Randomized controlled trial of EndoRings assisted colonoscopy versus standard colonoscopy.

OBJECTIVES: The EndoRings device is a distal attachment consisting of two layers of circular flexible rings that evert mucosal folds. The aim of this study was to investigate whether EndoRing assisted colonoscopy (ER) improves polyp and adenoma detection compared to standard colonoscopy (SC). METHODS: Multicenter, parallel group, randomized controlled trial. RESULTS: Total of 556 patients randomized to ER (n = 275) or SC (n = 281). Colonoscopy completed in 532/556 (96%) cases. EndoRings removed in 74/275 (27%) patients. Total number of polyps in ER limb 582 vs. 515 in SC limb, P = 0.04. Total number of adenomas in ER limb 361 vs. 343 for SC limb, P = 0.49. A statistically significant difference in the mean number of polyps per patient in both the intention to treat (1.84 SC vs. 2.10 ER, P = 0.027) and per protocol (PP) (1.84 SC vs. 2.25 ER, P = 0.004). CONCLUSIONS: Our study shows promise for the EndoRings device to improve polyp detection.

A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial.

BACKGROUND: Endoscopic submucosal dissection (ESD) is associated with a risk of bleeding. Bleeding is usually treated with diathermy, although this does carry a risk of mucosal thermal injury. Purastat is a topical hemostat that may be effective in controlling bleeding during ESD, thereby reducing the use of heat therapy. The aim of this study was to assess the reduction in heat therapy used in the interventional group (Purastat) compared with the control group. The secondary aims were to compare the procedure length, time for hemostasis, delayed bleeding rate, adverse events, and wound healing between the groups. METHODS: This was a single-center randomized controlled trial of 101 patients undergoing ESD. Participants were randomized to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used. Follow-up endoscopy was performed at 4 weeks to assess wound healing. RESULTS: There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P < 0.001). There were no significant differences in the procedure length, time for hemostasis, and delayed bleeding rate between the groups. Complete wound healing at 4 weeks was noted in 48.8 % of patients in the interventional group compared with 25.0 % of controls (P = 0.02). CONCLUSIONS: This study has demonstrated that Purastat is an effective hemostat that can reduce the need for heat therapy for bleeding during ESD. It may also have a role in improving post-resection wound healing.

Investigating the risk factors for contraction and diagnosis of human tuberculosis in Indonesia using data from the fifth wave of RAND's Indonesian Family Life Survey (IFLS-5).

Tuberculosis (TB) is a globally widespread disease, with approximately a quarter of the world's population currently infected (WHO, 2018). Some risk factors, such as HIV status, nutrition and body mass index, have already been thoroughly investigated. However, little attention has been given to behavioural and/or psychological risk factors such as stress and education level. This study investigated the risk factors for TB diagnosis by statistical analyses of publicly available data from the most recent wave of the Indonesian Family Life survey (IFLS-5) conducted in 2015. Out of 34,249 respondents there were 328 who reported having TB. For comparison and completeness, variables were divided into levels: individual-, household- and community-level variables. The most prominent and interesting variables found to influence TB diagnosis status (on each level) were investigated, and a logistic regression was subsequently developed to understand the extent to which each risk factor acts as a predictor for being diagnosed with TB. Age, health benefit or insurance, stress at work and living in a rural area all showed significant association with TB diagnosis status. This study's findings suggest that suitable control measures, such as schemes for improving mental health/stress reduction and improved access to health care in rural areas should be implemented in Indonesia to address each of the key factors identified.

DIFFERENTIAL RESPONSES IN FIRST BIRTH BEHAVIOUR TO ECONOMIC RECESSION IN THE UNITED KINGDOM.

Economic conditions have dramatic influences on fertility. This paper evaluates the effect of the 2008 'Great Recession' in the UK on first birth rate, which is the fertility behaviour most susceptible to external economic conditions. The key aim of the study was to assess the effect of the recession on fertility by individual-level characteristics, enabling variation in responses to economic hardship to be observed. Data were from the nationally representative UK Household Longitudinal Study (UK-HLS). Cumulative transition models were used to model the probability of first birth for women between the ages of 17 and 30 in three UK birth cohorts. The effect of the recession was captured using direct measures (local unemployment rates and individual unemployment status) and a pre-/post-comparison, capturing indirect effects. In general, higher birth rates were observed among more disadvantaged women compared with advantaged groups. The effect of the recession was disaggregated by social strata; the overall effect was counter-cyclical although at a slower rate among disadvantaged women.

MISSION ABC: transforming respiratory care through one-stop multidisciplinary clinics - an observational study.

OBJECTIVES: The Modern Innovative Solutions to Improve Outcomes in Asthma, Breathlessness and Chronic Obstructive Pulmonary Disease (COPD) (MABC) service aimed to enhance disease management for chronic respiratory conditions through specialist multidisciplinary clinics, predominantly in the community. This study assesses the outcomes of these clinics. DESIGN: This study used a prospective, longitudinal, participatory action research approach. SETTING: The study was conducted in primary care practices across Hampshire, UK. PARTICIPANTS: Adults aged 16 years and above with poorly controlled asthma or COPD, as well as those with undifferentiated breathlessness not under specialist care, were included. INTERVENTIONS: Participants received care through the multidisciplinary, specialist-led MABC clinics. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes included disease activity, quality of life and healthcare utilisation. Secondary outcomes encompassed clinic attendance, diagnostic changes, patient activation, participant and healthcare professional experiences and cost-effectiveness. RESULTS: A total of 441 participants from 11 general practitioner practices were recruited. Ninety-six per cent of participants would recommend MABC clinics. MABC assessments led to diagnosis changes for 64 (17%) participants with asthma and COPD and treatment adjustments for 252 participants (57%). Exacerbations decreased significantly from 236 to 30 after attending the clinics (p<0.005), with a mean reduction of 0.53 exacerbation events per participant. Reductions were also seen in unscheduled and out-of-hours primary care attendance, emergency department visits and hospital admissions (all p<0.005). Cost savings from reduced exacerbations and healthcare utilisation offset increased medication costs and clinic expenses. CONCLUSIONS: Specialist-supported multidisciplinary teams in MABC clinics improved diagnosis accuracy and adherence to guidelines. High patient satisfaction, disease control improvements and reduced exacerbations resulted in decreased unscheduled healthcare use and cost savings. TRIAL REGISTRATION NUMBER: NCT03096509.

Accuracy of Continuous Glucose Monitoring in an Insulin-Treated Population Requiring Haemodialysis.

BACKGROUND: Continuous glucose monitoring (CGM) is revolutionizing diabetes care by giving both patients and the healthcare professionals unprecedented insights into glucose variability and patterns. It is established in National Institute for Health and Care Excellence (NICE) guidance as a standard of care for type 1 diabetes and diabetes in pregnancy under certain conditions. Diabetes mellitus (DM) is recognized as an important risk factor for chronic kidney disease (CKD). Around a third of patients receiving in-center haemodialysis as renal replacement therapy (RRT) have diabetes, either as a direct cause of renal failure or as an additional co-morbidity. Evidence of poor compliance with the current standard of care (self-monitoring of blood glucose [SMBG]) and overall greater morbidity and mortality, suggests this patient population as an ideal target group for CGM. However, there exists no strong published evidence showing the validity of CGM devices in insulin-treated diabetes patients requiring haemodialysis. METHODS: We applied a Freestyle Libre Pro sensor to 69 insulin-treated diabetes haemodialysis (HD) patients on a dialysis day. Interstitial glucose levels were obtained, and time matched within 7 minutes to capillary blood glucose testing and any plasma blood glucose levels sent. Data cleansing techniques were applied to account for rapidly correcting hypoglycaemia and poor SMBG technique. RESULTS: Clarke-error grid analysis showed 97.9% of glucose values in an acceptable range of agreement (97.3% on dialysis days and 99.1% on non-dialysis days). CONCLUSIONS: We conclude that the Freestyle Libre sensor is accurate in measuring glucose levels when compared to glucose as measured by capillary SMBG testing and laboratory obtained serum glucose in patients on HD.

Does maternal health voucher scheme have association with distance inequality in maternal and newborn care utilization? Evidence from rural Bangladesh.

BACKGROUND: Bangladesh has made substantial progress in maternal health. However, persistent inequities in service use undermine the achievements at the national level. In 2007, the government introduced a Maternal Health Voucher Scheme (MHVS) to reduce barriers to service utilization. The current study explores the impact of MHVS on reducing distance inequality in utilization across the maternal and newborn continuum of care (MNCoC). METHODS: A cross-sectional survey was conducted from October'2017 to April'2018 in four selected MHVS sub-districts of Chattogram and Sylhet Divisions of Bangladesh. 2,400 women with at-least one child aged below two years were randomly selected. Both bivariate and multivariate analyses were carried out to explore the absolute and relative influence of the voucher scheme and chi-square test was used for hypothesis testing. RESULTS: Nineteen percent of the women were MHVS beneficiaries and 23% of them lived within 5 km of the health facility. Among the beneficiaries no significant differences were observed in the utilization of at-least 4 antenatal visits, skilled-assistance at delivery, postnatal care, and MNCoC between those living closer to the health facility and those living far away. However, a higher facility delivery rate was observed among beneficiary women living closer. By contrast, for non-beneficiaries, a significant difference was found in service use between women living closer to health facilities compared to those living further away. CONCLUSION: The study found the use of MNCoC to be similar for all MHVS beneficiaries irrespective of their distance to health facilities whereas non-beneficiary women living further away had lower utilization rates. MHVS could have potentially reduced distance-related inequality for its beneficiaries. However, despite the provision of transport incentives under MHVS the reduction in inequality in facility delivery was limited. We propose a revision of the transportation incentive adjusting for distance, geographical remoteness, road condition, and transport cost to enhance the impact of MHVS.

Is traditional contraceptive use in Moldova associated with poverty and isolation?

This study investigates the correlates of traditional contraceptive use in Moldova, a poor country in Europe with one of the highest proportions of traditional contraceptive method users. The high reliance on traditional methods, particularly in the context of sub-replacement level fertility rate, has not been systematically evaluated in demographic research. Using cross-sectional data on a sub-sample of 6039 sexually experienced women from the 2005 Moldovan Demographic and Health Survey, this study hypothesizes that (a) economic and spatial disadvantages increase the likelihood of traditional method use, and (b) high exposure to family planning/reproductive health (FP/RH) programmes increases the propensity to modern method use. Multilevel multinomial models are used to examine the correlates of traditional method use controlling for exposure to sexual activity, socioeconomic and demographic characteristics and data structure. The results show that economic disadvantage increases the probability of traditional method use, but the overall effect is small. Although higher family planning media exposure decreases the reliance on traditional methods among younger women, it has only a marginal effect in increasing modern method use among older women. Family planning programmes designed to encourage women to switch from traditional to modern methods have some success--although the effect is considerably reduced in regions outside of the capital Chisinau. The study concludes that FP/RH efforts directed towards the poorest may have limited impact, but interventions targeted at older women could reduce the burden of unwanted pregnancies and abortions. Addressing differentials in accessing modern methods could improve uptake in rural areas.

Married Women's Experience of Domestic Violence in Malawi: New Evidence From a Cluster and Multinomial Logistic Regression Analysis.

Violence against women is a global issue with estimates indicating that 35% of all women worldwide have experienced either physical and/or sexual intimate partner violence or nonpartner violence in their life time. In Malawi, 42% of ever-married women have experienced some form of violence perpetrated by their current or most recent spouse. A number of studies have investigated intimate partner violence in Malawi within the context of HIV/AIDS, girls' sexual abuse, and psychological distress, and a few studies report on the role of sociocultural factors in influencing gender-based violence. No study has used cluster analysis to systematically analyze different levels of abuse among married women in Malawi. Using the 2015 Malawi Demographic and Health Survey data, we employed cluster analysis and multinomial logistic regression to analyze the distribution of different levels of abuse among married women in Malawi and the key attributes associated with each level of abuse. Correlates of domestic violence significantly differ by levels of abuse and are distributed as follows: controlling behavior (11.8%), general controlling behavior (GCB; 27.1%), moderate physical and emotional abuse (27.2%), and the high and complete abuse (8.5%). Alcohol consumption, ethnicity, and women working status were significantly associated with all four levels of abuse, but age and religion were only associated with controlling behavior and generalized controlling behavior. The strength of association between husband's alcohol consumption, woman's working status, and marriage type and domestic violence increased by level of abuse. On each of these factors, the odds of experiencing violence were lowest in the controlling behavior group and highest in the high physical and emotional abuse group. Policies and programs that are designed to tackle violence against married women in Malawi should incorporate strategies that discourage excessive alcohol consumption, promote messages that women can be bread winners, and discourage polygamous marriage.

An Evaluation of Agreement of Breathing Rates Measured by a Novel Device, Manual Counting, and Other Techniques Used in Clinical Practice: Protocol for the Observational VENTILATE Study.

BACKGROUND: Respiratory rate (RR) is the most sensitive physiological observation to predict clinical deterioration on hospital wards, and poor clinical monitoring has been highlighted as a primary contributor to avoidable mortality. Patients in intensive care have their RR monitored continuously, but this equipment is rarely available on general hospital wards. OBJECTIVE: The primary objective is to assess the accuracy of the RespiraSense device in comparison with other methods currently used in clinical practice. The secondary objective is to assess the accuracy of the RespiraSense device in participants in different positions and when reading aloud. METHODS: A single-center, prospective observational study will investigate the agreement of the RespiraSense device as compared with other device measurements (capnography, electrocardiogram) and the current standard measurement of RR (manual counting by a trained health care professional). The different methods will be employed concurrently on the same participant as part of a single study visit. RESULTS: Recruitment to this study has not yet started as funding decisions are still pending. Therefore, results are not available at this stage. It is anticipated that the data required could be collected within 2 months of first recruitment to the study and data analysis completed within 6 months of the study start date. CONCLUSIONS: The Evaluation of Agreement of Breathing Rates Measured by a Novel Device, Manual Counting, and Other Techniques Used in Clinical Practice (VENTILATE) study will provide further validation of the use of the RespiraSense device in subjects with abnormal respiratory rates. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/15437.

Contraceptive method choice and spousal communication: Examining the effect of family planning method using an instrumental variable approach.

OBJECTIVES: Spousal communication is an important factor in reproductive health outcomes, including family size, contraceptive use and conflict. A purported advantage of traditional contraception is that it increases communication about family planning, since both partners need to be involved in contraceptive practice. However, there is likely to be some degree of endogeneity due to selection: couples who communicate better are more likely to select methods requiring higher degrees of communication. METHOD: This paper uses an instrumental variable approach to assess the causal effect of method choice on spousal communication in 7 countries in Sub-Saharan Africa. Religion is used as an instrument since this is correlated with method but not communication. RESULTS: Results indicate that both traditional and modern methods are associated with greater discussion of family planning, and this is robust to the introduction of controls. However, when using the instrumental variable to account for selection effect, many of the significant results for traditional methods disappear although they persist for modern methods. CONCLUSIONS: These findings indicate that the effect of traditional methods in improving communication is due to selection, rather than causation. While traditional methods still have a role to play in the contraceptive method mix, enthusiasm for side benefits such as family planning communication should be tempered.

Does healthcare voucher provision improve utilisation in the continuum of maternal care for poor pregnant women? Experience from Bangladesh.

Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest.Objective: The current paper reports the effect of vouchers on the use of continuum of maternal care.Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0-23 months. Using Cluster analysis utilisation groups for antenatal care, facility delivery and postnatal care were formed. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders.Results: Four clusters with varying levels of utilisation were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%).Conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programmes that improve access to quality healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.

Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya.

OBJECTIVES: Out-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants-two popular methods-differs by public/private provider type and user's sociodemographic characteristics. DESIGN, SETTING AND PARTICIPANTS: Secondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15-49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values. MAIN OUTCOME: Respondent's self-reported source and payment to obtain their current modern contraceptive method. METHODS: We used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth. RESULTS: Half of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users. CONCLUSIONS: More attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.

Who Meets the Contraceptive Needs of Young Women in Sub-Saharan Africa?

PURPOSE: Despite efforts to expand contraceptive access for young people, few studies have considered where young women (age 15-24) in low- and middle-income countries obtain modern contraceptives and how the capacity and content of care of sources used compares with older users. METHODS: We examined the first source of respondents' current modern contraceptive method using the most recent Demographic and Health Survey since 2000 for 33 sub-Saharan African countries. We classified providers according to sector (public/private) and capacity to provide a range of short- and long-term methods (limited/comprehensive). We also compared the content of care obtained from different providers. RESULTS: Although the public and private sectors were both important sources of family planning (FP), young women (15-24) used more short-term methods obtained from limited-capacity, private providers, compared with older women. The use of long-term methods among young women was low, but among those users, more than 85% reported a public sector source. Older women (25+) were significantly more likely to utilize a comprehensive provider in either sector compared with younger women. Although FP users of all ages reported poor content of care across all providers, young women had even lower content of care. CONCLUSIONS: The results suggest that method and provider choice are strongly linked, and recent efforts to increase access to long-term methods among young women may be restricted by where they seek care. Interventions to increase adolescents' access to a range of FP methods and quality counseling should target providers frequently used by young people, including limited-capacity providers in the private sector.

Trends in Demographic and Health Survey data quality: an analysis of age heaping over time in 34 countries in Sub Saharan Africa between 1987 and 2015.

OBJECTIVE: This paper evaluates one aspect of data quality within DHS surveys, the accuracy of age reporting as measured by age heaping. Other literature has explored this phenomenon, and this analysis build on previous work, expanding the analysis of the extent of age heaping across multiple countries, and across time. RESULTS: This paper makes a comparison of the magnitude of Whipple's index of age heaping across all Demographic and Health Surveys from 1986 to 2015 in Sub-Saharan Africa. A random slope multilevel model is used to evaluate the trend in the proportion of respondents within each survey rounding their age to the nearest age with terminal digit 0 or 5. The trend in the proportion of misreported ages has remained flat, in the region of 5% of respondents misreporting their age. We find that Nigeria and Ghana have demonstrated considerable improvements in age reporting quality, but that a number of countries have considerable increases in the proportion of age misreported, most notably Mali and Ethiopia with demonstrate increases in excess of 10% points.

Capturing the temporal sequence of interaction in young siblings.

We explored whether young children exhibit subtypes of behavioral sequences during sibling interaction. Ten-minute, free-play observations of over 300 sibling dyads were coded for positivity, negativity and disengagement. The data were analyzed using growth mixture modeling (GMM). Younger (18-month-old) children's temporal behavioral sequences showed a harmonious (53%) and a casual (47%) class. Older (approximately four-year-old) children's behavior was more differentiated revealing a harmonious (25%), a deteriorating (31%), a recovery (22%) and a casual (22%) class. A more positive maternal affective climate was associated with more positive patterns. Siblings' sequential behavioral patterns tended to be complementary rather than reciprocal in nature. The study illustrates a novel use of GMM and makes a theoretical contribution by showing that young children exhibit distinct types of temporal behavioral sequences that are related to parenting processes.

Early response of soil properties and function to riparian rainforest restoration.

Reforestation of riparian zones is increasingly practiced in many regions for purposes of biodiversity conservation, bank stabilisation, and improvement in water quality. This is in spite of the actual benefits of reforestation for recovering underlying soil properties and function remaining poorly understood. Here we compare remnant riparian rainforest, pasture and reforestation plantings aged 2-20 years in an Australian subtropical catchment on ferrosols to determine the extent to which reforestation restores key soil properties. Of the nine soil attributes measured (total nitrogen, nitrate and ammonium concentrations, net nitrification and ammonification rates, organic carbon, bulk density, fine root biomass and water infiltration rates), only infiltration rates were significantly lower in pasture than remnant riparian rainforest. Within reforestation plantings, bulk density decreased up to 1.4-fold and infiltration rates increased up to 60-fold with time post-reforestation. Our results suggest that the main outcome of belowground processes of early reforestation is the recovery of the soils' physical structure, with potential beneficial ecosystem services including reduced runoff, erosion and associated sediment and nutrient loads in waterways. We also demonstrate differential impacts of two commonly planted tree species on a subset of soil properties suggesting that preferential planting of select species could accelerate progress on specific restoration objectives.

Contraceptive behavior among women after abortion in Nepal.

OBJECTIVE: To investigate the timing of contraceptive use and estimate the discontinuation rates of temporary methods among women after abortion, or a live birth or stillbirth. METHODS: A sample of married women with detailed pregnancy and contraceptive histories was analyzed in a population-based cross-sectional study based on calendar data extracted from the 2011 Nepal Demographic and Health Survey. Kaplan-Meier cumulative and discrete-time hazard models were used to estimate the timing of contraceptive use and discontinuation rates among users of temporary methods. RESULTS: The final analysis sample included 3190 women. Of 684 women who had had an abortion, 298 (43.6%) had not initiated any contraceptive use in the 12 months afterwards. Women initiated contraceptive use significantly earlier after abortion (hazard ratio [HR] 2.25; 95% CI, 1.96-2.59; P<0.001). The rate of discontinuation among contraceptive users was significantly higher in the postabortion group (HR 1.32; 95% CI, 1.05-1.65; P<0.05). Women who were educated, wealthier, had used contraceptives before the index pregnancy, had two sons and had autonomy initiated contraceptive use significantly earlier in the post-abortion period than their counterparts. CONCLUSION: Postabortion contraceptive use is low in Nepal. Postabortion family-planning counseling and related services should be strengthened with systematic monitoring and follow-up interventions.

Contraceptive confidence and timing of first birth in Moldova: an event history analysis of retrospective data.

OBJECTIVES: To test the contraceptive confidence hypothesis in a modern context. The hypothesis is that women using effective or modern contraceptive methods have increased contraceptive confidence and hence a shorter interval between marriage and first birth than users of ineffective or traditional methods. We extend the hypothesis to incorporate the role of abortion, arguing that it acts as a substitute for contraception in the study context. SETTING: Moldova, a country in South-East Europe. Moldova exhibits high use of traditional contraceptive methods and abortion compared with other European countries. PARTICIPANTS: Data are from a secondary analysis of the 2005 Moldovan Demographic and Health Survey, a nationally representative sample survey. 5377 unmarried women were selected. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome measure was the interval between marriage and first birth. This was modelled using a piecewise-constant hazard regression, with abortion and contraceptive method types as primary variables along with relevant sociodemographic controls. RESULTS: Women with high contraceptive confidence (modern method users) have a higher cumulative hazard of first birth 36 months following marriage (0.88 (0.87 to 0.89)) compared with women with low contraceptive confidence (traditional method users, cumulative hazard: 0.85 (0.84 to 0.85)). This is consistent with the contraceptive confidence hypothesis. There is a higher cumulative hazard of first birth among women with low (0.80 (0.79 to 0.80)) and moderate abortion propensities (0.76 (0.75 to 0.77)) than women with no abortion propensity (0.73 (0.72 to 0.74)) 24 months after marriage. CONCLUSIONS: Effective contraceptive use tends to increase contraceptive confidence and is associated with a shorter interval between marriage and first birth. Increased use of abortion also tends to increase contraceptive confidence and shorten birth duration, although this effect is non-linear-women with a very high use of abortion tend to have lengthy intervals between marriage and first birth.