. The information about the risks of and alternatives to PPIUD, whether provided in hospital or in non-hospital settings, tended to lower the likelihood of acceptance to have a PPIUD insertion. Counselling in hospital admission wards was focused on women who had not been counselled at field clinics.

CONCLUSIONS

The study findings call for efforts that improve the training of midwives who provide PPIUD counselling at field clinics and during the home visits. We also recommend that routine PPIUD counselling be conducted in hospitals, even if women have already been counselled elsewhere.

Institutionalizing postpartum intrauterine device (IUD) services in Sri Lanka, Tanzania, and Nepal: study protocol for a cluster-randomized stepped-wedge trial

BACKGROUND

During the year following the birth of a child, 40% of women are estimated to have an unmet need for contraception. The copper IUD provides safe, effective, convenient, and long-term contraceptive protection that does not interfere with breastfeeding during the postpartum period. Postpartum IUD (PPIUD) insertion should be performed by a trained provider in the early postpartum period to reduce expulsion rates and complications, but these services are not widely available. The International Federation of Obstetricians and Gynecologists (FIGO) will implement an intervention that aims to institutionalize PPIUD training as a regular part of the OB/GYN training program and to integrate it as part of the standard practice at the time of delivery in intervention hospitals.

METHODS

This trial uses a cluster-randomized stepped wedge design to assess the causal effect of the FIGO intervention on the uptake and continued use of PPIUD and of the effect on subsequent pregnancy and birth. This trial also seeks to measure institutionalization of PPIUD services in study hospitals and diffusion of these services to other providers and health facilities. This study will also include a nested mixed-methods performance evaluation to describe intervention implementation.

DISCUSSION

This study will provide critical evidence on the causal effects of hospital-based PPIUD provision on contraceptive choices and reproductive health outcomes, as well as on the feasibility, acceptability and longer run institutional impacts in three low- and middle-income countries.

TRIAL REGISTRATION

Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Postpartum and Post-Abortion Contraception: From Research to Programs

Contraception following delivery or an induced abortion reduces the risk of an early unintended pregnancy and its associated adverse health consequences. Unmet need for contraception during the postpartum period and contraceptive counseling and services following abortion have been the focus of efforts for the last several decades. This article provides an introduction to the more focused contributions that follow in this special issue. We discuss the validity and measurement of the concept of unmet need for family planning during the postpartum period. We then present key findings on postpartum contraceptive protection, use dynamics, and method mix, followed by an assessment of interventions to improve postpartum family planning. The evidence on postabortion contraceptive uptake and continuation of use remains thin, although encouraging results are noted for implementation of comprehensive abortion care and for the impact of post-abortion contraceptive counseling and services. Drawing on these studies, we outline policy and program implications for improving postpartum and post-abortion contraceptive use.

Does the use of HIV testing and counseling services influence condom use among low-paid female sex workers in Guangxi, China?

HIV testing and counseling (HTC) are increasingly used in China during routine medical care visits to health facilities. However, limited data are available regarding the association between the utilization of HTC services and condom use among low-paid female sex workers (FSWs) who are at high risk of HIV infection but are hard to reach. A cross-sectional study was conducted among 794 low-paid FSWs in a city of Guangxi Zhuang Autonomous Region in 2011. Results showed that 71.7% of low-paid FSWs had utilized HTC services in the previous year and 65.7% reported having used a condom during the last sexual intercourse with their clients. Multivariate logistic regression analysis showed that utilizing HTC services was significantly and positively associated with the condom use. It also indicated that low-paid FSWs who were older, married, had higher education, earned less money, had high number of clients, had a history of sexually transmitted diseases, or had little or no HIV knowledge were less likely to use a condom during the last sexual encounter. The study suggests that HTC services need to be scaled up and made more accessible for this vulnerable population.

How to assess success of treatment when using multiple doses: the case of misoprostol for medical abortion

Background

The assessment of treatment success in clinical trials when multiple (repeated) doses (courses) are involved is quite common, for example, in the case of infertility treatment with assisted reproductive technology (ART), and medical abortion using misoprostol alone or in combination with mifepristone. Under these or similar circumstances, most researchers assess success using binomial proportions after a certain number of consecutive doses, and some have used survival analysis. In this paper we discuss the main problems in using binomial proportions to summarize (the overall) efficacy after two or more consecutive doses of the relevant treatment, particularly for the case of misoprostol in medical abortion studies. We later discuss why the survival analysis is best suited under these circumstances, and illustrate this by using simulated data.

Methods

The formulas required for the binomial proportion and survival analysis (without and with competing risks) approaches are summarized and analytically compared. Additionally, numerical results are computed and compared between the two approaches, for several theoretical scenarios.

Results

The main conceptual limitations of the binomial proportion approach are identified and discussed, caused mainly by the presence of censoring and competing risks, and it is demonstrated how survival analysis can solve these problems. In general, the binomial proportion approach tends to underestimate the “real” success rate, and tends to overestimate the corresponding standard error.

Conclusions

Depending on the rates of censored observations or competing events between repeated doses of the treatment, the bias of the binomial proportion approach as compared to the survival analysis approaches varies; however, the use of the binomial approach is unjustified as the survival analysis options are well known and available in multiple statistical packages. Our conclusions also apply to other situations where success is estimated after multiple (repeated) doses (courses) of the treatment.

Unmet need for contraception: issues and challenges

Unmet need for contraception has been a central indicator for monitoring the progress of family planning programs for 25 years. The purpose of this article is to provide a broad context for the more focused contributions that follow in this special issue. The validity and measurement of the concept of unmet need are discussed. We then present regional trends among married women since 1970. Major reductions in unmet need have been achieved, with the clear exception of sub-Saharan Africa. Less success can be claimed in addressing the needs of sexually active unmarried women, who contribute nearly 20 percent to overall unmet need in developing countries. Prominent reasons for unmet need in settings where contraceptive uptake is low include social resistance and insufficient information concerning methods. As contraceptive use increases, the importance of these reasons wanes, but concerns regarding side effects and health impact remain a barrier, and discontinued users now constitute a large proportion of those with unmet need. Drawing on these reasons, we outline measures to further reduce unmet need.

Access to safe abortion: progress and challenges since the 1994 International Conference on Population and Development (ICPD)

BACKGROUND

The 1994 International Conference on Population and Development (ICPD) viewed access to safe abortion as imperative for public health.

PROGRESS SINCE ICPD

Globally, the number of induced abortions (safe and unsafe) per 1000 women aged 15-44 years declined from 35 in 1995 to 28 in 2008. The number of deaths due to unsafe abortion declined from 69,000 in 1990 to 47,000 in 2008, as safe and effective methods of abortion, including manual vacuum aspiration and medical abortion, became more widely available. During the same period, there was a slight increase in the number of countries where abortion is permitted on request, and 70 countries made grounds for abortion more liberal.

CHALLENGES

Since ICPD, the decline in unsafe abortion was slower than that in safe abortion, and unsafe-abortion-related mortality continued to be a problem. Nearly all unsafe abortions and mortality occur in developing countries.

RECOMMENDATIONS

While more must be done to ensure universal access to safe, acceptable and affordable contraception to reduce the need for abortion, this need will always exist. Information on grounds for safe abortion should be made widely available for women to access services to which they are legally entitled to. As recommended by ICPD, quality postabortion care including contraception counseling and provision should be available to all women, regardless of the legal grounds for abortion. The paper provides the evidence on unsafe abortion, a reproductive health issue that is entirely preventable but has been largely neglected or tarnished by emotional and contentious debates.

Effects of sleeve gastrectomy and ileal transposition, alone and in combination, on food intake, body weight, gut hormones, and glucose metabolism in rats

Bariatric surgeries are hypothesized to produce weight loss and improve diabetes control by multiple mechanisms including gastric restriction and lower gut stimulation; the relative importance of these mechanisms remains poorly understood. We compared the effects of a typical foregut procedure, sleeve gastrectomy, (SG) with a primarily hindgut surgery, ileal transposition (IT), alone and together (SGIT), or sham manipulations, on food intake, body weight, gut hormones, glucose tolerance, and key markers of glucose homeostasis in peripheral tissues of adult male Sprague-Dawley rats (450-550 g, n = 7-9/group). SG, IT, and SGIT surgeries produced transient reduction in food intake and weight gain; the effects of SG and IT on intake and body weight were nonadditive. SG, IT, and SGIT surgeries resulted in increased tissue expression and plasma concentrations of the lower gut hormones glucagon-like peptide-1 and peptide YY and decreased plasma glucose-dependent insulinotropic peptide, insulin, and leptin concentrations. Despite transient effects on intake and weight gain, the SG, IT, and SGIT surgeries produced a significant improvement in glucose tolerance. In support of glycemic improvements, the protein abundance of key markers of glucose metabolism (e.g., GLUT4, PKA, IRS-1) in muscle and adipose tissue were increased, whereas the expression of key gluconeogenic enzyme in liver (G-6-Pase) were decreased following the surgeries. Therefore, our data suggest that enhanced lower gut stimulation following SG, IT, and SGIT surgeries leads to transient reduction in food intake and weight gain together with enhanced secretion of lower gut hormones and improved glucose clearance by peripheral tissues.

Parental support for sexual and reproductive health information and services for unmarried youth in Chengdu, China

The objective of the study was to explore parental perspectives and attitudes towards the provision of sexual and reproductive health (SRH) information and services to unmarried youth in Chengdu, China. A representative sample of parents was drawn using multi-stage stratified cluster sampling technique, and information was collected using a structured questionnaire. The eligible respondents were parents (both fathers and mothers) who had at least one unmarried adolescent and/or youth aged 15 to 24 years old. A total of 2,871 fathers and mothers were interviewed. Parents' SRH-related knowledge was poor and dissonant attitudes of tolerance and ambivalence towards provision of SRH information and services to unmarried youth were found. About 80% of parents accepted and understood unmarried youth seeking SRH counseling service, but the percentages of such positive attitude was much lower for premarital contraceptive use. Over half of the parents were supportive of providing SRH education and information to unmarried youth; whereas on the provision of contraceptive services to sexually active unmarried youth, 27% were negative, 25% accepted, 36% indicated an understanding, and the rest 12% had no opinion. Parents' SRH-related knowledge and attitudes were associated with parental social-demographic characteristics. Findings from this study suggest that parent-oriented programs are needed to apprise them of the existing SRH conditions of the unmarried youth in China, to allay fears and misconceptions of parents, and to enhance family-based sex education in terms of increasing parents' SRH knowledge and their capacity and skills of providing such information to unmarried youth.

Induced abortion: incidence and trends worldwide from 1995 to 2008

BACKGROUND

Data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe abortion worldwide have only been made for 1995 and 2003.

METHODS

We used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. We used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. We assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology. We used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008.

FINDINGS

The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15-44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05).

INTERPRETATION

The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals.

FUNDING

UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.

Contraceptive use, fertility, and unsafe abortion in developing countries

OBJECTIVES

Despite a substantial rise in contraceptive use around the world, unplanned pregnancies and induced abortion continue to occur. Each year an estimated 19 million abortions are carried out outside the legal system, often by unskilled practitioners or under unhygienic conditions. This paper explores the relationship between contraceptive prevalence and unsafe abortion in developing regions with different levels of fertility. These relationships manifest the extent to which the desire to regulate fertility is addressed by contraception or by unsafe abortion, where access to safe abortion is legally restricted.

METHODS

Secondary analysis of estimates of unsafe abortion, total fertility rate and contraceptive prevalence, by geographical regions.

RESULTS

High levels of unsafe abortion persist even where contraceptive prevalence is increasing and fertility is declining. It appears that a high dependence on sterilization for limiting family size may by be preceded by reliance on unsafe abortion, where abortion is restricted, for birth spacing.

CONCLUSIONS

The reliance on unsafe abortion could be reduced during fertility transition by improving women's access to reversible contraceptives for spacing births as well as to sterilization for terminating childbearing. Expanding contraceptive choices and a balanced method mix can serve as an effective strategy to prevent unsafe abortion where reliance on sterilization to limit childbearing is not preceded by the use of reversible modern methods for spacing and where access to safe abortion is restricted by law. The intriguing association between contraceptive method choice and the incidence of unsafe abortion deserves further exploration.

Access to contraceptive services among unmarried young people in the north-east of China

OBJECTIVE

The concerns about the potential threats of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have increased, since, in China, there is a lack of sexual education and condom use is rare. A community-based survey was conducted in September 2001 in Changchun city among 1227 unmarried young people aged 15-24 years (619 males and 608 females) to assess risky sexual practices and the obstacles to accessing appropriate contraceptive and other services.

METHOD

The study comprised a survey employing self-administered questionnaires, as well as key informant interviews, focus group discussions and in-depth interviews. This paper investigates the factors associated with young people's access to contraceptive services.

RESULTS

Results showed that 16% of young people had experienced premarital sexual intercourse and, among them, only 48.2% used contraceptive methods during the first sexual intercourse; 29.9% used a condom. Drug stores were the main source of contraceptives.

CONCLUSIONS

While data are sparse, findings suggest that the hostile and judgmental attitudes of providers, as well as the lack of counseling and privacy, were the key obstacles that unmarried youth encountered in their search for contraceptive services. Findings suggest the need for a reorientation of the contraceptive services to focus on unmarried youth, and generally to make contraceptive services more accessible to young people.

Maternal mortality and maternity care from 1990 to 2005: uneven but important gains

Maternal mortality continues to be the major cause of death among women of reproductive age in many countries. Data from published studies and Demographic and Health Surveys show that gains in reducing maternal mortality between 1990 and 2005 have been modest overall. In 2005, there were about 536,000 maternal deaths, and the maternal mortality ratio was estimated at 400 per 100,000 live births, compared to 430 in 1990. Noteworthy declines took place in east Asia (4% per year) and north Africa (3% per year). Maternal deaths and mortality ratios were highest in sub-Saharan Africa and southeast Asia and low in east Asia and Latin America/Caribbean. In 11 of 53 countries with data, fewer than 25% of women had had at least four antenatal visits. About 63% of births were attended by a skilled attendant: from 47% in Africa to 88% in Latin America/Caribbean. In 16 of 23 countries with data, less than 50% of the recommended levels of emergency obstetric care had been fulfilled. Only 61% of women who delivered in a health facility in 30 developing countries received post-partum care, and far fewer who gave birth at home. Countries with maternal mortality ratios of 750+ per 100,000 live births shared problems of high fertility and unplanned pregnancies, poor health infrastructure with limited resources and low availability of health personnel. The task ahead is enormous.

Parent-adolescent sex communication in China

BACKGROUND

Communication concerning sexual matters between parents and their adolescent children serve as a protective factor and exerts a favourable influence on adolescents' sexual behaviours. As limited data regarding parent-adolescent sex communication are available in China, this study was undertaken with the aim of exploring the patterns and related factors of such communication and its relationship with adolescent sexual behaviour.

STUDY DESIGN

Community-based data were collected in 2001 in Changchun, China. Unmarried adolescents 15-19 years of age (322 young men and 360 young women) were included in a survey using self-administered questionnaires.

RESULTS

Overall, sex communication with parents was relatively infrequent. There was a significant gender difference in the pattern of sex communication, with male adolescents being more likely to talk with fathers and female adolescents with mothers. Logistic regression analysis revealed that gender of adolescents, quality of communication with mothers on general topics, and adolescent's perception of mother being the main source of sex knowledge were predictive of the level of sex communication between mother and her adolescent children.

CONCLUSION

This study reveals that communication regarding sexual matters between parents and adolescents was limited in China. The quality of communication on general topics between parents and their adolescent children is one of the important factors related to sex communication between them. It is essential that Chinese parents are better informed and skilled to be involved, in addition to school and community, in the sex education of their adolescent children. They should be able to communicate appropriately on sex-related issues with them.

Induced abortion: estimated rates and trends worldwide

BACKGROUND

Information on incidence of induced abortion is crucial for identifying policy and programmatic needs aimed at reducing unintended pregnancy. Because unsafe abortion is a cause of maternal morbidity and mortality, measures of its incidence are also important for monitoring progress towards Millennium Development Goal 5. We present new worldwide estimates of abortion rates and trends and discuss their implications for policies and programmes to reduce unintended pregnancy and unsafe abortion and to increase access to safe abortion.

METHODS

The worldwide and regional incidences of safe abortions in 2003 were calculated by use of reports from official national reporting systems, nationally representative surveys, and published studies. Unsafe abortion rates in 2003 were estimated from hospital data, surveys, and other published studies. Demographic techniques were applied to estimate numbers of abortions and to calculate rates and ratios for 2003. UN estimates of female populations and livebirths were the source for denominators for rates and ratios, respectively. Regions are defined according to UN classifications. Trends in abortion rates and incidences between 1995 and 2003 are presented.

FINDINGS

An estimated 42 million abortions were induced in 2003, compared with 46 million in 1995. The induced abortion rate in 2003 was 29 per 1000 women aged 15-44 years, down from 35 in 1995. Abortion rates were lowest in western Europe (12 per 1000 women). Rates were 17 per 1000 women in northern Europe, 18 per 1000 women in southern Europe, and 21 per 1000 women in northern America (USA and Canada). In 2003, 48% of all abortions worldwide were unsafe, and more than 97% of all unsafe abortions were in developing countries. There were 31 abortions for every 100 livebirths worldwide in 2003, and this ratio was highest in eastern Europe (105 for every 100 livebirths).

INTERPRETATION

Overall abortion rates are similar in the developing and developed world, but unsafe abortion is concentrated in developing countries. Ensuring that the need for contraception is met and that all abortions are safe will reduce maternal mortality substantially and protect maternal health.

Where do Chinese adolescents obtain knowledge of sex? Implications for sex education in China

Purpose

Sex education in China has been promoted for many years, but limited data are available regarding the sources from which adolescents receive sex‐related knowledge. The present study was designed to examine the sources from which Chinese adolescents obtain their information on puberty, sexuality and STI/HIV/AIDS, and whether there are any differences in sources of sex knowledge according to adolescents' demographic characteristics and sexual status.

Design/methodology/approach

The data were collected in 2001 in Changchun City, China. Unmarried adolescents 15‐19 years of age (322 males and 360 females) were included in a cross‐sectional survey using self‐administered questionnaires.

Findings

Schoolteachers and mass media were identified as the two most important sources of sex knowledge. Sources of sex knowledge among adolescents on various topics (puberty, sexuality, and STI/HIV/AIDS) differed by the level of taboo associated with these topics in Chinese culture. The percentage of adolescents obtaining knowledge for puberty, sexuality, and STI/HIV/AIDS from teachers declined by topic (45.4, 30.7 and 18.4 percent, respectively), while the percentage of adolescents obtaining knowledge from television/movie increased by topic (6.7, 12.2 and 27.5 percent, respectively). Adolescents obtained knowledge on topics with less taboo (e.g. puberty) from teachers and obtained knowledge on topics with more taboo (e.g. sexuality, STI/HIV/AIDS) from mass media. However, this differs by having been sexually experienced or not. Parents were the primary source for sex knowledge on less taboo subjects. Doctors were the primary source for STI/HIV/AIDS knowledge. Sexually active adolescents obtained sex knowledge mainly from peers or mass media, while those adolescents who were not sexually experienced identified teachers and parents as the main sources of sex knowledge.

Originality/value

The current study illustrates that it is necessary to improve and enhance current sex education programs in China by recognizing and strengthening the role of parents, teachers, and health care professionals in adolescent sex education.

Unsafe abortion: the preventable pandemic

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

Can the Internet be used effectively to provide sex education to young people in China?

PURPOSE

To assess the feasibility and effectiveness of sex education conducted through the Internet.

METHODS

Two high schools and four colleges of a university in Shanghai were selected as the research sites. Half of these were assigned to the intervention group and the other half to the control group. The interventions consisted of offering sexual and reproductive health knowledge, service information, counseling and discussion to all grade one students in the intervention group. The intervention phase lasted for 10 months and was implemented through a special website, with web pages, online videos, Bulletin Board System (BBS) and expert mailbox. In total, 624 students from the intervention, and 713 from the control schools and colleges participated in the baseline survey, and about 97% of them were followed up in postintervention survey to assess changes that can be attributed to the sex education interventions provided through the Internet.

RESULTS

The median scores of the overall knowledge and of each specific aspect of reproductive health such as reproduction, contraception, condom, sexually transmitted infections (STIs) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) were significantly higher in the intervention group as compared with those in the control group at postintervention (p < .0001), although no significant differences were found between these two groups in the baseline survey (p > .05). Group by time interaction effects in ordinal logistic regression analysis were found on knowledge score (p < .0001) and in attitude of high school students toward sex-related issues (p < .05), suggesting that interventions increased subjects' knowledge significantly and changed high school students' attitudes to being less liberal toward sex. The intervention also had positive influence on students' attitudes toward providing contraceptive service for unmarried people.

CONCLUSIONS

Providing sex education to students in Shanghai through the Internet was found feasible and effective. The Internet-based sex education program increased students' reproductive health knowledge effectively and changed their attitudes toward sex-related issues in terms of being less liberal toward sex and more favorable to providing services to unmarried young people. The Internet thus offers an important and hitherto untapped potential for providing sex education to students and young people in China.

Contraceptive use, fertility, and unsafe abortion in developing countries

OBJECTIVES

Despite a substantial rise in contraceptive use around the world, unplanned pregnancies and induced abortion continue to occur. Each year an estimated 19 million abortions are carried out outside the legal system, often by unskilled practitioners or under unhygienic conditions. This paper explores the relationship between contraceptive prevalence and unsafe abortion in developing regions with different levels of fertility. These relationships manifest the extent to which the desire to regulate fertility is addressed by contraception or by unsafe abortion, where access to safe abortion is legally restricted.

METHODS

Secondary analysis of estimates of unsafe abortion, total fertility rate and contraceptive prevalence, by geographical regions.

RESULTS

High levels of unsafe abortion persist even where contraceptive prevalence is increasing and fertility is declining. It appears that a high dependence on sterilization for limiting family size may by be preceded by reliance on unsafe abortion, where abortion is restricted, for birth spacing.

CONCLUSIONS

The reliance on unsafe abortion could be reduced during fertility transition by improving women's access to reversible contraceptives for spacing births as well as to sterilization for terminating childbearing. Expanding contraceptive choices and a balanced method mix can serve as an effective strategy to prevent unsafe abortion where reliance on sterilization to limit childbearing is not preceded by the use of reversible modern methods for spacing and where access to safe abortion is restricted by law. The intriguing association between contraceptive method choice and the incidence of unsafe abortion deserves further exploration.

The acceptability of an injectable, once-a-month male contraceptive in China

PURPOSE

An acceptability study of an injectable preparation of the synthetic steroid testosterone undecanoate as a once-a-month male contraceptive method was carried out concurrently with, but independently from, a clinical safety and efficacy trial of this preparation in China, from 1997 to 1999.

METHOD

Three hundred eight men, the entire group of volunteers enrolled in the clinical trial, were interviewed using a structured questionnaire. In addition, 24 sessions of focus group discussions and 54 in-depth interviews were conducted with a broad range of stakeholders, including men enrolled in the trial and their wives, potential users, service providers, principal investigators of the six participating clinical trial centers, provincial and national policy makers, and experts engaged in research and development of male methods of contraception.

RESULTS

Overall, men found the regimen to be acceptable, and most reported no change or an improvement in their well-being as a result of participating in the clinical study. The frequency of the injections, monthly semen analyses and the need to use another contraceptive method during the period of sperm suppression were reported inconveniences of the trial.

CONCLUSION

Further research is needed to assess the long-term safety, continuation rates, satisfaction among users and issues related to service delivery.

Trends in reproductive behavior among young single women in Colombia and Peru: 1985-1999

Using "calendar" data for single women aged 15-24 from successive Demographic and Health Surveys (DHS) conducted in Colombia and Peru during the 1990s, we document trends, year by year, in sexual activity, the use of contraceptives, and subsequent reproductive outcomes. We provide evidence of the important and hitherto largely untapped potential of DHS calendar data to draw complete sexual and reproductive profiles when data from various surveys are integrated. Over the period 1985-1999, young single women in both Colombia and Peru became sexually active at younger ages. The use of contraceptives, especially the use of condoms, increased but did not fully offset the rise in sexual activity, and thus the incidence of premarital conceptions rose among young single women. In both countries, sharp declines occurred in the proportion of premaritally conceived births that were reported as being wanted.

Condom use within marriage: a neglected HIV intervention

OBJECTIVE

To assess the contraceptive effectiveness of condoms versus oral contraceptive pills and estimate the reproductive consequences of a major shift from pill to condom use.

METHODS

Secondary analysis was performed on nationally representative cross-sectional surveys of women in 16 developing countries.

FINDINGS

In the 16 countries, the median per cent of married couples currently using condoms was 2%, compared with 13% for the pill. Condom users reported a higher 12-month failure and higher method-related discontinuation rates than pill users (9% and 44% vs 6% and 30%, respectively). Condom users were more likely to report subsequent abortion following failure (21% vs 14%), and also more likely to switch rapidly to another method (76% vs 58%). The reproductive consequences, in terms of abortion and unwanted births, of a hypothetical reversal of the relative prevalence of condom and pill were estimated to be minor. The main reason for this unexpected result is that the majority of abortions and unwanted births arise from non-use of any contraceptive method.

CONCLUSION

A massive shift from the more effective oral contraceptive pills to the less effective condom would not jeopardize policy goals of reducing abortions and unwanted births. However, such a shift would potentially have an added benefit of preventing human immunodeficiency virus (HIV) infections, especially in countries with generalized HIV epidemics.

Breastfeeding, amenorrhea and contraceptive practice among postpartum women in Zibo, China

This paper reports a hospital-based longitudinal study that was conducted in Zibo, China, in June 1996. The objective was to investigate the existing patterns of breastfeeding, amenorrhea and contraceptive use among postpartum women in urban areas of China. Information was obtained from 492 newly parturient women. Follow-up interviews were done at 42 days. 4 months and 1 year after delivery. The results showed that the full breastfeeding rate (including exclusive and almost exclusive breastfeeding) was 78% and 43% at 42 days and 4 months after delivery, respectively. The mean reported length of abstinence from sexual intercourse after delivery was 71 days. The mean reported time to menses resumption was 184 days. Ninety-three per cent of women had resumed sexual intercourse at 4 months after delivery. Seventy-three per cent of women were using contraceptive methods when they resumed sexual activity after delivery. After childbirth, the majority ofthe women interviewed used condoms within 3 months. Thereafter, most of them switched to intrauterine device (IUD)). Life table analysis shows that the continuation rates of full breastfeeding and amenorrhea at 4 months after delivery were 35% and 68%, respectively. This implies that if the full breastfeeding rate can be prolonged, it is feasible to use the lactational amenorrhea method (LAM) among Chinese postpartum women. The policy implications of this study are that quality care on contraceptive services and information for postpartum women in urban areas need to be improved further.

Postpartum thyroiditis in India: prevalence of postpartum thyroiditis in Kashmir Valley of Indian sub-continent

Various studies have reported a spectrum of thyroid dysfunction in the postpartum period. Postpartum thyroiditis is a syndrome of thyroid dysfunction that occurs in the first year after parturition. Prevalence of postpartum thyroiditis has been reported to vary from 3 to 6 percent in different regions of the world. Kashmir Valley is inhabited by a relatively homogeneous racial group and the Valley has been documented to have significant iodine deficiency. We studied the prevalence and pattern of postpartum thyroiditis in an urban region of this Valley. 120 women were registered within first month of postpartum period for the study along with one hundred controls. Of these 120 women, 104 reported for follow-up at 3 months postpartum and 106 reported for follow-up at 6 months postpartum. Initial and subsequent clinical details at follow-up were recorded on a pre-determined questionnaire. Overall, postpartum thyroiditis (PPT) was seen in 8 (7%) study subjects. Of these 8 patients with PPT, 4 had biochemical evidence of thyrotoxicosis at first month, 3 developed biochemical thyrotoxicosis at 3-month follow-up while as one study subject developed thyrotoxicosis at 6 months. Most of these subjects were antithyroid antibodies (anti-microsomal and anti-thyroglobulin) positive. We conclude that iodine deficient status of the community doesn't seem to influence the incidence of PPT.

Sanctions and childhood mortality in Iraq

BACKGROUND

In 1999 UNICEF, in cooperation with the government of Iraq and the local authorities in the "autonomous" (northern Kurdish) region, conducted two similar surveys to provide regionally representative and reliable estimates of child mortality (the subject of this paper) and maternal mortality.

METHODS

In a cross-sectional household survey in the south/centre of Iraq in February and March, 1999, 23105 ever-married women aged 15-49 years living in sampled households were interviewed by trained interviewers with a structured questionnaire that was developed using the Demographic and Health Surveys questionnaire and following a pre-test. In a similar survey in the autonomous region in April and May 14 035 ever-married women age 15-49 were interviewed.

FINDINGS

In the south/centre, infant and under-5 mortality increased during the 10 years before the survey, which roughly corresponds to the period following the Gulf conflict and the start of the United Nations sanctions. Infant mortality rose from 47 per 1000 live births during 1984-89 to 108 per 1000 in 1994-99, and under-5 mortality rose from 56 to 131 per 1000 live births. In the autonomous region during the same period, infant mortality declined from 64 to 59 per 1000 and under-5 mortality fell from 80 to 72 per 1000. Childhood mortality was higher among children born in rural areas, children born to women with no education, and in boys, and these differentials were broadly similar in the two regions.

INTERPRETATION

Childhood mortality clearly increased after the Gulf conflict and under UN sanctions in the south/centre of Iraq, but in the autonomous region since the start of the Oil-for-Food Programme childhood mortality has begun to decline. Better food and resource allocation to the autonomous region contributed to the continued gains in lower mortality, whereas the situation in the south/centre deteriorated despite the high level of literacy in that region.

Fertility in Pakistan during the 1970s

A survey conducted in 1975, as part of the World Fertility Survey programme, provided evidence that fertility began to decline in Pakistan during the early 1970s. Because of the low level of contraceptive use recorded in that survey, the fertility decline was attributed to delayed marriage. However, a second and similar survey conducted approximately 5 years later showed almost exactly the same pattern of very recent decline, and indeed a reduction in contraceptive use. The two surveys disagreed for the period of overlap. It is concluded that there were essentially no changes in fertility during the decade, and that it remained at pre-1970 levels.

Malaria control and long-term periodicity of the disease in Pakistan

The classic investigations of the malaria epidemics in the Punjab led to the conclusion that in this most populous and most malarious province of the present-day Pakistan, epidemics occurred regularly at intervals of approximately eight years. Against this background, the results of a Malaria Control Programme launched in 1975 are examined. The Programme, supported by USAID and WHO, represents in economic terms the greatest effort made against malaria in the country. Malathion, the main attack weapon of the Programme, was used on an unprecedented scale. This created logistic and--unexpectedly--toxicity problems among the spraying workers. Despite these difficulties, an over-all reduction of 76% in the slide positivity rate was observed in the first two years of operations of the Programme. The authors warn against measures which may curtail the activities of the Programme when, according to the cyclical periodicity of malaria in the Punjab, an epidemic wave can be expected in 1980-81, with inevitable repercussions all over the country.