Selected vaginal bacteria and risk of preterm birth: an ecological perspective.

We examined the community ecology of vaginal microbial samples taken from pregnant women with previous preterm birth experience to investigate whether targeted pathogenic and commensal bacteria are related to risk of preterm birth in the current pregnancy. We found a significant correlation between the community structure of selected bacteria and birth outcome, but the correlation differed among self-reported racial/ethnic groups. Using a community ordination analysis, we observed infrequent co-occurrence of Mycoplasma and bacteria vaginosis associated bacteria 3 (BVAB3) among black and Hispanic participants. In addition, we found that the vaginal bacteria responded differently in different racial/ethnic groups to modifications of maternal behavioral (ie, douching and smoking) and biological traits (ie, body mass index [BMI]). Even after accounting for these maternal behaviors and traits, the selected vaginal bacteria was significantly associated with preterm birth among black and Hispanic participants. By contrast, white participants did not exhibit significant correlation between microbial community and birth outcome. Findings from this study affirm the necessity of considering women's race/ethnicity when evaluating the correlation between vaginal bacteria and preterm birth. The study also illustrates the importance of studying the vaginal microbiota from an ecological perspective, and demonstrates the power of ecological community analysis to improve understanding of infectious disease.

Uropathogenic Escherichia coli are less likely than paired fecal E. coli to have CRISPR loci.

CRISPRs (Clustered Regularly Interspaced Short Palindromic Repeats) are short fragments of DNA that act as an adaptive immune system protecting bacteria against invasion by phages, plasmids or other forms of foreign DNA. Bacteria without a CRISPR locus may more readily adapt to environmental changes by acquiring foreign genetic material. Uropathogenic Escherichia coli (UPEC) live in a number of environments suggesting an ability to rapidly adapt to new environments. If UPEC are more adaptive than commensal E. coli we would expect that UPEC would have fewer CRISPR loci, and--if loci are present--that they would harbor fewer spacers than CRISPR loci in fecal E. coli. We tested this in vivo by comparing the number of CRISPR loci and spacers, and sensitivity to antibiotics (resistance is often obtained via plasmids) among 81 pairs of UPEC and fecal E. coli isolated from women with urinary tract infection. Each pair included one uropathogen and one commensal (fecal) sample from the same female patient. Fecal isolates had more repeats (p=0.009) and more unique spacers (p<0.0001) at four CRISPR loci than uropathogens. By contrast, uropathogens were more likely than fecal E. coli to be resistant to ampicillin, cefazolin and trimethoprim/sulfamethoxazole. However, no consistent association between CRISPRs and antibiotic resistance was identified. To our knowledge, this is the first study to compare fecal E. coli and pathogenic E. coli from the same individuals, and to test the association of CRISPR loci with antibiotic resistance. Our results suggest that the absence of CRISPR loci may make UPEC more susceptible to infection by phages or plasmids and allow them to adapt more quickly to various environments.

Family planning in Pakistan: applying what we have learned.

Despite six decades of government and private sector programs, CPR in Pakistan is among the lowest in the region. This article reviews published and grey literature to understand why despite sufficient time and usually sufficient funding, CPR remains low in Pakistan. This paper looks beyond the usual factors of quality of services, coverage and supplies and management issues to examine how family planning may be improved in Pakistan. Based on analysis of the Pakistan Demographic Health Survey 2006-7, the public sector provides around a third of FP services, while NGOs and private providers another 15%. More than half of all family planning users buy their methods directly from stores. Within the government, the services cost 5-8 fold more than the private sector. Nearly a fifth of pregnancies end in an abortion suggesting the role of abortions as a key FP method. This together with a high unmet need pose the question: why is there such low uptake of FP services in the country. To explain this lack of uptake, we explore the limitations of the public sector in providing services, the lack of effect of religious beliefs, of abundant, yet misdirected funding and gaps in demand creation. The increasing role of NGOs and donors in filling the void left by the public sector is discussed. Suggestions are provided about improving public and private sector services including better information gathering and use in defining needs, measuring results and creating demand for FP.

From contraceptive prevalence to family planning service users: implications for policy and programmes.

INTRODUCTION: Contraceptive prevalence rate (CPR) is a widely accepted measure of maternal health and uptake of family planning (FP) services. However, the overall CPR obscures the actual utilization of FP services due to over-representation of long-term methods. This study used CPR from 2007 to arrive at and compare the number of actual number of women who availed different FP services in order to understand issues and gaps in FP services in Pakistan. METHODS: This study used secondary data from the Pakistan Demographic and Health Survey 2006-7 estimate the CPR and modern method mix for 2007.These were then multiplied by the estimated number of married women of reproductive age (MWRA) to arrive at the actual numbers of women using specific FP methods and utilizing FP services in a given year. RESULTS: In 2007 the CPR was 30% overall and 22% for modern methods. However, the number of women availing FP services decreased to 12% when adjusted for FP users who had availed services in the past 12 months. Within this "service mix", self-procurement of FP commodities directly from stores without a advice from a health provider constitutes around 37% of all FP "services" and the public sector accounts for another 33%. Condoms are the commonest method served, accounting for over half of all "services". CONCLUSIONS: The bulk of FP is self-procured and the service mixed is skewed towards client controlled methods that do not require medical advice. Thus, lack of quality for contraceptive services that require some form of supportive healthcare services and counselling may be a bottleneck to improving CPR.

The context and limitations of female sterilization services in Pakistan.

INTRODUCTION: Female sterilization has long been the most popular method of family planning (FP) in Pakistan, and yet most public health experts feel it contributes little to controlling family size or to population welfare. We used Pakistan Demographic Health Survey (PDHS) data to understand the role female sterilization plays in the overall context of FP in Pakistan. METHODS: We performed a secondary analysis of data from the PDHS 1990-1 and 2006-7 to study factors that lead to sterilization and trends in the use of the procedure. In addition, census data were multiplied by proportions from PDHS data to estimate the number of women availing sterilization services. RESULTS: Around 1.9 million women in Pakistan are currently sterilized--up from 0.55 million in 1990-1, and around 173,867 undergo the procedure, annually. Women usually receive sterilization after 30 years of age (mean = 39) and after six children. The probability of sterilization increases with age, family size, and urban residence, and is unaffected by poverty, province of residence, or the woman or her husband's education. Most sterilizationis conducted in public sector facilities. CONCLUSIONS: Sterilization in Pakistan may be common, but occurs too late to have any significant effect on family size or benefit public health. Future avenues to make this option more useful to women and society would be to improve the repertoire and access and quality of FP services that are available, and to address governance issues that limit the performance and utility of government facilities.

Costs and utilization of public sector family planning services in Pakistan.

INTRODUCTION: The public sector provides a third of family planning (FP) services in Pakistan. However, these services are viewed as being underutilized and expensive. We explored the utilization patterns and costs of FP services in the public sector. METHODS: We used overall budgets and time allocation by health and population departments to estimate the total costs of FP by these departments, costs per woman served, and costs per couple-year of protection (CYP). RESULTS: The public sector is the predominant provider of FP to the poorest and is the main provider of female sterilization services. The overall costs of FP in the public sector are USD 55 per woman served, annually (USD 17 per CYP). Within the public sector, the population welfare departments provide services at USD 72 per woman served, annually (USD 17 per CYP) and the health departments at USD 39 per woman per year (USD 29 per CYP). CONCLUSION: While the public sector has a critical niche in serving the poor and providing female sterilization, its services are considerably more expensive compared to international and even some Pakistani non-government organization (NGO) costs. This reflects inefficiencies in services provided, client mistrust in the quality of services provided, and inadequate referrals, and will require specific actions for improving referrals and the quality of services.