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ROUND UP
Research Women’s health and mortality from chronic diseases: beyond reproduction
Female genital mutilation, obstetric outcomes and primary infertility
from November 2001–March 2003 with 28,393 women in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. Participants were examined before delivery to ascertain whether or not they had undergone FGM and the type classified. Participants and infants were followed up after hospital discharge. Compared with women who had not undergone FGM, women with FGM I, II and III were at greater risk of certain obstetric complications: caeserean section, post-partum haemorrhage, extended maternal hospital stay, infant resuscitation, stillbirth or early neonatal death and low birthweight. Parity did not significantly affect these relative risks. FGM is estimated to lead to an additional 1–2 perinatal deaths per 100 deliveries. Study outcomes were limited to those occurring within hospital settings. Longerterm outcomes such as post-partum infections, fistulae and later neonatal or infant mortality could therefore not be investigated.1 A commentary summarises the study findings as: ‘‘the more brutal the procedure, the worse the complications’’. There is an apparent decline of the practice, and it is hoped that these findings will be combined with legislation, public education and sustained campaigning for the elimination of FGM.2 A case-control study of 99 infertile women in Khartoum, Sudan, investigated the possible association between female genital mutilation (FGM) and primary infertility. The women underwent diagnostic laparoscopy. Of the 99 women with primary infertility examined, 48 had adnexal pathology indicative of previous inflammation. After controlling for other risk factors, these women had significantly higher risk than a control group of having undergone the most extensive form of FGM, that involves the labia majora. The anatomical extent of FGM, rather than whether or not the vulva had been sutured or closed, was associated with primary infertility.3
Reliable evidence concerning the effect of female genital mutilation (FGM) on obstetric outcome is scarce. To address this, a study was conducted
1. WHO Study Group on Female Genital Mutilation and Obstetric Outcome. Female genital mutilation and
In less developed countries, chronic disease is the most important cause of female death, even during childbearing years and among women with young families, and women’s health should not be synonymous only with reproductive health. In least developed countries, international attention and resources are focused on obstetric events and more recently on HIV/AIDS. Cause of death data for women aged 15–34 years and 35–44 years were examined for nine less developed countries: Argentina, Chile, Colombia, Ecuador, Mexico, Peru, South Africa, China and India. Deaths associated with pregnancy, childbirth and HIV were compared with deaths from three chronic disease categories (cancer, cardiovascular disease and diabetes). Between 1980 and 1998, maternal mortality delcined by 42% in Mexico, 43% in Argentina, 58% in Chile and 35% in China. In seven of the nine countries, chronic disease caused more than 20% of deaths among women aged 15–34, while reproductive causes and HIV together accounted for 10% of deaths in all countries, except India. Among women aged 35–44, in all countries but India, chronic diseases accounted for more than four times the deaths attributable to reproductive causes and HIV. Extending the definition of women’s ill-health beyond reproduction to include chronic diseases is vital if the needs of women in less developed countries are to be met.1 1. Raymond S, Greenberg H, Leeder SR. Beyond reproduction: women’s health in today’s developing world. International Journal of Epidemiology 2005; 34(5):1144–48.
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Round Up: Research / Reproductive Health Matters 2006;14(28):210–218 obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367:1835–41. 2. Eke N, Nkanginieme KEO. Female genital mutilation and obstetric outcome [Comment]. Lancet 2006;367: 1799–80. 3. Almroth L, Elmusharaf S, El Hadi N, et al. Primary infertility after genital mutilation in girlhood in Sudan: a case-control study. Lancet 2005;366:385–91.
Gender and the social context of child rape in southern Africa 77 semi-structured in-depth interviews and three small group discussions were conducted in Namibia and South Africa with children who had been abused, parents and a range of key informants, such as police, social workers, health workers, NGO staff and teachers, about experiences and perceptions of child rape and childrearing. The researchers argue that children are vulnerable to abuse because the high status of men creates expectations in men that they should control women and children and reduces girls’ ability to refuse sexual advances. Rape is often used as an act of punishment or of communication (by individual men with themselves) about masculinity and power. Avoiding being caught was important in some rapes and some children came from backgrounds where the likelihood of cases being pursued was low. Despite a common assertion that communities abhor child rape, responses demonstrate that strong action is often not taken against a perpetrator, who is protected while victims are blamed.1 1. Jewkes R, Penn-Kekana L, Rose-Junius H.‘‘If they rape me, I can’t blame them’’: reflections on gender in the social context of child rape in South Africa and Namibia. Social Science and Medicine 2005;61:1809–20.
Sexual risk reduction interventions do not increase frequency of sexual activity Researchers from Syracuse University, USA conducted a meta-analysis of the influence of HIV risk reduction interventions on sexual occasions, number of partners and abstinence. They aimed to assess whether condom-related interventions inadvertently undermined sexual risk reduction efforts by increasing the frequency of sex. Data from 174 studies covering 206 separate interventions (84% US-based) were included, involving 116,735 participants. Participants included
equal numbers of men and women; 54% were black. Most interventions provided HIV education (97%), counselling and testing (74%) and condom distribution (74%). Fewer interventions taught negotiation skills (66%) or skills for avoiding risky sex (58%), gave condom information (45%) or taught condom skills (41%). Intervention groups averaged eight participants per session and three sessions of 75 minutes length. HIV risk reduction interventions neither increased nor decreased sexual occasions or number of reported partners. Participants in interventions were less likely than controls to be sexually active. Men who have sex with men and people buying or selling sex appeared more successful at reducing number of partners or adopting abstinence. Interventions that included more information, motivational enhancement and skills training also led to greater risk reduction. HIV risk reduction interventions did not increase the overall frequency of sexual activity.1 1. Smoak ND, Scott-Sheldon LAJ, Johnson BT, et al. Sexual risk reduction interventions do not inadvertently increase the overall frequency of sexual behaviour: a metaanalysis of 174 studies with 116, 735 participants. Journal of Acquired Immune Deficiency 2006;41(3):374–84.
Contradictory sexual norms and expectations for Tanzanian youth Participant observation in rural Northern Tanzania of sexual culture found both permissive and restrictive norms and expectations for young people. Sexual activity is constrained by norms of school pupil abstinence, female sexual respectability and taboos surrounding the discussion of sex. These norms are incompatible with a number of widely held expectations that: sexual activity is inevitable unless prevented, sex is a female resource to be exploited, restrictions on sex are relaxed at festivals and masculine esteem is boosted through sexual experience. Differential commitment to these norms and expectations reflects conflicts between generations and the sexes. Young people appear to manage these contradictions by concealing their sexual relationships, which in turn appears to contribute to their short duration and high levels of partner change.1 1. Wight D, Plummer ML, Mshana G, et al. Contradictory sexual norms and expectations for young people in
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Round Up: Research / Reproductive Health Matters 2006;14(28):210–218 rural Northern Tanzania. Social Science and Medicine 2006;62:987–97.
Sexual activity, contraceptive use and pregnancy among single women in eight Latin American countries A comparative analysis of sexual activity, contraceptive use, conception and pregnancy resolution among single women aged 15–24 in eight Latin American countries (Bolivia, Brazil, Colombia, Dominican Republic, Guatemala, Nicaragua, Paraguay, Peru) found that over half the young women had not had sex by age 24, and that the proportion has fallen over time, particularly in Northeast Brazil and Colombia. The number who were sexually active and protected by contraception was Iess than 20% in five countries, about 30% in Peru and 50% in Brazil and Colombia. Condoms contributed 10–20% of contraceptive protection, and uptake of condoms has increased faster than use of other methods. Premarital conception rates among those who were sexually active ranged from 14.1 per 100 womanyears in Nicaragua to 25.8 in Bolivia. Most premarital conceptions ended in a live birth. Births legitimised by marriage or cohabitation were more likely to be wanted. Conception rates among single women in Latin America are rising. While contraceptive uptake is increasing, in particular use of condoms, it is not sufficient to offset the increase in sexual activity.1 1. Ali MM, Cleland J. Sexual and reproductive behaviour among single women aged 15–24 in eight Latin American countries: a comparative analysis. Social Science and Medicine 2005;60:1175–85.
Pregnancy and sexuality during adolescence: multicentre study in Brazil This study consisted of 123 in-depth interviews in 1999–2000 and a quantitative survey in 2001– 2002 of a random sample of 4,634 young men and women aged 18–24 years living in Porto Alegre, Rio de Janeiro and Salvador in Brazil. It focused on family background, sexual socialisation, first romantic relationship, sexual initiation, sexual morality, sexual practices with oppositesex and same-sex partners, pregnancy, abortion and experience of motherhood or fatherhood. The aim was to understand adolescent pregnancy as part of a wider picture of sexual and gender relations. Sexual initiation occurred at a mean 212
age of 16.2 for men and 17.9 for women. The majority of those interviewed (70%) reported using protection and/or contraceptive methods for first sexual intercourse. Nevertheless, partners did not discuss protection openly or explicitly, partly because they were not of the same age, background or social status. Sexual experience with same-sex partners was reported by 3.3% of survey participants. For most young people sexual intercourse occurred in stable relationships, including in living-together relationships, for women (42.4%) more than men (25.6%). Union and pregnancy were generally associated, and more frequent among lower-income women, and constituted an important strategy to attain the status of adulthood. At least one pregnancy during adolescence was reported by 29.6% of women and 21.4% of men aged 16–19, with few instances before age 15. The need for abortion and attempted abortion were mentioned by 15–20% of young women and men. The birth of a child happened for 40% of young women and 48% of young men under 19 years of age after they had left school. Adolescent parenthood derived from a complex set of social determinants which linked sex and reproduction, mostly in the low-income population, among whom having a family is valued, but for whom this was detrimental to continuation of education.1 1. Heilborn ML, Aquino EML, Knauth DR. Youth, sexuality, and reproduction. Cadernos Sau´de Pu´blica 2006;22(7):1362–63.
Methods of hysterectomy and long-term effects Hysterectomy remains one of the most commonly performed operations in the world, with nine of every ten hysterectomies performed for non-cancerous conditions. Yet little is known about the long term effects of hysterectomy. Currently, three main types of hysterectomy are used: abdominal, vaginal and laparoscopic. A systematic review and meta-analysis of 27 trials with a total of 3,643 participants found that return to normal activities was quicker after vaginal than abdominal hysterectomy (mean difference 9.5 days) and after laparoscopic than after abdominal hysterectomy (mean difference 13.6 days), but not significantly different for laparoscopic versus vaginal hysterectomy (mean difference 1.1 days).
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There were two to three times as many urinary tract injuries with laparoscopic than with abdominal hysterectomy, but no other significant intraoperative visceral injuries were noted. However, data were absent for many important long-term outcomes. The authors conclude that significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy, where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it carries a higher chance of bladder or ureter injury.1 1. Johnson N, Barlow D, Lethaby A, et al. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005;330: 1478–81.
Diaphragm use among sex workers in Madagascar 91 women from three cities in Madagascar participated in an eight-week study to assess acceptability and feasibility of silicone Wider-Seal Arcing Diaphragms. 96% completed follow-up. At enrolment, participants reported a median of six sex acts with five clients in the previous week. During follow-up, participants reported a median of three sex acts with three clients during the previous two days; self-reported continuous diaphragm use during the previous day increased from 87% to 93%. Self-reported use of male condoms and diaphragms was fairly consistent over the study period, with women reporting condom use in 61–70% of acts and diaphragms in 95–97% of acts. Seven women became pregnant. The number of women reporting diaphragm problems decreased from 15 (16%) at first visit to six (7%) at the final visit. Twenty women (22%) needed to replace diaphragms because the original had been lost, damaged or was the wrong size. The authors conclude that diaphragm use is acceptable and feasible among this resource-poor, low education, sex worker population.1 1. Behets F, Turner AN, Van Damme K, et al. Acceptability and feasibility of continuous diaphragm use among sex workers in Madagascar. Sexually Transmitted Infections 2005;81(6):472–76.
Predictors of diaphragm use for HIV/STI prevention in Zimbabwe In order to assess diaphragm uptake and use over time in Zimbabwe and identify factors associated with self-reported, consistent use, a study was conducted with women attending family planning clinics. 186 women who were inconsistent condom users received a diaphragm intervention and were followed for six months. 99% reported ever using the diaphragm and at study exit 96% reported using it within the previous two months. Consistent use since the previous visit was reported by 13–16% and was found to be associated with never using condoms. Other factors included discreet use, preferring diaphragms to condoms, timing of insertion, domestic violence and contraception.1 1. van der Straten A, Kang MS, Posner SF, et al. Predictors of diaphragm use as a potential sexually transmitted disease/HIV prevention method in Zimbabwe. Sexually Transmitted Diseases 2005;32(1):64–71.
Effects of facility-based maternal death reviews on maternal mortality in Senegal Reviewing maternal deaths and complications may make pregnancy safer but no evidence exists as to the effectiveness of this strategy. The researchers assessed the effect of facility-based maternal death reviews on maternal mortality rates in a district hospital that provides primary and referral maternity services in Senegal. All women admitted to the maternity unit for childbirth or within 24 hours of delivery were included in the study and maternal mortality was recorded during a one-year baseline period from January–December 1997, and during a threeyear period from 1998–2000 after a review. The maternal death review was found to lead to changes in organisational structure that improved life-saving interventions, with a relatively large contribution from the community. Overall mortality decreased significantly from 0.83 during the baseline period to 0.41 per 100 women, three years later. The authors conclude that maternal death review had a marked effect on resources, management and maternity outcomes in the facility, but further research would be necessary to confirm its feasibility in other settings.1 1. Dumont A, Gaye A, de Bernis L, et al. Facility-based maternal death reviews: effects on maternal mortality
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Round Up: Research / Reproductive Health Matters 2006;14(28):210–218 in a district hospital in Senegal. Bulletin of World Health Organization 2006;84(3):218–25.
Pre-eclampsia: risks at antenatal booking and recurrence across generations Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity, yet clinicians may spend more time screening for other problems in pregnancy that have a lower incidence than pre-eclampsia. While all the criteria for screening are not met for pre-eclampsia, different risk factors have been quantified and informed the development of the Pre-Ecclampsia Community Guideline (PRECOG) under the auspices of the UK charity Action on Pre-Eclampsia. The guideline relies on clinical features for assessment, with straightforward management plans. There is an evidencebased risk assessment with criteria for early referral for specialist input, a two-tiered schedule for monitoring women in the community after 20 weeks’ gestation, and referral criteria for step-up care.1–3 A systematic review of studies published from 1966-2002 of risk factors for pre-eclampsia present at antenatal booking found that the risk is increased in women with a family or previous history or pre-eclampsia, pre-existing diabetes, raised blood pressure at booking, multiple (twin) pregnancy, nulliparity, raised body mass index before pregnancy or at booking, presence of antiphospholipid antibodies and maternal age greater than 40. Individual studies show that risk also increases with an interval of ten years or more between pregnancies, auto-immune diseases and chronic hypertension. These factors and the evidence base can be used to assess risk at booking.3 In order to improve the quality of clinical care for women with severe pre-eclampsia in Uganda, a criteria-based audit was conducted in a large government hospital in Kampala. Management practices were evaluated against standards developed by an expert panel through retrospective evaluation of 43 case files. Based on the audit, additional supplies were purchased, labour ward procedures streamlined and staffing increased. A re-audit discovered significant improvements in diagnosis, monitoring and treatment. A further audit against the same standards was planned in 12 months time.4 A population-based cohort study, using Norwegian birth registry data from 1967–2003, of 438,597 women and 286,945 men, assessed the impact on risk of pre-eclampsia of genes that 214
work through the mother and genes of paternal origin that work through the fetus. The authors conclude that maternal and fetal genes from either mother or father may trigger pre-eclampsia and that the maternal association is stronger than the fetal association. The familial association predicts more severe pre-eclampsia.5 1. Greer IA. Pre-eclampsia matters [Editorial]. BMJ 2005;330:549–50. 2. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005;330:576–80. 3. Duckitt K, Harrington D. Risk factors for preeclampsia at antenatal booking: systematic review of controlled studies. BMJ 2005;330:565–67. 4. Weeks AD, Alia G, Ononge S, et al. A criteria-based audit of the management of severe pre-eclampsia in Kampala, Uganda. International Journal of Gynecology and Obstetrics 2005;91:292–97. 5. Skjaerven R, Vatten LJ, Wilcox AJ, et al. Recurrence of pre-eclampsia across generations: exploring fetal and maternal genetic components in a population based cohort. BMJ 2005;331(7521):877.
Caesarean delivery rates and pregnancy outcomes: WHO global survey 2005 Caesarean delivery rates continue to increase worldwide. For the 2005 WHO global survey on maternal and perinatal health, researchers looked at 24 geographic regions in eight countries in Latin America. Data were obtained for all women admitted for delivery over three months to 120 randomly selected institutions (out of 410). Data were obtained for 97,095 of 105,546 deliveries. The median rate of caesarean delivery was 33% with the highest rates in private hospitals (51%). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery and institutional norms. The rate of caesarean deliveries was positively associated with post-partum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increases in the rate of caesarean deliveries were also associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for seven days or longer, even after adjustment for preterm-delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery between 10% and 20%.1 In Brazil and other Latin American countries, caesarean section
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rates are often determined by non-clinical dimensions of medical practice, such as time-management concerns of private practitioners and demand among mothers who have been told that caesarean sections are convenient and harmless.2 1. Villar J, Valladares E, et al. Caesarian delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367:1819-29. 2. Victora CG, Barros FC. Beware: unnecessary caesarean sections may be hazardous [Comment]. Lancet 2006;367:1796–97.
Paternal depression Depression is common and frequently affects mothers and fathers of young children. Postnatal depression in mothers affects the quality of maternal care and can lead to disturbances in children’s social, behavioural, cognitive and physical development. The effect of depression in fathers during the early years of a child’s life has received little attention. As part of a large, UK population-based study of childhood, using the Edinburgh depression scale, researchers assessed the presence of depressive symptoms in 13,351 mothers and 12,884 fathers eight weeks after the birth of their child. Fathers were reassessed at 21 months. Depression in fathers during the postnatal period was associated with adverse emotional and behavioural outcomes in children aged 3–5 years and with an increased risk of conduct problems in boys. Paternal depression has a specific and persisting detrimental effect on children’s early behavioural and emotional development, and seems especially notable in boys.1 1. Ramchandani P, Stein A, Evans J, et al. Paternal depression in the postnatal period and child development: a prospective population study. Lancet 2005;365:2201–05.
Stillbirth rates There is a lack of usable data and underreporting on stillbirths (babies born dead in the last 12 weeks of pregnancy) in the countries and regions in which most stillbirths occur. Investigators assessed three sources of stillbirth data: vital registration, demographic and health survey (DHS) data, published and unpublished studies
identified through searches of more than 30,000 abstracts. Data from 44 countries with vital registration (71,442 stillbirths), 30 DHS surveys from 16 countries (2,989 stillbirths) and 249 study populations from 103 countries (93,023 stillbirths) met the inclusion criteria. Estimates for 190 countries were derived. The resultant stillbirth rates ranged from 5 per 1,000 in rich countries to 32 per 1,000 in South Asia and sub-Saharan Africa. The estimated global total of stillbirths was 3.2 million (range 2.5–4.1 million). While these are still probably under-estimates, they do represent a rigorous attempt at measurement. Improved data are crucial for addressing stillbirth as part of the public health agenda.1 1. Stanton C, Lawn JE, et al. Stillbirth rates: delivering estimates in 190 countries. Lancet 2006;367:1487-94.
Neuro-developmental outcomes after pre-term birth Most pre-term infants have good neuro-developmental outcomes and cannot easily be distinguished from full-term infants. However as survival rates for extremely pre-term infants improve, the overall number of pre-term infants with disability and handicap has not fallen, which is having an important impact on social, educational and health services resources and adversely affecting family life. Longer-term neurodevelopmental outcomes need to be considered when reviewing the impact of neonatal intensive care for pre-term infants.1 1. Colvin M, McGuire W, Fowlie PW. Neurodevelopmental outcomes after preterm birth. BMJ 2004;329:1390–93.
Folic acid recommendations for neural tube defects A retrospective cohort study of births monitored by 13 birth defect registries in 11 European countries between 1988–98 was conducted to evaluate the effectiveness of recommendations on folic acid aimed at reducing the occurrence of neural tube defects. No detectable improvement in trends of incidence of neural tube defects followed the issuing of recommendations. The paper concludes that recommendations alone did not appear to influence trends up to six years after the confirmation of the effectiveness of 215
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folic acid in clinical trials, regardless of the form, timing or intended target of recommendations. New cases of neural tube defects which are preventable by folic acid continue to occur. A reasonable strategy would be to integrate food fortification with fuller implementation of recommendations on supplements.1 1. Botto LD, Lisi A, Robert-Gnansia E, et al. International retrospective cohort study of neural tube defects in relation to folic acid recommendations: are the recommendations working? BMJ 2005;330(7491):571–77.
Rise in maternal age in Europe and increase in Down’s syndrome The rise in average maternal age in Europe has brought with it an increase in the number of pregnancies affected by Down’s syndrome. Down’s syndrome constitutes approximately 8% of cases of registered congenital anomaly in the European Union, with over 7,000 affected pregnancies each year in the 15 member states. An analysis of data from 24 registries, covering 8.3 million births 1980–99 found that the proportion of births to mothers aged 35+ years rose from 8% to 14% overall. In 1995–99, the proportion of older mothers was 10–25%, and the total prevalence (including terminations of pregnancy) of Down’s syndrome varied from 1–3 per 1,000 births. The proportion of cases of Down’s syndrome which were prenatally diagnosed followed by termination of pregnancy in 1995–99 varied from nil in Ireland and Malta, where termination of pregnancy is illegal, to 77% in Paris. The extent to which terminations of pregnancy were concentrated among older mothers varied between regions. The widespread practice of antenatal screening and termination of pregnancy has counteracted the effect of maternal age in its effect on live birth prevalence of the syndrome.1 1. Dolk H, Loane M, et al. Trends and geographic inequalities in the prevalence of Down’s syndrome in Europe, 1980–1999. Revue d’e´pide´miologie et de sante´ publique 2005;53:2587–95.
Hormone treatment to reduce the adult height of tall girls Treatment with synthetic oestrogens to reduce adult height in tall girls has been available 216
since the 1950s to reduce psychosocial problems associated with tall stature, but little is know of the long-term outcomes. A retrospective cohort of 1,248 women, both those who were treated and those who were assessed but did not receive treatment, were identified through the records of Australian paediatricians between 1959 and 1993, together with 184 women who self-referred. All but five women were traced and invited to participate in a postal questionnaire, with 67.9% agreeing (396 treated, 448 untreated). They were asked how they felt about their current height, the assessment and treatment procedures, and the decision whether or not to have treatment. Untreated women were almost unanimously (99.1%) glad not to have been treated, no matter their current height; 42.1% of the treated women expressed dissatisfaction with the decision that was made. Dissatisfaction was related to whether or not as girls they had had a say in the decisionmaking, negative experiences of the assessment or treatment procedures, side-effects experienced in treatment and later side-effects which they believed were associated with treatment.1 1. Pyett P, Yarner J, Venn A, et al. Using hormone treatment to reduce the adult height of tall girls. Are women satisfied with the decision in later years. Social Science and Medicine 2005;61:1629–39.
Factors predisposing women to chronic pelvic pain A systematic review of 122 studies was conducted to evaluate factors predisposing women to chronic and recurrent pelvic pain, of which 63 evaluated 54 risk factors for dysmenorrhoea, 19 evaluated 14 risk factors for dyspareunia and 40 evaluated 48 factors for non-cyclical pelvic pain. Age less than 30 years, low body mass index, smoking, menarche before 12 years of age, long cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, sterilisation, clinically suspected pelvic inflammatory disease, sexual abuse and psychological symptoms were associated with dysmenorrhoea. Younger age at first childbirth, exercise and oral contraceptives were negatively associated with dysmenorrhoea. Menopause, pelvic inflammatory disease, sexual abuse, anxiety and depression were associated with dyspareunia. Drug or alcohol abuse, miscarriage, heavy menstrual flow, pelvic
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inflammatory disease, previous caesarean section, pelvic pathology, abuse and psychological co-morbidity were associated with an increased risk of non-cyclical pelvic pain. The researchers conclude that severe gynaecological and psychosocial factors are strongly associated with chronic pelvic pain and that randomised. controlled trials of interventions targeting the potentially modifiable factors are needed to assess their clinical relevance.1 1. Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: a systematic review. BMJ 2006;332(7544):749–55.
Women’s views of prophylactic mastectomy Data are accumulating on the efficacy of prophylactic mastectomy as a means to reduce breast cancer risk in high risk women. A multi-method study was conducted in Seattle (USA), among 246 women of varying ethnicities with familial breast cancer risk of their interest in and understanding of genetic testing for breast cancer susceptibility and their responses to surgery as a prophylactic measure. The majority of participants rejected the hypothetical idea of prophylactic mastectomy as a way of preventing breast cancer. They found the idea confusing, illogical and distressing and were inclined to be suspicious of any professional who might suggest it. They compared the intervention to cutting off part of one’s body for fear of future damage to that same body part. The authors argue that the logic behind these responses reflects an underlying distinction between ‘disease’ and ‘illness’. While prophylactic mastectomy may indeed prevent the ‘‘disease’’ (clinical pathology) of breast cancer, for these women surgery would actually imitate the ‘‘illness’’ (experience) of breast cancer. The authors encourage awareness among providers of this distinction and its implications for patient-provider consultations and decisions made in this context.1 1. Press N, Reynolds S, Pinsky L, et al. ‘‘That’s like chopping off a finger because you’re afraid it might get broken’’: disease and illness in women’s views of prophylactic mastectomy. Social Science & Medicine 2005;61(5):1106–17.
Reduction in mortality from breast cancer in Europe The survival of women with breast cancer in Europe in 2005 will be significantly better than for their counterparts diagnosed in the 1970–80s, although five year survival is lower in Europe than in the United States at 79% vs. 89%. Improvement in survival is unlikely to be due to a change in the biological behaviour of the cancer. It must therefore reflect improvements in diagnosing and managing breast cancer with early detection through screening and improved systemic treatment with adjuvants after surgery.1 A cohort study in Copenhagen, Denmark, evaluated the effect on breast cancer mortality of the first ten years of mammography services. Mortality in the screening period was reduced by 25% compared to what would be expected in the absence of screening. For women actually participating in screening, breast cancer mortality was reduced by 37%.2 In the United States, seven statistical models independently developed to investigate the reduction in death rates from breast cancer 1975–2000 show that mammographical screening and adjuvant treatment contributed almost equally. The proportion of the total reduction attributed to screening varied from 28% to 65% (median 46%) with adjuvant treatment contributing the rest. Variability across models in the absolute contribution of screening was larger than it was for treatment, reflecting the greater uncertainty about the benefit of screening.3 1. Jones A. Reduction in mortality from breast cancer. Screening and increased use of adjuvants are responsible – adjuvants more so [Editorial]. BMJ 2005;330:205–06. 2. Olsen AH, Njor SH, Vejborg I, et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study. BMJ 2005; 330:220–24. 3. Spurgeon D. Fall in mortality from breast cancer is due almost equally to screening and adjuvant therapy [News Roundup]. BMJ 2005;331:894.
Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions Conservative methods are commonly used to treat cervical intraepithelial neoplasia and microinvasive cervical cancer in young women. Through 217
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review and analysis of 27 studies, a group of European researchers investigated the effect of these procedures on subsequent fertility and pregnancy outcomes. Cold knife incision was significantly associated with preterm delivery, low birthweight and caesarean section. Large loop excision of the transformation zone was also significantly associated with preterm delivery and premature rupture of membranes. Similar but marginally non-significant adverse effects were recorded for laser conisation. Significantly increased risks were not detected for obstetric outcomes after laser ablation. While severe outcomes such as admission to a neonatal intensive care unit or perinatal mortality showed adverse trends, these changes were not significant. The authors conclude that all the excision procedures are associated with similar pregnancy-related morbidity, without apparent neonatal morbidity, and recommend caution in the treatment of young women with mild cervical abnormalities.1 1. Kyrgiou M, Koliapoulos G, Martin-Hirsch P, et al. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet 2006; 367:489–98.
Ovarian function post-chemotherapy following ovarian cryopreservation and transplantation Ovarian function was assessed after treatment of cancer in 22 women who previously had cortical tissue from an entire ovary cryopreserved (frozen) prior to chemotherapy and after transplantation of the cryopreserved tissue. All were treated with chemotherapeutic drugs, with a risk of inducing ovarian failure. The sample of 22 women included eight with breast cancer, six with Hodgkin’s disease, two with nonHodgkin’s disease, five with leukaemia and one with a brain tumour. All underwent clinical examination after 18 months of cryopreservation. Three patients with premature ovarian failure had ovarian tissue transplanted. Nine women had signs of ovarian failure. Thirteen women still menstruated and ten had seemingly normal ovarian
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function and normal oestradiol levels. All three with transplanted ovarian tissue regained ovarian function as confirmed by return of menses, follicles on ultrasonography and normalised hormone levels. Two embryos were created from the cryopreserved tissue after IVF.1 1. Schmidt KLT, Andersen CY, Loft A. Follow-up of ovarian function post-chemotherapy following ovarian cryopreservation and transplantation. Human Reproduction 2005; 20(12):3539–46.
Control of fertility historically in China This paper challenges the widespread belief that, historically, people’s reproductive strategies were necessarily intended to maximise the number of surviving offspring and demand for children (or sons). Scholars now accept that total fertility rates historically were moderate in China, but they still disagree as to whether the Chinese could intentionally control family size. Fertility patterns were closely linked to relatively low fertility among the newly married, long birth intervals and early cessation of childbearing, and were related to the practice of child marriage, intensive and prolonged breastfeeding, comparatively low coital frequency, poor health and periodic separation. Recent examination of historical population data shows that intentional control of fertility did exist in the past. Evidence suggests that, as early as 1,000 years ago, many Chinese wished to regulate family size. The widespread practice of infanticide observed during the Song period is an example. While popular sayings promoted large families, notions discouraging high fertility were also expressed. Chinese scholars and government officials were concerned with the danger of uncontrolled population growth and commented upon it, and intellectual concerns of this nature increased markedly over the course of the last four hundred years.1 1. Zhao ZW. Towards a better understanding of past fertility regimes: the ideas and practice of controlling family size in Chinese history. Continuity and Change 2006;21(1):9–35.
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ROUND UP
Research Women’s health and mortality from chronic diseases: beyond reproduction
Female genital mutilation, obstetric outcomes and primary infertility
from November 2001–March 2003 with 28,393 women in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. Participants were examined before delivery to ascertain whether or not they had undergone FGM and the type classified. Participants and infants were followed up after hospital discharge. Compared with women who had not undergone FGM, women with FGM I, II and III were at greater risk of certain obstetric complications: caeserean section, post-partum haemorrhage, extended maternal hospital stay, infant resuscitation, stillbirth or early neonatal death and low birthweight. Parity did not significantly affect these relative risks. FGM is estimated to lead to an additional 1–2 perinatal deaths per 100 deliveries. Study outcomes were limited to those occurring within hospital settings. Longerterm outcomes such as post-partum infections, fistulae and later neonatal or infant mortality could therefore not be investigated.1 A commentary summarises the study findings as: ‘‘the more brutal the procedure, the worse the complications’’. There is an apparent decline of the practice, and it is hoped that these findings will be combined with legislation, public education and sustained campaigning for the elimination of FGM.2 A case-control study of 99 infertile women in Khartoum, Sudan, investigated the possible association between female genital mutilation (FGM) and primary infertility. The women underwent diagnostic laparoscopy. Of the 99 women with primary infertility examined, 48 had adnexal pathology indicative of previous inflammation. After controlling for other risk factors, these women had significantly higher risk than a control group of having undergone the most extensive form of FGM, that involves the labia majora. The anatomical extent of FGM, rather than whether or not the vulva had been sutured or closed, was associated with primary infertility.3
Reliable evidence concerning the effect of female genital mutilation (FGM) on obstetric outcome is scarce. To address this, a study was conducted
1. WHO Study Group on Female Genital Mutilation and Obstetric Outcome. Female genital mutilation and
In less developed countries, chronic disease is the most important cause of female death, even during childbearing years and among women with young families, and women’s health should not be synonymous only with reproductive health. In least developed countries, international attention and resources are focused on obstetric events and more recently on HIV/AIDS. Cause of death data for women aged 15–34 years and 35–44 years were examined for nine less developed countries: Argentina, Chile, Colombia, Ecuador, Mexico, Peru, South Africa, China and India. Deaths associated with pregnancy, childbirth and HIV were compared with deaths from three chronic disease categories (cancer, cardiovascular disease and diabetes). Between 1980 and 1998, maternal mortality delcined by 42% in Mexico, 43% in Argentina, 58% in Chile and 35% in China. In seven of the nine countries, chronic disease caused more than 20% of deaths among women aged 15–34, while reproductive causes and HIV together accounted for 10% of deaths in all countries, except India. Among women aged 35–44, in all countries but India, chronic diseases accounted for more than four times the deaths attributable to reproductive causes and HIV. Extending the definition of women’s ill-health beyond reproduction to include chronic diseases is vital if the needs of women in less developed countries are to be met.1 1. Raymond S, Greenberg H, Leeder SR. Beyond reproduction: women’s health in today’s developing world. International Journal of Epidemiology 2005; 34(5):1144–48.
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Round Up: Research / Reproductive Health Matters 2006;14(28):210–218 obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006;367:1835–41. 2. Eke N, Nkanginieme KEO. Female genital mutilation and obstetric outcome [Comment]. Lancet 2006;367: 1799–80. 3. Almroth L, Elmusharaf S, El Hadi N, et al. Primary infertility after genital mutilation in girlhood in Sudan: a case-control study. Lancet 2005;366:385–91.
Gender and the social context of child rape in southern Africa 77 semi-structured in-depth interviews and three small group discussions were conducted in Namibia and South Africa with children who had been abused, parents and a range of key informants, such as police, social workers, health workers, NGO staff and teachers, about experiences and perceptions of child rape and childrearing. The researchers argue that children are vulnerable to abuse because the high status of men creates expectations in men that they should control women and children and reduces girls’ ability to refuse sexual advances. Rape is often used as an act of punishment or of communication (by individual men with themselves) about masculinity and power. Avoiding being caught was important in some rapes and some children came from backgrounds where the likelihood of cases being pursued was low. Despite a common assertion that communities abhor child rape, responses demonstrate that strong action is often not taken against a perpetrator, who is protected while victims are blamed.1 1. Jewkes R, Penn-Kekana L, Rose-Junius H.‘‘If they rape me, I can’t blame them’’: reflections on gender in the social context of child rape in South Africa and Namibia. Social Science and Medicine 2005;61:1809–20.
Sexual risk reduction interventions do not increase frequency of sexual activity Researchers from Syracuse University, USA conducted a meta-analysis of the influence of HIV risk reduction interventions on sexual occasions, number of partners and abstinence. They aimed to assess whether condom-related interventions inadvertently undermined sexual risk reduction efforts by increasing the frequency of sex. Data from 174 studies covering 206 separate interventions (84% US-based) were included, involving 116,735 participants. Participants included
equal numbers of men and women; 54% were black. Most interventions provided HIV education (97%), counselling and testing (74%) and condom distribution (74%). Fewer interventions taught negotiation skills (66%) or skills for avoiding risky sex (58%), gave condom information (45%) or taught condom skills (41%). Intervention groups averaged eight participants per session and three sessions of 75 minutes length. HIV risk reduction interventions neither increased nor decreased sexual occasions or number of reported partners. Participants in interventions were less likely than controls to be sexually active. Men who have sex with men and people buying or selling sex appeared more successful at reducing number of partners or adopting abstinence. Interventions that included more information, motivational enhancement and skills training also led to greater risk reduction. HIV risk reduction interventions did not increase the overall frequency of sexual activity.1 1. Smoak ND, Scott-Sheldon LAJ, Johnson BT, et al. Sexual risk reduction interventions do not inadvertently increase the overall frequency of sexual behaviour: a metaanalysis of 174 studies with 116, 735 participants. Journal of Acquired Immune Deficiency 2006;41(3):374–84.
Contradictory sexual norms and expectations for Tanzanian youth Participant observation in rural Northern Tanzania of sexual culture found both permissive and restrictive norms and expectations for young people. Sexual activity is constrained by norms of school pupil abstinence, female sexual respectability and taboos surrounding the discussion of sex. These norms are incompatible with a number of widely held expectations that: sexual activity is inevitable unless prevented, sex is a female resource to be exploited, restrictions on sex are relaxed at festivals and masculine esteem is boosted through sexual experience. Differential commitment to these norms and expectations reflects conflicts between generations and the sexes. Young people appear to manage these contradictions by concealing their sexual relationships, which in turn appears to contribute to their short duration and high levels of partner change.1 1. Wight D, Plummer ML, Mshana G, et al. Contradictory sexual norms and expectations for young people in
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Round Up: Research / Reproductive Health Matters 2006;14(28):210–218 rural Northern Tanzania. Social Science and Medicine 2006;62:987–97.
Sexual activity, contraceptive use and pregnancy among single women in eight Latin American countries A comparative analysis of sexual activity, contraceptive use, conception and pregnancy resolution among single women aged 15–24 in eight Latin American countries (Bolivia, Brazil, Colombia, Dominican Republic, Guatemala, Nicaragua, Paraguay, Peru) found that over half the young women had not had sex by age 24, and that the proportion has fallen over time, particularly in Northeast Brazil and Colombia. The number who were sexually active and protected by contraception was Iess than 20% in five countries, about 30% in Peru and 50% in Brazil and Colombia. Condoms contributed 10–20% of contraceptive protection, and uptake of condoms has increased faster than use of other methods. Premarital conception rates among those who were sexually active ranged from 14.1 per 100 womanyears in Nicaragua to 25.8 in Bolivia. Most premarital conceptions ended in a live birth. Births legitimised by marriage or cohabitation were more likely to be wanted. Conception rates among single women in Latin America are rising. While contraceptive uptake is increasing, in particular use of condoms, it is not sufficient to offset the increase in sexual activity.1 1. Ali MM, Cleland J. Sexual and reproductive behaviour among single women aged 15–24 in eight Latin American countries: a comparative analysis. Social Science and Medicine 2005;60:1175–85.
Pregnancy and sexuality during adolescence: multicentre study in Brazil This study consisted of 123 in-depth interviews in 1999–2000 and a quantitative survey in 2001– 2002 of a random sample of 4,634 young men and women aged 18–24 years living in Porto Alegre, Rio de Janeiro and Salvador in Brazil. It focused on family background, sexual socialisation, first romantic relationship, sexual initiation, sexual morality, sexual practices with oppositesex and same-sex partners, pregnancy, abortion and experience of motherhood or fatherhood. The aim was to understand adolescent pregnancy as part of a wider picture of sexual and gender relations. Sexual initiation occurred at a mean 212
age of 16.2 for men and 17.9 for women. The majority of those interviewed (70%) reported using protection and/or contraceptive methods for first sexual intercourse. Nevertheless, partners did not discuss protection openly or explicitly, partly because they were not of the same age, background or social status. Sexual experience with same-sex partners was reported by 3.3% of survey participants. For most young people sexual intercourse occurred in stable relationships, including in living-together relationships, for women (42.4%) more than men (25.6%). Union and pregnancy were generally associated, and more frequent among lower-income women, and constituted an important strategy to attain the status of adulthood. At least one pregnancy during adolescence was reported by 29.6% of women and 21.4% of men aged 16–19, with few instances before age 15. The need for abortion and attempted abortion were mentioned by 15–20% of young women and men. The birth of a child happened for 40% of young women and 48% of young men under 19 years of age after they had left school. Adolescent parenthood derived from a complex set of social determinants which linked sex and reproduction, mostly in the low-income population, among whom having a family is valued, but for whom this was detrimental to continuation of education.1 1. Heilborn ML, Aquino EML, Knauth DR. Youth, sexuality, and reproduction. Cadernos Sau´de Pu´blica 2006;22(7):1362–63.
Methods of hysterectomy and long-term effects Hysterectomy remains one of the most commonly performed operations in the world, with nine of every ten hysterectomies performed for non-cancerous conditions. Yet little is known about the long term effects of hysterectomy. Currently, three main types of hysterectomy are used: abdominal, vaginal and laparoscopic. A systematic review and meta-analysis of 27 trials with a total of 3,643 participants found that return to normal activities was quicker after vaginal than abdominal hysterectomy (mean difference 9.5 days) and after laparoscopic than after abdominal hysterectomy (mean difference 13.6 days), but not significantly different for laparoscopic versus vaginal hysterectomy (mean difference 1.1 days).
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There were two to three times as many urinary tract injuries with laparoscopic than with abdominal hysterectomy, but no other significant intraoperative visceral injuries were noted. However, data were absent for many important long-term outcomes. The authors conclude that significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy, where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it carries a higher chance of bladder or ureter injury.1 1. Johnson N, Barlow D, Lethaby A, et al. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005;330: 1478–81.
Diaphragm use among sex workers in Madagascar 91 women from three cities in Madagascar participated in an eight-week study to assess acceptability and feasibility of silicone Wider-Seal Arcing Diaphragms. 96% completed follow-up. At enrolment, participants reported a median of six sex acts with five clients in the previous week. During follow-up, participants reported a median of three sex acts with three clients during the previous two days; self-reported continuous diaphragm use during the previous day increased from 87% to 93%. Self-reported use of male condoms and diaphragms was fairly consistent over the study period, with women reporting condom use in 61–70% of acts and diaphragms in 95–97% of acts. Seven women became pregnant. The number of women reporting diaphragm problems decreased from 15 (16%) at first visit to six (7%) at the final visit. Twenty women (22%) needed to replace diaphragms because the original had been lost, damaged or was the wrong size. The authors conclude that diaphragm use is acceptable and feasible among this resource-poor, low education, sex worker population.1 1. Behets F, Turner AN, Van Damme K, et al. Acceptability and feasibility of continuous diaphragm use among sex workers in Madagascar. Sexually Transmitted Infections 2005;81(6):472–76.
Predictors of diaphragm use for HIV/STI prevention in Zimbabwe In order to assess diaphragm uptake and use over time in Zimbabwe and identify factors associated with self-reported, consistent use, a study was conducted with women attending family planning clinics. 186 women who were inconsistent condom users received a diaphragm intervention and were followed for six months. 99% reported ever using the diaphragm and at study exit 96% reported using it within the previous two months. Consistent use since the previous visit was reported by 13–16% and was found to be associated with never using condoms. Other factors included discreet use, preferring diaphragms to condoms, timing of insertion, domestic violence and contraception.1 1. van der Straten A, Kang MS, Posner SF, et al. Predictors of diaphragm use as a potential sexually transmitted disease/HIV prevention method in Zimbabwe. Sexually Transmitted Diseases 2005;32(1):64–71.
Effects of facility-based maternal death reviews on maternal mortality in Senegal Reviewing maternal deaths and complications may make pregnancy safer but no evidence exists as to the effectiveness of this strategy. The researchers assessed the effect of facility-based maternal death reviews on maternal mortality rates in a district hospital that provides primary and referral maternity services in Senegal. All women admitted to the maternity unit for childbirth or within 24 hours of delivery were included in the study and maternal mortality was recorded during a one-year baseline period from January–December 1997, and during a threeyear period from 1998–2000 after a review. The maternal death review was found to lead to changes in organisational structure that improved life-saving interventions, with a relatively large contribution from the community. Overall mortality decreased significantly from 0.83 during the baseline period to 0.41 per 100 women, three years later. The authors conclude that maternal death review had a marked effect on resources, management and maternity outcomes in the facility, but further research would be necessary to confirm its feasibility in other settings.1 1. Dumont A, Gaye A, de Bernis L, et al. Facility-based maternal death reviews: effects on maternal mortality
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Round Up: Research / Reproductive Health Matters 2006;14(28):210–218 in a district hospital in Senegal. Bulletin of World Health Organization 2006;84(3):218–25.
Pre-eclampsia: risks at antenatal booking and recurrence across generations Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity, yet clinicians may spend more time screening for other problems in pregnancy that have a lower incidence than pre-eclampsia. While all the criteria for screening are not met for pre-eclampsia, different risk factors have been quantified and informed the development of the Pre-Ecclampsia Community Guideline (PRECOG) under the auspices of the UK charity Action on Pre-Eclampsia. The guideline relies on clinical features for assessment, with straightforward management plans. There is an evidencebased risk assessment with criteria for early referral for specialist input, a two-tiered schedule for monitoring women in the community after 20 weeks’ gestation, and referral criteria for step-up care.1–3 A systematic review of studies published from 1966-2002 of risk factors for pre-eclampsia present at antenatal booking found that the risk is increased in women with a family or previous history or pre-eclampsia, pre-existing diabetes, raised blood pressure at booking, multiple (twin) pregnancy, nulliparity, raised body mass index before pregnancy or at booking, presence of antiphospholipid antibodies and maternal age greater than 40. Individual studies show that risk also increases with an interval of ten years or more between pregnancies, auto-immune diseases and chronic hypertension. These factors and the evidence base can be used to assess risk at booking.3 In order to improve the quality of clinical care for women with severe pre-eclampsia in Uganda, a criteria-based audit was conducted in a large government hospital in Kampala. Management practices were evaluated against standards developed by an expert panel through retrospective evaluation of 43 case files. Based on the audit, additional supplies were purchased, labour ward procedures streamlined and staffing increased. A re-audit discovered significant improvements in diagnosis, monitoring and treatment. A further audit against the same standards was planned in 12 months time.4 A population-based cohort study, using Norwegian birth registry data from 1967–2003, of 438,597 women and 286,945 men, assessed the impact on risk of pre-eclampsia of genes that 214
work through the mother and genes of paternal origin that work through the fetus. The authors conclude that maternal and fetal genes from either mother or father may trigger pre-eclampsia and that the maternal association is stronger than the fetal association. The familial association predicts more severe pre-eclampsia.5 1. Greer IA. Pre-eclampsia matters [Editorial]. BMJ 2005;330:549–50. 2. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005;330:576–80. 3. Duckitt K, Harrington D. Risk factors for preeclampsia at antenatal booking: systematic review of controlled studies. BMJ 2005;330:565–67. 4. Weeks AD, Alia G, Ononge S, et al. A criteria-based audit of the management of severe pre-eclampsia in Kampala, Uganda. International Journal of Gynecology and Obstetrics 2005;91:292–97. 5. Skjaerven R, Vatten LJ, Wilcox AJ, et al. Recurrence of pre-eclampsia across generations: exploring fetal and maternal genetic components in a population based cohort. BMJ 2005;331(7521):877.
Caesarean delivery rates and pregnancy outcomes: WHO global survey 2005 Caesarean delivery rates continue to increase worldwide. For the 2005 WHO global survey on maternal and perinatal health, researchers looked at 24 geographic regions in eight countries in Latin America. Data were obtained for all women admitted for delivery over three months to 120 randomly selected institutions (out of 410). Data were obtained for 97,095 of 105,546 deliveries. The median rate of caesarean delivery was 33% with the highest rates in private hospitals (51%). Institution-specific rates of caesarean delivery were affected by primiparity, previous caesarean delivery and institutional norms. The rate of caesarean deliveries was positively associated with post-partum antibiotic treatment and severe maternal morbidity and mortality, even after adjustment for risk factors. Increases in the rate of caesarean deliveries were also associated with an increase in fetal mortality rates and higher numbers of babies admitted to intensive care for seven days or longer, even after adjustment for preterm-delivery. Rates of preterm delivery and neonatal mortality both rose at rates of caesarean delivery between 10% and 20%.1 In Brazil and other Latin American countries, caesarean section
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rates are often determined by non-clinical dimensions of medical practice, such as time-management concerns of private practitioners and demand among mothers who have been told that caesarean sections are convenient and harmless.2 1. Villar J, Valladares E, et al. Caesarian delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367:1819-29. 2. Victora CG, Barros FC. Beware: unnecessary caesarean sections may be hazardous [Comment]. Lancet 2006;367:1796–97.
Paternal depression Depression is common and frequently affects mothers and fathers of young children. Postnatal depression in mothers affects the quality of maternal care and can lead to disturbances in children’s social, behavioural, cognitive and physical development. The effect of depression in fathers during the early years of a child’s life has received little attention. As part of a large, UK population-based study of childhood, using the Edinburgh depression scale, researchers assessed the presence of depressive symptoms in 13,351 mothers and 12,884 fathers eight weeks after the birth of their child. Fathers were reassessed at 21 months. Depression in fathers during the postnatal period was associated with adverse emotional and behavioural outcomes in children aged 3–5 years and with an increased risk of conduct problems in boys. Paternal depression has a specific and persisting detrimental effect on children’s early behavioural and emotional development, and seems especially notable in boys.1 1. Ramchandani P, Stein A, Evans J, et al. Paternal depression in the postnatal period and child development: a prospective population study. Lancet 2005;365:2201–05.
Stillbirth rates There is a lack of usable data and underreporting on stillbirths (babies born dead in the last 12 weeks of pregnancy) in the countries and regions in which most stillbirths occur. Investigators assessed three sources of stillbirth data: vital registration, demographic and health survey (DHS) data, published and unpublished studies
identified through searches of more than 30,000 abstracts. Data from 44 countries with vital registration (71,442 stillbirths), 30 DHS surveys from 16 countries (2,989 stillbirths) and 249 study populations from 103 countries (93,023 stillbirths) met the inclusion criteria. Estimates for 190 countries were derived. The resultant stillbirth rates ranged from 5 per 1,000 in rich countries to 32 per 1,000 in South Asia and sub-Saharan Africa. The estimated global total of stillbirths was 3.2 million (range 2.5–4.1 million). While these are still probably under-estimates, they do represent a rigorous attempt at measurement. Improved data are crucial for addressing stillbirth as part of the public health agenda.1 1. Stanton C, Lawn JE, et al. Stillbirth rates: delivering estimates in 190 countries. Lancet 2006;367:1487-94.
Neuro-developmental outcomes after pre-term birth Most pre-term infants have good neuro-developmental outcomes and cannot easily be distinguished from full-term infants. However as survival rates for extremely pre-term infants improve, the overall number of pre-term infants with disability and handicap has not fallen, which is having an important impact on social, educational and health services resources and adversely affecting family life. Longer-term neurodevelopmental outcomes need to be considered when reviewing the impact of neonatal intensive care for pre-term infants.1 1. Colvin M, McGuire W, Fowlie PW. Neurodevelopmental outcomes after preterm birth. BMJ 2004;329:1390–93.
Folic acid recommendations for neural tube defects A retrospective cohort study of births monitored by 13 birth defect registries in 11 European countries between 1988–98 was conducted to evaluate the effectiveness of recommendations on folic acid aimed at reducing the occurrence of neural tube defects. No detectable improvement in trends of incidence of neural tube defects followed the issuing of recommendations. The paper concludes that recommendations alone did not appear to influence trends up to six years after the confirmation of the effectiveness of 215
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folic acid in clinical trials, regardless of the form, timing or intended target of recommendations. New cases of neural tube defects which are preventable by folic acid continue to occur. A reasonable strategy would be to integrate food fortification with fuller implementation of recommendations on supplements.1 1. Botto LD, Lisi A, Robert-Gnansia E, et al. International retrospective cohort study of neural tube defects in relation to folic acid recommendations: are the recommendations working? BMJ 2005;330(7491):571–77.
Rise in maternal age in Europe and increase in Down’s syndrome The rise in average maternal age in Europe has brought with it an increase in the number of pregnancies affected by Down’s syndrome. Down’s syndrome constitutes approximately 8% of cases of registered congenital anomaly in the European Union, with over 7,000 affected pregnancies each year in the 15 member states. An analysis of data from 24 registries, covering 8.3 million births 1980–99 found that the proportion of births to mothers aged 35+ years rose from 8% to 14% overall. In 1995–99, the proportion of older mothers was 10–25%, and the total prevalence (including terminations of pregnancy) of Down’s syndrome varied from 1–3 per 1,000 births. The proportion of cases of Down’s syndrome which were prenatally diagnosed followed by termination of pregnancy in 1995–99 varied from nil in Ireland and Malta, where termination of pregnancy is illegal, to 77% in Paris. The extent to which terminations of pregnancy were concentrated among older mothers varied between regions. The widespread practice of antenatal screening and termination of pregnancy has counteracted the effect of maternal age in its effect on live birth prevalence of the syndrome.1 1. Dolk H, Loane M, et al. Trends and geographic inequalities in the prevalence of Down’s syndrome in Europe, 1980–1999. Revue d’e´pide´miologie et de sante´ publique 2005;53:2587–95.
Hormone treatment to reduce the adult height of tall girls Treatment with synthetic oestrogens to reduce adult height in tall girls has been available 216
since the 1950s to reduce psychosocial problems associated with tall stature, but little is know of the long-term outcomes. A retrospective cohort of 1,248 women, both those who were treated and those who were assessed but did not receive treatment, were identified through the records of Australian paediatricians between 1959 and 1993, together with 184 women who self-referred. All but five women were traced and invited to participate in a postal questionnaire, with 67.9% agreeing (396 treated, 448 untreated). They were asked how they felt about their current height, the assessment and treatment procedures, and the decision whether or not to have treatment. Untreated women were almost unanimously (99.1%) glad not to have been treated, no matter their current height; 42.1% of the treated women expressed dissatisfaction with the decision that was made. Dissatisfaction was related to whether or not as girls they had had a say in the decisionmaking, negative experiences of the assessment or treatment procedures, side-effects experienced in treatment and later side-effects which they believed were associated with treatment.1 1. Pyett P, Yarner J, Venn A, et al. Using hormone treatment to reduce the adult height of tall girls. Are women satisfied with the decision in later years. Social Science and Medicine 2005;61:1629–39.
Factors predisposing women to chronic pelvic pain A systematic review of 122 studies was conducted to evaluate factors predisposing women to chronic and recurrent pelvic pain, of which 63 evaluated 54 risk factors for dysmenorrhoea, 19 evaluated 14 risk factors for dyspareunia and 40 evaluated 48 factors for non-cyclical pelvic pain. Age less than 30 years, low body mass index, smoking, menarche before 12 years of age, long cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, sterilisation, clinically suspected pelvic inflammatory disease, sexual abuse and psychological symptoms were associated with dysmenorrhoea. Younger age at first childbirth, exercise and oral contraceptives were negatively associated with dysmenorrhoea. Menopause, pelvic inflammatory disease, sexual abuse, anxiety and depression were associated with dyspareunia. Drug or alcohol abuse, miscarriage, heavy menstrual flow, pelvic
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inflammatory disease, previous caesarean section, pelvic pathology, abuse and psychological co-morbidity were associated with an increased risk of non-cyclical pelvic pain. The researchers conclude that severe gynaecological and psychosocial factors are strongly associated with chronic pelvic pain and that randomised. controlled trials of interventions targeting the potentially modifiable factors are needed to assess their clinical relevance.1 1. Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: a systematic review. BMJ 2006;332(7544):749–55.
Women’s views of prophylactic mastectomy Data are accumulating on the efficacy of prophylactic mastectomy as a means to reduce breast cancer risk in high risk women. A multi-method study was conducted in Seattle (USA), among 246 women of varying ethnicities with familial breast cancer risk of their interest in and understanding of genetic testing for breast cancer susceptibility and their responses to surgery as a prophylactic measure. The majority of participants rejected the hypothetical idea of prophylactic mastectomy as a way of preventing breast cancer. They found the idea confusing, illogical and distressing and were inclined to be suspicious of any professional who might suggest it. They compared the intervention to cutting off part of one’s body for fear of future damage to that same body part. The authors argue that the logic behind these responses reflects an underlying distinction between ‘disease’ and ‘illness’. While prophylactic mastectomy may indeed prevent the ‘‘disease’’ (clinical pathology) of breast cancer, for these women surgery would actually imitate the ‘‘illness’’ (experience) of breast cancer. The authors encourage awareness among providers of this distinction and its implications for patient-provider consultations and decisions made in this context.1 1. Press N, Reynolds S, Pinsky L, et al. ‘‘That’s like chopping off a finger because you’re afraid it might get broken’’: disease and illness in women’s views of prophylactic mastectomy. Social Science & Medicine 2005;61(5):1106–17.
Reduction in mortality from breast cancer in Europe The survival of women with breast cancer in Europe in 2005 will be significantly better than for their counterparts diagnosed in the 1970–80s, although five year survival is lower in Europe than in the United States at 79% vs. 89%. Improvement in survival is unlikely to be due to a change in the biological behaviour of the cancer. It must therefore reflect improvements in diagnosing and managing breast cancer with early detection through screening and improved systemic treatment with adjuvants after surgery.1 A cohort study in Copenhagen, Denmark, evaluated the effect on breast cancer mortality of the first ten years of mammography services. Mortality in the screening period was reduced by 25% compared to what would be expected in the absence of screening. For women actually participating in screening, breast cancer mortality was reduced by 37%.2 In the United States, seven statistical models independently developed to investigate the reduction in death rates from breast cancer 1975–2000 show that mammographical screening and adjuvant treatment contributed almost equally. The proportion of the total reduction attributed to screening varied from 28% to 65% (median 46%) with adjuvant treatment contributing the rest. Variability across models in the absolute contribution of screening was larger than it was for treatment, reflecting the greater uncertainty about the benefit of screening.3 1. Jones A. Reduction in mortality from breast cancer. Screening and increased use of adjuvants are responsible – adjuvants more so [Editorial]. BMJ 2005;330:205–06. 2. Olsen AH, Njor SH, Vejborg I, et al. Breast cancer mortality in Copenhagen after introduction of mammography screening: cohort study. BMJ 2005; 330:220–24. 3. Spurgeon D. Fall in mortality from breast cancer is due almost equally to screening and adjuvant therapy [News Roundup]. BMJ 2005;331:894.
Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions Conservative methods are commonly used to treat cervical intraepithelial neoplasia and microinvasive cervical cancer in young women. Through 217
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review and analysis of 27 studies, a group of European researchers investigated the effect of these procedures on subsequent fertility and pregnancy outcomes. Cold knife incision was significantly associated with preterm delivery, low birthweight and caesarean section. Large loop excision of the transformation zone was also significantly associated with preterm delivery and premature rupture of membranes. Similar but marginally non-significant adverse effects were recorded for laser conisation. Significantly increased risks were not detected for obstetric outcomes after laser ablation. While severe outcomes such as admission to a neonatal intensive care unit or perinatal mortality showed adverse trends, these changes were not significant. The authors conclude that all the excision procedures are associated with similar pregnancy-related morbidity, without apparent neonatal morbidity, and recommend caution in the treatment of young women with mild cervical abnormalities.1 1. Kyrgiou M, Koliapoulos G, Martin-Hirsch P, et al. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet 2006; 367:489–98.
Ovarian function post-chemotherapy following ovarian cryopreservation and transplantation Ovarian function was assessed after treatment of cancer in 22 women who previously had cortical tissue from an entire ovary cryopreserved (frozen) prior to chemotherapy and after transplantation of the cryopreserved tissue. All were treated with chemotherapeutic drugs, with a risk of inducing ovarian failure. The sample of 22 women included eight with breast cancer, six with Hodgkin’s disease, two with nonHodgkin’s disease, five with leukaemia and one with a brain tumour. All underwent clinical examination after 18 months of cryopreservation. Three patients with premature ovarian failure had ovarian tissue transplanted. Nine women had signs of ovarian failure. Thirteen women still menstruated and ten had seemingly normal ovarian
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function and normal oestradiol levels. All three with transplanted ovarian tissue regained ovarian function as confirmed by return of menses, follicles on ultrasonography and normalised hormone levels. Two embryos were created from the cryopreserved tissue after IVF.1 1. Schmidt KLT, Andersen CY, Loft A. Follow-up of ovarian function post-chemotherapy following ovarian cryopreservation and transplantation. Human Reproduction 2005; 20(12):3539–46.
Control of fertility historically in China This paper challenges the widespread belief that, historically, people’s reproductive strategies were necessarily intended to maximise the number of surviving offspring and demand for children (or sons). Scholars now accept that total fertility rates historically were moderate in China, but they still disagree as to whether the Chinese could intentionally control family size. Fertility patterns were closely linked to relatively low fertility among the newly married, long birth intervals and early cessation of childbearing, and were related to the practice of child marriage, intensive and prolonged breastfeeding, comparatively low coital frequency, poor health and periodic separation. Recent examination of historical population data shows that intentional control of fertility did exist in the past. Evidence suggests that, as early as 1,000 years ago, many Chinese wished to regulate family size. The widespread practice of infanticide observed during the Song period is an example. While popular sayings promoted large families, notions discouraging high fertility were also expressed. Chinese scholars and government officials were concerned with the danger of uncontrolled population growth and commented upon it, and intellectual concerns of this nature increased markedly over the course of the last four hundred years.1 1. Zhao ZW. Towards a better understanding of past fertility regimes: the ideas and practice of controlling family size in Chinese history. Continuity and Change 2006;21(1):9–35.