Sexually Transmitted Infection (STI) screening, case and contact treatment, and condom promotion resulting in STI reduction two years later in rural Malawi.

As part of a longitudinal cohort study in rural Malawi in 2000, 469 men and 758 women were asked to respond to a series of surveys, were tested for gonorrhea and chlamydia, and received their results and treatment, if applicable, for themselves and up to 2 partners if positive for either sexually transmitted infection (STI). Two years later, in 2002, 328 men and 525 women were again asked to respond to survey questions, tested again for gonorrhea and chlamydia, and were also tested for HIV--of these, 247 men and 453 women had also given urine samples in 2000. In 2000, the gonorrhea and chlamydia prevalence was 6.2% and 5.8% among men, and 3.6% and 4.9% among women. Two years later, prevalence of gonorrhea and chlamydia was 0.7% and 1.4% among men, and 1.3% and 1.1% among women. Although we did not test for HIV in the first round, the HIV prevalence in 2002 was 19.2%. The implications of the findings are discussed in the context of interventions for STI prevention and to reduce HIV transmission in sub-Saharan Africa.

Experiences with fistula repair surgery among women and families in Malawi.

Fistula treatment through surgery is reported to be successful in 80-90% of cases. Success in fistula repair has been defined by medical professionals in terms of clinical outcomes; beyond these definitions, it is important to understand how women perceive a positive clinical outcome and how it affects her family and home environment. This research was conducted in the Mangochi District of Malawi to answer these questions through interviews with women living with fistula and after surgical repair, as well as their partners and families. Over 104 interviews were conducted in June and October 2007. While eventually experiencing clinically successful surgical outcomes, women reported difficulty in seeking and receiving healthcare. Bureaucratic challenges were complicated by community misperceptions about the condition and fear of the healthcare system. Perspectives of women's families suggest that burdens and social disabilities caused by fistula extended beyond the individual to affect these family members. When women experienced surgical treatment, positive outcomes spread to her family and community. Positive experiences with the healthcare system turned women into advocates for healthcare in their communities. These findings illustrate that issues of obstetric fistula are not limited to individual women, but can dramatically affect their families, partners and communities.

Low use of contraception among poor women in Africa: an equity issue

Objective To examine the use of contraception in 13 countries in sub-Saharan Africa; to assess changes in met need for contraception associated with wealth-related inequity; and to describe the relationship between the use of long-term versus short-term contraceptive methods and a woman's fertility intentions and household wealth. Methods The analysis was conducted with Demographic and Health Survey data from 13 sub-Saharan African countries. Wealth-related inequities in the use of contraception were calculated using household wealth and concentration indices. Logistic regression models were fitted for the likelihood of using a long-term contraceptive method; with adjustments for: wealth index quintile; fertility intentions (to space births versus to stop childbearing); residence (urban/rural); education; number of living children; marital status and survey year. Findings The use of contraception has increased substantially between surveys in Ethiopia; Madagascar; Mozambique; Namibia and Zambia but has declined slightly in Kenya; Senegal and Uganda. Wealth-related inequalities in the met need for contraception have decreased in most countries and especially so in Mozambique; but they have increased in Kenya; Uganda and Zambia with regard to spacing births; and in Malawi; Senegal; Uganda; the United Republic of Tanzania and Zambia with regard to limiting childbearing. After adjustment for fertility intention; women in the richest wealth quintile were more likely than those in the poorest quintile to practice long-term contraception. Conclusion Family planning programmes in sub-Saharan Africa show varying success in reaching all social segments; but inequities persist in all countries

The role of delayed childbearing in the prevention of obstetric fistulas.

OBJECTIVE: To examine the role of delayed childbearing in the prevention of obstetric fistulas (OFs). METHODS: Data on 4798 deliveries in Niger (1995-1998), 3552 in Nigeria (1996-1999), and 6789 in Tanzania (1991-1996) were analyzed with logistic regression models. RESULTS: Young maternal age and primiparous status were identified as correlates of prolonged/obstructed labor. The annual incidence of OFs in Nigeria was found to be 2.11 per 1000 births, with 9817 cases developing each year, 28% in women and girls younger than 20 years. The predicted proportion of women experiencing prolonged/obstructed labor would be reduced by 11.2% in Niger, 11.4% in Nigeria, and 13.1% in Tanzania if the risks associated with young maternal age at first delivery and primiparity were eliminated. CONCLUSIONS: Community programs to educate young, newly married women about delaying childbearing until they reach physical maturity should be implemented in countries with a high incidence of OFs.

Prevalence of self-reported symptoms of reproductive tract infections among recently pregnant women in Uttar Pradesh, India.

This study examines the prevalence of self-reported reproductive tract infections (RTIs) and treatment seeking among married, recently pregnant women in Uttar Pradesh state, India. Associations between RTI symptom reporting and background characteristics are examined in a population-based sample of 18,506 married women with a pregnancy in the 3 years prior to a 1995 statewide survey. Logistic regression analyses are used to assess the effects of sociodemographic covariates on the probability of reporting an RTI symptom. Nearly one out of four women reports experiencing at least one RTI symptom, with the most common symptoms being abnormal vaginal discharge and pain during urination. Reporting of RTI symptoms significantly increases if the woman's last pregnancy did not end in a live birth or if she has low economic status. Symptom reports also increase with age and decrease with parity. Only one-third of women reporting an RTI symptom sought treatment. The results indicate that survey interviews can be a cost-effective option for measuring the magnitude of RTI symptoms experienced and identifying sociodemographic influences. The findings suggest the need for improved RTI screening procedures and treatment at health facilities in this populous state of northern India.

Unintended pregnancy and low birthweight in Ecuador.

OBJECTIVES: This study assessed the relationship between unintended pregnancy and infant birthweight in Ecuador, differentiating between unwanted and mistimed pregnancies. METHODS: Analyses focused on a subsample of women (n = 2490) interviewed in the 1994 Ecuador Demographic and Maternal-Child Health Survey. Logistic regression was used to assess the relationship between pregnancy intention status and low birthweight after control for other factors. RESULTS: Infants from unwanted pregnancies were more likely than infants from planned pregnancies to have low birthweight (odds ratio = 1.64, 95% confidence interval = 1.22, 2.20). Mistimed pregnancy was not associated with low birthweight. CONCLUSIONS: Unwanted pregnancy, but not mistimed pregnancy, is associated with low birthweight in Ecuador. Further research is needed to understand the mechanism through which pregnancy intention status affects birthweight.

The relationship between prenatal care and subsequent modern contraceptive use in Bolivia, Egypt and Thailand.

Determinants of modern contraceptive use are usually examined in isolation of the effect of exposure to other aspects of health care systems. Maternal interaction with organised health service provision during post-conception and postpartum stages of reproduction can provide an opportunity to transfer contraceptive service information and counselling. We found that living in a community in which women have widespread health service contact is related to both prenatal care use and subsequent modern contraceptive use. After controlling for effects of living in high health service contact areas and various demographic and background factors, our results suggest that prior use of prenatal care has a strong influence on subsequent use of modern contraception in Bolivia, Egypt and Thailand.

Assessing survey measures of infant birth weight and birth size in Ecuador.

The purpose of this study was to assess the utility of using maternal assessments of infant birth size as proxy measures for birth weight in Ecuador, a country in which a sizeable proportion of births take place at home, where birth weight is typically not recorded. Four thousand and seventy-eight women who experienced a live singleton birth between January 1992 and August 1994 were interviewed in the Ecuador Demographic and Maternal-Child Health Survey. All women were asked if their child was weighed at birth, his/her weight, and what they considered to be his/her birth size relative to other newborns. The consistency between birth size and birth weight measures was assessed, and the differences between infants with and without reported birth weights were explored. The authors conclude that maternal assessments of birth size are poor proxy indicators of birth weight. Estimates of low birth weight based on maternal assessments of birth size as very small should be recognized as underestimates of the actual prevalence of low birth weight. Moreover, infants for whom birth weights are missing should not be considered similar to those for whom weight was reported. Those without reported birth weights are more likely to be low birth weight. Thus, relying solely on reports of numeric birth weight will underestimate the prevalence of low birth weight.

What husbands in northern India know about reproductive health: correlates of knowledge about pregnancy and maternal and sexual health.

Women in India suffer from a high incidence of reproductive disease, disability and death. Very little work has been done on men, but a much higher incidence of sexual experience outside marriage and sexually transmitted diseases (STDs) among males than previously expected for this population is now being documented. In north India, women are dependent on their husbands and other family members for health-related decisions. Therefore, the behaviour, knowledge and attitudes of men are integral to the reproductive health status of couples there. This study explores knowledge about three distinct areas of reproductive health among 6549 married men in five districts of the northern state of Uttar Pradesh, India. Factors contributing to men's knowledge in the areas of fertility, maternal health and STDs were investigated. Results showed that very few men had basic knowledge in any of these areas. The likelihood of reporting knowledge was associated with a set of determinants that differed in their magnitude and effect across the areas of reproductive health explored. In particular, men's belief about the ability of an individual to prevent pregnancy demonstrated an independent association with men's knowledge. After controlling for factors such as age, parity and educational and economic status, men who believed it not possible to prevent a pregnancy were less likely to know when during the menstrual cycle women would become pregnant and certain facts about STDs, but they were more likely to be able to name two or more symptoms of serious maternal health conditions. Possible explanations for this trend are discussed.

Sexual behaviors and reproductive health outcomes: associations with wife abuse in India.

CONTEXT: Wife abuse has been associated with a variety of health concerns. Associations between abuse and reproductive health in India are not well known. OBJECTIVE: To examine relationships between men's reports of wife abuse and reproductive health issues in northern India. DESIGN: Structured face-to-face interviews were conducted as part of the male reproductive health supplement of the PERFORM System of Indicators Survey, a systematic multistage survey conducted in 1995-1996. SETTING: The northern state of Uttar Pradesh, one of the least developed states in India. PARTICIPANTS: A total of 6632 married men aged 15 to 65 years who lived with their wives and completed all survey questions for the study variables reported here. MAIN MEASURES: Physically and sexually abusive behaviors toward wives, sexual activities outside marriage, sexually transmitted disease (STD) symptoms, contraception use, unplanned pregnancies, and sociodemographic characteristics. RESULTS: Fifty-four percent of men reported not abusing their wives, while 17% reported physically but not sexually abusing their wives, 22% reported sexual abuse without physical force, and 7% reported sexual abuse with physical force. Abuse was more common among men who had extramarital sex (for sexual abuse using force: odds ratio [OR], 6.22; 95% confidence interval [CI], 3.98-9.72). Similarly, men who had STD symptoms were more likely to abuse their wives (with current symptoms: OR, 2.43; 95% CI, 1.73-3.42). Unplanned pregnancies were significantly more common among wives of abusive men, especially sexually abusive men who used force (OR, 2.62; 95% CI, 1.91-3.60). CONCLUSIONS: Wife abuse appears to be fairly common in northern India. Our findings that abusive men were more likely to engage in extramarital sex and have STD symptoms suggest that these men may be acquiring STDs from their extramarital relationships, thereby placing their wives at risk for STD acquisition, sometimes via sexual abuse. These abusive sexual behaviors also may result in an elevated rate of unplanned pregnancies.

Domestic violence in northern India.

This study examined the prevalence and characteristics of wife abuse as reported by nearly 6,700 married men living in five districts of northern India during 1995-1996. In addition, associations between wife abuse and sociodemographic factors were investigated to enable two theoretical/conceptual perspectives regarding abuse to be evaluated: that abuse is more common among families under stress and among more "private" families. The district-specific percentages of men who reported physically abusing their wives ranged from 18% to 45%, with 18-40% of the men in each district having had nonconsensual sex with their wives and 4-9% having physically forced their wives to have sex. The authors used logistic regression analyses to control for a variety of sociodemographic variables and found positive associations between wife abuse and stress-related factors, including the husband having a low educational level, the couple living in poverty, the husband being young when he first lived with his wife, and the couple having multiple children. Contrariwise, there was no strong empirical support for the idea that wife abuse may be more common in more "private" families.

Husbands' reproductive health knowledge, attitudes, and behavior in Uttar Pradesh, India.

To enhance the reproductive health status of couples in developing countries, the knowledge, attitudes, and behavior of both women and men must be investigated, especially where women depend on men for the decision to seek care. This study analyzes data from a survey of 6,727 husbands from five districts in the northern state of Uttar Pradesh, India. Data are presented on men's knowledge of women's health and on their own sexual behavior outside the context of marriage, on their perceptions of sexual morbidity and their attempts at treatment for specific conditions, and on their opinions concerning the social role of wives. Findings indicate that men know little about maternal morbidity or sexual morbidity conditions. Few husbands reported that they had had sexual experience outside of marriage and the majority of these few said they had had such a relationship with more than one partner. Of men who said they had had reproductive morbidity symptoms, many said they had not sought treatment. Men's views concerning the role of wives indicate a low level of women's autonomy in this region of India. Results indicate a pressing need for reproductive health education that targets both women and men in Uttar Pradesh.

Ethnic differentials in child-spacing ideals and practices in Ghana.

Postpartum sexual abstinence may be a major determinant of fertility and of maternal and child health in sub-Saharan Africa. This study examines the relationship between ethnicity and abstinence using data from the 1988 Ghana Demographic and Health Survey. There is considerable diversity in the length of abstinence although only for one ethnic group, the Mole-Dagbani and other Ghanaians, is abstinence, both actual and ideal, very long. Respondents in most ethnic groups believe their abstinence to be adequate. A key motivation for abstinence is the unwillingness to have sexual intercourse with nursing mothers. Education, urbanisation, changes in marriage patterns and religious traditions are major factors shaping the ethnic differentials in abstinence. In comparison to breast-feeding, abstinence appears to have relatively little impact on the length of the birth interval and for Ghana, has relatively few implications for fertility and child health.

PIP: Ethnic differences in the extent of postpartum sexual abstinence occur among the Mole-Dagbani, the Twi, the Fante, and the Akan as matrilineal and the Ga-Adangbe as patrilineal groups from Ghana. The recommendation is made that family planning (FP) programs would more effectively address postpartum FP among the Mole-Dagbani and other Ghanaians group by introducing modern contraception as a means of substituting or supplementing long abstinence periods. Policy interventions should also be directed more to breast feeding changes, which have a greater impact on fertility than abstinence changes. The ethnic differences in sexual abstinence practices appear to be more related to differences in exposure to modernization and changes in marriage patterns and religious traditions. The sexual taboos are a direct determinant of ethnic variation. For example, the Akan have the shortest delay in resuming sexual intercourse. Very few hold to the belief that intercourse should be delayed until after weaning. The Mole-Dagbani prefer to avoid intercourse with nursing mothers and practice long periods of sexual abstinence. Data were obtained from the 1988 Ghana Demographic and Health Survey of 4488 women aged 15-49 years. Life table methods were used in the determination of the number of months of sexual abstention postpartum and the duration of breast feeding. These methods avoid the bias of underestimation and heaping. Results are provided in a table comparing duration of sexual abstinence behavior and reported ideal sexual abstinence practices. The Mole-Dagbani and other Ghanaians group practice sexual abstinence for 24 months, while the remaining ethnic groups vary between seven and 11 months. The Twi, Fante, and other Akan have lengths of around seven months, while the Ewe, Guan, and other Africans have lengths of about 10-11 months. The median ideal of the sample is seven months and the median behavior is 8.8 months. The two Akan ethnic groups and the Ga-Adangbe have a median ideal of six months and the other groups range from 7-10 months. The Mole-Dagbani have the same ideal and practice of 24 months. All the ethnic groups practice lengthy breast feeding.

Pregnancy avoidance and coital behavior.

This study proposes a behavioral model that identifies determinants of coital activity in the context of pregnancy avoidance and assesses the relationships using weekly panel data collected on 300 rural married women in Sri Lanka in 1988. We discuss the utility of the design, which is similar to that of an epidemiological surveillance system, for the measurement of coital behavior and pregnancy risk perceptions. Perceptions of pregnancy risk, spousal agreement on sexual relations, menstrual and lactational status, and cycle timing, all measured daily, are found to influence significantly the probability of coitus on that day. The findings suggest that substantial gains in studying fertility regulation are likely from closer investigation of the behavioral connections between motivation for pregnancy avoidance and coital incidence. Comparison of such panel data with those of cross-sectional sample surveys also provides insights into the validity of measures of coital and contraceptive behavior.

The settlement of Somali nomads.

PIP: During the April 1973-June 1975 drought in Somalia, the government settled 100,000 nomads over 5 years in 3 agricultural (Dujuma, Sablaale, and Kurtunwary) and 3 fishing settlements (Brava, Adale, and Eil). They had earlier sought relief from the drought at some 20 relief camps. In 1982, the Ministry of National Planning and the Settlement Development Agency conducted a household survey in 4 of the 6 settlements (2059 households). Considerable problems occurred during the survey thus the data must be interpreted with caution. Nevertheless this survey provided 1 of the few sources on nomadic settlement conditions. 47.5% of the population in the settlement areas were children 15 years old. Fewer middle aged men than women lived in the settlement areas (9% vs. 22%). Males tended to be more literate and/or in school than females (74% vs. 50% and 64% vs. 43% respectively). Despite the disparity, the researchers found these proportions considerable and encouraging. Women headed many households (47.25%), especially in Adale (61%). Presumedly many of the husbands returned to their pastoral ways. Other adult relatives and older children often lived in women headed households and provided support for farming, fishing, and other economic activities. Most respondents were satisfied with settled life and felt it would be permanent. Further 70-90% of respondents wanted their sons and daughters to be civil servants while 0-8% wanted them to be herders. 78-87% of respondents lost all livestock during the drought while only 2-10% acquired livestock after the drought. Since livestock provided considerable wealth in relation to incomes from agriculture and fishing and since nomads tended to be inexperienced in these new occupants, they underwent an extreme adjustment to settled life. In conclusion, the resettlement program had mixed successes.^ieng

Young women's work and family formation in Sri Lanka.

"Patterns of family formation in Sri Lanka resemble those of wealthier nations, with late marriage, delayed childbearing, and moderately low fertility. This article addresses two questions: How have these family formation patterns emerged in the absence of the normally expected levels of economic development? And what activities have occupied young women in the premarital, prechildbearing period? Answers are suggested by data from three sources: the 1981 census; a set of focus-group discussions on the rights, obligations, and aspirations of young women related to marriage, work, childbearing, and child care; and a sample survey of 1,535 women of ages 15-30 in Kalutara District. The article describes the interplay of socioeconomic and familial forces that have affected the status of young Sri Lankan women."

Determinants of contraceptive switching behavior in rural Sri Lanka.

This study examines the influence of a selected set of determinants of contraceptive method switching in rural Sri Lanka. Of interest is the question of how change in contraceptive practice at the individual level can account for patterns observed at the aggregate level. Based on calendar data on contraceptive use over a 3-year period, collected for more than 3,000 married women in a 1986 survey, the multivariate analysis shows that women who attain all or a significant proportion of their desired fertility tend to switch to more effective methods. Women who experience method failure tend to switch methods, usually to a type that is more effective. The woman's background determinants of age and education have small but significant effects on method switching, whereas the effect of household economic well-being is not significant. There is strong indication that rural couples are practicing contraception in a nonrandom fashion, switching methods in accordance with changes in their fertility motivations and contraceptive experience.

The international family planning movement.

PIP: Over the past 3 decades, the number of women using family planning has increased 6-fold to over 400 million married women of childbearing age. The evolution of behavior and attitudes toward using birth control among third world couples reflects the goals and hard work of an international network of individuals, governments and organizations. This article follows the progression of this movement, from early opposition in developed as well as developing countries, to the present day, when birth control is practiced by a slight majority of the world's women of childbearing age. Among world regions, contraceptive use ranges from about 17% in Africa to 75% in Asia. In some African countries, however, family planning is still a foreign concept, and fewer than 5% of women use any birth control. International organizations played a crucial role in spread of family planning by providing training for developing country professionals, funding actual family planning programs and helping to evaluate programs. But the success of a country's family planning program also was dependent upon a national commitment, and often on a strong socioeconomic setting. The private sector has had a limited role except in some countries, notably in Latin America, but its involvement is likely to expand in the future. Also, as financial support from the US and international organizations wanes, national governments will cover a larger share of the cost. The worldwide increase in the practice of family planning has led to fertility declines in many third world countries, slowing rapid population growth rates. For individuals, family planning has been a liberating influence, allowing them to participate more fully in the shift from traditional to modern society.^ieng

A study of infant mortality and causes of death in a rural north-east Brazilian community.

In 1984 a prospective study of 1645 women and 1677 births in a rural community in north-eastern Brazil showed the infant mortality rate to be 65 per 1000 live births. Neonatal, post-neonatal and infant mortality are analysed to determine the most important risk factors for each period. Post-neonatal survival depends largely on factors relating to child care, while neonatal deaths are more likely to be associated with biological factors. The principal cause of death, diarrhoeal disease, was responsible for a third of the deaths.

PIP: In 1984 a prospective study of 1645 women and 1677 births in a rural community in north-eastern Brazil showed the infant mortality rate to be 65/1000 live births. Neonatal, post-neonatal and infant mortality are analyzed to determine the most important risk factors for each period. Data were obtained from all women in Trairi who gave birth between May 1984 and April 1985, and all mothers were followed-up on 4 occasions by hospital personnel or a TBA when the child reached 6 weeks and 6, 12, and 18 months of age. When an infant death occurred, community leaders and TBAs notified hospital personnel and a physician visited the mother, completing a questionnaire on the cause of death. Neonatal deaths were related to problems associated with pregnancy and low birthweight, factors associated with post-neonatal mortality are related to infants of younger women and of mothers of high parity. Low birthweight babies had an increased risk of post-neonatal death when mothers only had 1-3 prenatal visits; they were 14 times more likely to die during the post- neonatal period than those whose mothers had 4-5 visits and weighed 2500-4999 g. Infant mortality could be prevented by child survival interventions such as breastfeeding, oral rehydration therapy, and early diagnosis. Post-neonatal survival seems to depends on factors relating to child care, while neonatal deaths are more likely to be associated with biological factors. Diarrhea was responsible for 1/3 of all deaths.

Family planning needs and costs: Nepal, 1985-2000.

PIP: Achievement of the Government of Nepal's goal of a total fertility rate of 2.5 by the year 2000 requires careful consideration of the levels of contraceptive prevalence required to meet this target, the optimal contraceptive method mix, and program costs. The scenario envisioned by government planners is for the fertility rate to fall from 5.8 in 1985 to 4.0 by 1990 and finally to 2.5 by the end of the century. The 2.5 target is 54% lower than what the United Nations regards as a plausible course of fertility decline and will require a 4-fold increase in contraceptive prevalence, form 15% in 1985 to 62% in 2000, given no change in method mix and high discontinuation rates, and a rise in the number of contraceptive users form a half-million to 2.8-2.9 million over a 15-year period. If no change of method mix occurs, the 2.5 fertility rate target requires that sterilization use increase from 13% to 53%. An alternative contraceptive mix for the year 2000 is pill use, 13%; IUD use, 19%; and sterilization, 13%. In terms of cost, achievement of the government's target will require a 5-fold increase in annual spending for contraception, from US$2.74 million in 1985 to US$16.39 million in 2000, and a 24-fold increase, to US$67.76 million, in total family planning expenditures. These projections suggest that the government may need to reassess its target; the United Nations has suggested that a fertility rate of 4.6 by the year 2000 is more realistic. Such a goal would require a contraceptive prevalence rate of 34%, 1.6 million users, and annual family planning costs of US$38.54 million. Regardless of the scenario selected, there is a need for the government to examine carefully the cost-benefit ratios for contraceptives such as improved IUD's and subdermal implants.^ieng