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Round Up Research
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A 2007 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2007;15(29):225–229 0968-8080/06 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 07 ) 2 9 2 8 9 - 4
www.rhmjournal.org.uk
ROUND UP
Research Serious faults in design and reporting of abstinence-only studies Studies exploring the effectiveness of abstinenceonly programmes to prevent HIV are limited by severe methodological weaknesses, investigators from the Centre for Evidence-Based Medicine at Oxford University report. The studies included too few participants to justify the initiation of large-scale public health initiatives; did not specify randomisation procedures; did not report clinically meaningful outcomes (such as incident HIV infections); did not use intent-to-treat analysis to counter reporting bias by accounting for drop-outs; did not provide enough details to demonstrate if interventions were delivered as planned; and did not compare the effectiveness of abstinence programmes with health education initiatives that provided wider information on sexual health, including condom use. Missing data was also an obstacle to meta-analysis. Terms such as ‘‘virginity’’ and ‘‘intercourse’’ were often poorly defined and self-reports of sexually transmitted infections were accepted as outcome measures. Moreover, there were no comparison data; only one study compared abstinence programmes with more comprehensive sexual health education.1 1. Underhill K, et al. Reporting deficiencies in trials of abstinence-only programmes for HIV prevention. AIDS 2007;21:266–67, summarised by Carter M. Aidsmap. 12 January 2007. At: bwww.aidsmap.com/en/news/ 919D99F3-ED3E-42BB-AB4B-48D708B81702.asp? type=previewN.
Breast cancer rises in Australia and survival rate increases too The number of new cases of breast cancer in Australia has more than doubled in the past 20 years from 5,318 cases in 1983 to 12,027 women in 2002, according to a report by the National Breast Cancer Centre and Australian Institute of Health and Welfare. Those in higher socio-economic groups are at greatest risk with
Aboriginal and Torres Strait Islander women at least risk (though breast cancer is the most common cancer in this group). The increased incidence of breast cancer is accompanied by an increase in survival rates, with the risk of dying from breast cancer falling from one in 29 in 1983 to one in 36 in 2004, a lower death rate than in New Zealand, the UK, Canada or the US. Better survival rates are attributed to advances in early detection and treatment using multidisciplinary teams to deliver evidence-based care. Greater attention now needs to be given to both medical and psychosocial issues related to surviving.1 1. Pincock S. Incidence of breast cancer is rising in Australia, while death rate falls. BMJ 2006;333:876.
Views on cervical cancer screening: Trinidad and Tobago and Zimbabwe Caribbean countries have high rates of cervical cancer, and an organised screening and prevention programme is now being set up to replace the current practice of opportunistic screening. The authors of this research article used a crosssectional survey of 63 general practitioners and gynaecologists and 102 randomly sampled household members (men and women) in Port-of-Spain, Trinidad and Tobago, to find out how much they knew about Pap smears and the value of screening programmes. Many women and their partners did not fully understand the purpose of the test; almost half the women believed that one normal test result meant they were not at risk, and many believed that menopausal women need not be tested. Amongst male partners, misconceptions were even higher than in women, while doctors did not have enough information to explain the reasons for screening to women. The authors conclude that high coverage alone cannot be the sole aim of a screening programme; accurate information is needed by doctors, women and their partners.1 A study was done in two rural districts in Zimbabwe of women’s perceptions and understanding 225
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
of cervical cancer and screening through a questionnaire, in-depth interviews with women and health personnel and 20 focus groups with women. Cases of cervical cancer are increasing in Zimbabwe, but despite widespread concern about the disease more than 95% of women interviewed had not had screening and knew little about the causes, prevention or treatment of cervical disease. In Shurugwi district, no screening programme existed. Even where screening was available the uptake was low due to lack of information about availability, the misconception that lack of symptoms and pain indicated an absence of disease, reluctance to be screened by male nurses, perceived discomfort of having a smear, and the failure to prioritise screening in the light of more pressing ‘‘bread and butter’’ issues. The authors call for a national screening programme, including the use of visual inspection, health education to encourage women’s uptake of services, and research to identify the most prevalent HPV types in order to prepare for a future HPV vaccination programme.2
method at all three points had a lower educational level, were less likely to have private health insurance and less likely to have attended preand post-abortion counselling. Those who had used highly effective contraceptive methods continuously were less likely to be unemployed and more likely to report being in a stable relationship. 50% of the women who had had an abortion had changed their contraceptive practice before they got pregnant, leading to the use of a less effective contraceptive method in 67% of cases. Only 16% of those in the non-abortion group had changed their contraceptive practice in the previous six months. Many women have a break from using a highly effective method of contraception, which may be related to changes in their social lives, relationships or material conditions, while the profile of others showed a consistently high risk. However, abortion presents an opportunity for women who have little contact with health services to get the information and support they need to use highly effective contraception more consistently.1
1. Chingang LC, Bischof U, Andall-Brereton G, et al. ‘Have a Pap smear!’ – doctors, their clients, and opportunistic cervical cancer screening. International Journal of STD and AIDS 2005;16:233–36. 2. Mangoma JF, Chirenje MZ, Chimbari MJ, et al. An assessment of rural women’s knowledge, constraints and perceptions of cervical cancer screening: the case of two districts in Zimbabwe. African Journal of Reproductive Health 2006;10(1):91–103.
1. Bajos N, Lamarche-Vadel A, Gilbert F, et al. Contraception at the time of abortion: high-risk time or high-risk women? Human Reproduction 2006;21(11):2862–67.
Contraceptive use and abortion in France Despite widespread use of highly effective contraceptive methods in France, unintended pregnancies are frequent. Researchers analysed data from a population-based cohort study including 163 women who reported a recent abortion and responded to questions about their lifetime contraceptive history, and 1,787 women who had not had an abortion, but who were sexually active, non-sterile, not pregnant and not trying to get pregnant. The contraceptive practices of the women in the abortion group were mapped – six months before abortion, at the time of abortion and one month after abortion, and their postabortion contraceptive use was compared with that of the non-abortion group. Those in the abortion group using a non-highly effective 226
Induced abortion again shown not to affect the risk of breast cancer Researchers examined the role of abortion on breast cancer risk among 267,361 women in 20 centres across nine countries enrolled in the European Prospective Investigation into Cancer and Nutrition between 1992 and 2000. No evidence of a relationship between one or more induced abortions and breast cancer was found.1 1. Reeves GK, Kan S, Key T, et al. Breast cancer risk in relation to abortion: results from the EPIC study. International Journal of Cancer 2006;119(7):1741–45.
Actual fertility and fertility preference, Europe This study looks at the influence of observed fertility behaviours on fertility preference using a multi-level analysis of data from the Eurobarometer sample of 2001. The sample selected from the survey includes 5,302 individuals aged
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
20–39 including 2,563 childless individuals, from 72 regions in the 15 countries that were European Union members at the time. The effect of school attendance, age, marital status, household size, and actual fertility were analysed. In some regions, such as West Germany, actual childbearing explains family size ideals. That is, the desire for smaller families seems to result from the actual experience of low fertility.1
mothers who had continued to breastfeed exclusively were not focusing on the quantity of the milk, however. A long-term intervention involving home visits over several months to support breastfeeding was successful in increasing the duration and rates of exclusive breastfeeding, leading the authors of the study to conclude that public health campaigns would be more successful if they emphasised the processual nature of breastfeeding.1
1. Testa MR, Grilli L. The influence of childbearing regional contexts on ideal family size in Europe. Population 2006;61(1/2):109–37.
1. Scavenius M, van Hulsel L, Meijer J, et al. In practice, the theory is different: a processual analysis of breastfeeding in northeast Brazil. Social Science and Medicine 2007;64:676–88.
Breastfeeding in Brazil: product or process Despite almost total commitment to breastfeeding amongst Brazilian women, only 29% of babies are exclusively breastfed for six months. In order to understand the discrepancy between the mothers’ intentions and practice, and the impact of biological and social factors, researchers interviewed 300 mothers with infants 3–10 months old in the North East region of Aracaju about their knowledge of breastfeeding and their history and practice of breastfeeding. The women who had continued to breastfeed exclusively for an extended period described it as a process in which they needed to actively engage, using diet, massage and patience, and asking for advice and support. Several of them reported obstacles they needed to overcome, e.g. sore nipples. Of the two-thirds of women who had stopped breastfeeding altogether or were supplementing breastmilk with formula, half cited inadequate milk as the reason. Many had begun supplementing breastmilk with water to satisfy the baby’s thirst, despite being aware of advice to give breastmilk exclusively. The researchers identified the interaction of social and biological factors as creating a self-fulfilling prophecy, i.e. the belief in the need to give the baby water on a hot day combined with the practical need to leave the baby at home while at work led to the baby suckling less often, which led to lower milk production and a perceived need to supplement breastmilk. The authors argue that there is a process of stopping breastfeeding that is not recognised as such. It takes place in the context both of aggressive marketing of milk formula and the ‘‘‘breast is best’’ campaign, both of which focus on the quality of the product rather than the process itself. Those
Rape by young, rural South African men Baseline data from an evaluation of an HIV behavioural intervention was analysed to assess the prevalence, patterns and factors associated with rape of an intimate partner and of women who were not partners of young men in rural South Africa. 1,370 men aged 13–26 years were recruited from 70 study villages in the rural Eastern Cape province. The researchers asked about rape of an intimate partner, a non-intimate partner, gang rape, their own experience of childhood trauma, susceptibility to peer pressure, alcohol and substance use, sexual violence against a partner and transactional sex. Rape was highly prevalent, with gang rape the most common form. Some men reported both partner and non-partner rape. Both forms of rape were strongly associated with physical violence, transactional sex, sex with a casual partner and more sexual partners. Risk factors for perpetration of rape have much in common with risk factors for HIV, and integrated prevention planning is needed.1 1. Jewkes R, Dunkle K, Koss MP. Rape perpetration by young, rural South African men: prevalence, patterns and risk factors. Social Science and Medicine 2006;63:2949–61.
Poor pregnancy outcomes among adolescents in Kenya An adolescent Safe Motherhood survey in 2002, which included: a household-based survey of girls aged 12–19, in-depth interviews with adolescents with experience of abortion and stillbirth or pregnancy at 15 years or younger, and a community assessment of reproductive health 227
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
services found a high rate of poor pregnancy outcomes. This paper contains data on factors associated with poor outcomes, including the effect of socio-economic and demographic characteristics, the desirability of pregnancy and maternal care factors among 269 adolescent girls who had a completed pregnancy in South Nyanza, Kenya. The authors note a strong association between unintended pregnancy and pre-term birth than with wanted pregnancies. Pre-term birth was also higher in cases where antenatal care was initiated late in pregnancy and where childbirth took place outside a health facility. Pregnancies outside marriage were six times more likely to result in an abortion or stillbirth. Half of all births were reported as pre-term, possibly due to health or cultural practices amongst Luo women and a high incidence of poor nutrition, malaria, STIs and HIV, which are all risk factors for pre-term delivery. Unintended pregnancy is highly associated with poor antenatal care, and might explain the association with pre-term birth. Unintended pregnancies are also more likely to be associated with failed abortion attempts, which may also shorten gestation. With unintended pregnancies, a high incidence of reporting errors on timing of pregnancy is likely to confound statistics. Accessibility of family planning and maternity care for pregnant adolescents.1 1. Magadi M. Poor pregnancy outcomes among adolescents in South Nyanza region of Kenya. African Journal of Reproductive Health 2006;10(1):26–38.
Weight gain increases pregnancy risks in Sweden This population-based, cohort study analysed the Swedish Birth Register records of 151,025 women who had their first two singleton births between 1992 and 2001, in order to establish whether there is a causal relationship between obesity and adverse pregnancy outcomes. Information was gathered on the interval between the two pregnancies, education level, height, whether a smoker or not, and change in body mass index between the two pregnancies. Maternal and perinatal complications in the second pregnancy were noted from records made at birth and at hospital discharge, including stillbirth and largefor-gestational-age infants, pre-eclampsia, gestational hypertension, gestational diabetes and 228
caesarean delivery. Weight gain was associated with the risk of major maternal and perinatal complications, whether or not the woman was overweight, with a small gain in body mass index of one unit increasing the risk of gestational diabetes by more than 30%. A dose–response was also found: an additional two body mass index units increased average risk by 100% and three units by 200%. Pre-eclampsia and large-forgestational-age birthweight fell significantly in women who had lost more than one body mass index unit. Stillbirth, particularly at term, was strongly associated with inter-pregnancy weight change after adjusting for maternal diabetes, pre-eclampsia and hypertension. The impact of weight gain on pregnancy outcomes, even in women who were not overweight and in the absence of obesity-related conditions, led to the following conclusion: there is a causal relationship between weight gain and poor pregnancy outcomes, independent of factors common both to obesity and to maternal and perinatal complications. The authors call for public health interventions to help women avoid post-partum weight retention.1 Randomised trials of weight loss interventions before pregnancy and postpartum weight loss are needed in the context of an increase in obesity in the developed world. Such interventions could affect women’s health in the long term as well as pregnancy outcomes. Further research should assess what level of body mass index reduction is necessary in obese and overweight women if they are to reduce their risks.2 1. Villamore E, Cnattingius S. Inter-pregnancy weight change and risk of adverse pregnancy outcomes: a population-based study. Lancet 2006;368:1164–70. 2. Caughey AB. Obesity, weight loss and pregnancy outcomes [Commentary]. Lancet 2006;368:1136–38.
Tackling maternal mortality Though some countries have reduced maternal mortality over the past 25 years, the lifetime risk of dying as a result of pregnancy or childbirth is still one in six in the poorest parts of the world. In order to achieve progress towards Millennium Development Goal 5 on reducing maternal mortality, efforts need to target those most at risk at the times and places they are most at risk. Those countries with the greatest burden of maternal mortality such as sub-Saharan Africa and South
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
that the impact on maternal mortality is not accurately understood. Deaths due to accident, murder or suicide during or after pregnancy need to be examined to understand whether they are related to or independent of pregnancy. Only by distinguishing between direct causes and the impact of background factors will strategies be effective in tackling maternal mortality. A further distinction needs to be made between those women who reach hospital in time, but die due to lack of adequate professional care, and those who are unable to reach a hospital at all or in time to access care. A country’s wealth alone is not an adequate indicator of likely risks. Great inequalities in risk exist within countries between rural and urban areas, and between rich and poor. Non-economic factors relating to culture, marital status, ethnicity, race and caste have their own impact. Specific strategies are needed; otherwise, resources will not be targeted accurately towards meeting the MDG goal.1 1. Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006;368:1189–1200.
THOMAS HOEPKER / MAGNUM PHOTOS
Asia have the poorest data, but evidence shows that a substantial proportion of maternal deaths take place in hospital and mainly occur around labour, delivery and the immediate post-partum period. Inequalities in the risk of maternal death exist within as well as between countries. Progress in Thailand, Sri Lanka, Honduras and Egypt is attributable to more access to trained and supervised medical and midwifery staff. In Matlab, Bangladesh, in contrast, health and family planning services leading to better general health, lower fertility and fewer deaths from abortion have resulted in a substantial decrease in maternal mortality, even though most women still deliver at home without a professional attendant. Understanding the epidemiology of maternal mortality and the timing of deaths from different causes in different areas can help to identify the most useful interventions and inform strategies to dramatically reduce mortality rates. Reporting of deaths from complications of unsafe abortion varies hugely, especially the incidence at population level. Insufficient diagnosis of HIV and AIDS in pregnant women means
Welcome for Chile’s first woman president, 2006 229
A 2007 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2007;15(29):225–229 0968-8080/06 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 07 ) 2 9 2 8 9 - 4
www.rhmjournal.org.uk
ROUND UP
Research Serious faults in design and reporting of abstinence-only studies Studies exploring the effectiveness of abstinenceonly programmes to prevent HIV are limited by severe methodological weaknesses, investigators from the Centre for Evidence-Based Medicine at Oxford University report. The studies included too few participants to justify the initiation of large-scale public health initiatives; did not specify randomisation procedures; did not report clinically meaningful outcomes (such as incident HIV infections); did not use intent-to-treat analysis to counter reporting bias by accounting for drop-outs; did not provide enough details to demonstrate if interventions were delivered as planned; and did not compare the effectiveness of abstinence programmes with health education initiatives that provided wider information on sexual health, including condom use. Missing data was also an obstacle to meta-analysis. Terms such as ‘‘virginity’’ and ‘‘intercourse’’ were often poorly defined and self-reports of sexually transmitted infections were accepted as outcome measures. Moreover, there were no comparison data; only one study compared abstinence programmes with more comprehensive sexual health education.1 1. Underhill K, et al. Reporting deficiencies in trials of abstinence-only programmes for HIV prevention. AIDS 2007;21:266–67, summarised by Carter M. Aidsmap. 12 January 2007. At: bwww.aidsmap.com/en/news/ 919D99F3-ED3E-42BB-AB4B-48D708B81702.asp? type=previewN.
Breast cancer rises in Australia and survival rate increases too The number of new cases of breast cancer in Australia has more than doubled in the past 20 years from 5,318 cases in 1983 to 12,027 women in 2002, according to a report by the National Breast Cancer Centre and Australian Institute of Health and Welfare. Those in higher socio-economic groups are at greatest risk with
Aboriginal and Torres Strait Islander women at least risk (though breast cancer is the most common cancer in this group). The increased incidence of breast cancer is accompanied by an increase in survival rates, with the risk of dying from breast cancer falling from one in 29 in 1983 to one in 36 in 2004, a lower death rate than in New Zealand, the UK, Canada or the US. Better survival rates are attributed to advances in early detection and treatment using multidisciplinary teams to deliver evidence-based care. Greater attention now needs to be given to both medical and psychosocial issues related to surviving.1 1. Pincock S. Incidence of breast cancer is rising in Australia, while death rate falls. BMJ 2006;333:876.
Views on cervical cancer screening: Trinidad and Tobago and Zimbabwe Caribbean countries have high rates of cervical cancer, and an organised screening and prevention programme is now being set up to replace the current practice of opportunistic screening. The authors of this research article used a crosssectional survey of 63 general practitioners and gynaecologists and 102 randomly sampled household members (men and women) in Port-of-Spain, Trinidad and Tobago, to find out how much they knew about Pap smears and the value of screening programmes. Many women and their partners did not fully understand the purpose of the test; almost half the women believed that one normal test result meant they were not at risk, and many believed that menopausal women need not be tested. Amongst male partners, misconceptions were even higher than in women, while doctors did not have enough information to explain the reasons for screening to women. The authors conclude that high coverage alone cannot be the sole aim of a screening programme; accurate information is needed by doctors, women and their partners.1 A study was done in two rural districts in Zimbabwe of women’s perceptions and understanding 225
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
of cervical cancer and screening through a questionnaire, in-depth interviews with women and health personnel and 20 focus groups with women. Cases of cervical cancer are increasing in Zimbabwe, but despite widespread concern about the disease more than 95% of women interviewed had not had screening and knew little about the causes, prevention or treatment of cervical disease. In Shurugwi district, no screening programme existed. Even where screening was available the uptake was low due to lack of information about availability, the misconception that lack of symptoms and pain indicated an absence of disease, reluctance to be screened by male nurses, perceived discomfort of having a smear, and the failure to prioritise screening in the light of more pressing ‘‘bread and butter’’ issues. The authors call for a national screening programme, including the use of visual inspection, health education to encourage women’s uptake of services, and research to identify the most prevalent HPV types in order to prepare for a future HPV vaccination programme.2
method at all three points had a lower educational level, were less likely to have private health insurance and less likely to have attended preand post-abortion counselling. Those who had used highly effective contraceptive methods continuously were less likely to be unemployed and more likely to report being in a stable relationship. 50% of the women who had had an abortion had changed their contraceptive practice before they got pregnant, leading to the use of a less effective contraceptive method in 67% of cases. Only 16% of those in the non-abortion group had changed their contraceptive practice in the previous six months. Many women have a break from using a highly effective method of contraception, which may be related to changes in their social lives, relationships or material conditions, while the profile of others showed a consistently high risk. However, abortion presents an opportunity for women who have little contact with health services to get the information and support they need to use highly effective contraception more consistently.1
1. Chingang LC, Bischof U, Andall-Brereton G, et al. ‘Have a Pap smear!’ – doctors, their clients, and opportunistic cervical cancer screening. International Journal of STD and AIDS 2005;16:233–36. 2. Mangoma JF, Chirenje MZ, Chimbari MJ, et al. An assessment of rural women’s knowledge, constraints and perceptions of cervical cancer screening: the case of two districts in Zimbabwe. African Journal of Reproductive Health 2006;10(1):91–103.
1. Bajos N, Lamarche-Vadel A, Gilbert F, et al. Contraception at the time of abortion: high-risk time or high-risk women? Human Reproduction 2006;21(11):2862–67.
Contraceptive use and abortion in France Despite widespread use of highly effective contraceptive methods in France, unintended pregnancies are frequent. Researchers analysed data from a population-based cohort study including 163 women who reported a recent abortion and responded to questions about their lifetime contraceptive history, and 1,787 women who had not had an abortion, but who were sexually active, non-sterile, not pregnant and not trying to get pregnant. The contraceptive practices of the women in the abortion group were mapped – six months before abortion, at the time of abortion and one month after abortion, and their postabortion contraceptive use was compared with that of the non-abortion group. Those in the abortion group using a non-highly effective 226
Induced abortion again shown not to affect the risk of breast cancer Researchers examined the role of abortion on breast cancer risk among 267,361 women in 20 centres across nine countries enrolled in the European Prospective Investigation into Cancer and Nutrition between 1992 and 2000. No evidence of a relationship between one or more induced abortions and breast cancer was found.1 1. Reeves GK, Kan S, Key T, et al. Breast cancer risk in relation to abortion: results from the EPIC study. International Journal of Cancer 2006;119(7):1741–45.
Actual fertility and fertility preference, Europe This study looks at the influence of observed fertility behaviours on fertility preference using a multi-level analysis of data from the Eurobarometer sample of 2001. The sample selected from the survey includes 5,302 individuals aged
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
20–39 including 2,563 childless individuals, from 72 regions in the 15 countries that were European Union members at the time. The effect of school attendance, age, marital status, household size, and actual fertility were analysed. In some regions, such as West Germany, actual childbearing explains family size ideals. That is, the desire for smaller families seems to result from the actual experience of low fertility.1
mothers who had continued to breastfeed exclusively were not focusing on the quantity of the milk, however. A long-term intervention involving home visits over several months to support breastfeeding was successful in increasing the duration and rates of exclusive breastfeeding, leading the authors of the study to conclude that public health campaigns would be more successful if they emphasised the processual nature of breastfeeding.1
1. Testa MR, Grilli L. The influence of childbearing regional contexts on ideal family size in Europe. Population 2006;61(1/2):109–37.
1. Scavenius M, van Hulsel L, Meijer J, et al. In practice, the theory is different: a processual analysis of breastfeeding in northeast Brazil. Social Science and Medicine 2007;64:676–88.
Breastfeeding in Brazil: product or process Despite almost total commitment to breastfeeding amongst Brazilian women, only 29% of babies are exclusively breastfed for six months. In order to understand the discrepancy between the mothers’ intentions and practice, and the impact of biological and social factors, researchers interviewed 300 mothers with infants 3–10 months old in the North East region of Aracaju about their knowledge of breastfeeding and their history and practice of breastfeeding. The women who had continued to breastfeed exclusively for an extended period described it as a process in which they needed to actively engage, using diet, massage and patience, and asking for advice and support. Several of them reported obstacles they needed to overcome, e.g. sore nipples. Of the two-thirds of women who had stopped breastfeeding altogether or were supplementing breastmilk with formula, half cited inadequate milk as the reason. Many had begun supplementing breastmilk with water to satisfy the baby’s thirst, despite being aware of advice to give breastmilk exclusively. The researchers identified the interaction of social and biological factors as creating a self-fulfilling prophecy, i.e. the belief in the need to give the baby water on a hot day combined with the practical need to leave the baby at home while at work led to the baby suckling less often, which led to lower milk production and a perceived need to supplement breastmilk. The authors argue that there is a process of stopping breastfeeding that is not recognised as such. It takes place in the context both of aggressive marketing of milk formula and the ‘‘‘breast is best’’ campaign, both of which focus on the quality of the product rather than the process itself. Those
Rape by young, rural South African men Baseline data from an evaluation of an HIV behavioural intervention was analysed to assess the prevalence, patterns and factors associated with rape of an intimate partner and of women who were not partners of young men in rural South Africa. 1,370 men aged 13–26 years were recruited from 70 study villages in the rural Eastern Cape province. The researchers asked about rape of an intimate partner, a non-intimate partner, gang rape, their own experience of childhood trauma, susceptibility to peer pressure, alcohol and substance use, sexual violence against a partner and transactional sex. Rape was highly prevalent, with gang rape the most common form. Some men reported both partner and non-partner rape. Both forms of rape were strongly associated with physical violence, transactional sex, sex with a casual partner and more sexual partners. Risk factors for perpetration of rape have much in common with risk factors for HIV, and integrated prevention planning is needed.1 1. Jewkes R, Dunkle K, Koss MP. Rape perpetration by young, rural South African men: prevalence, patterns and risk factors. Social Science and Medicine 2006;63:2949–61.
Poor pregnancy outcomes among adolescents in Kenya An adolescent Safe Motherhood survey in 2002, which included: a household-based survey of girls aged 12–19, in-depth interviews with adolescents with experience of abortion and stillbirth or pregnancy at 15 years or younger, and a community assessment of reproductive health 227
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
services found a high rate of poor pregnancy outcomes. This paper contains data on factors associated with poor outcomes, including the effect of socio-economic and demographic characteristics, the desirability of pregnancy and maternal care factors among 269 adolescent girls who had a completed pregnancy in South Nyanza, Kenya. The authors note a strong association between unintended pregnancy and pre-term birth than with wanted pregnancies. Pre-term birth was also higher in cases where antenatal care was initiated late in pregnancy and where childbirth took place outside a health facility. Pregnancies outside marriage were six times more likely to result in an abortion or stillbirth. Half of all births were reported as pre-term, possibly due to health or cultural practices amongst Luo women and a high incidence of poor nutrition, malaria, STIs and HIV, which are all risk factors for pre-term delivery. Unintended pregnancy is highly associated with poor antenatal care, and might explain the association with pre-term birth. Unintended pregnancies are also more likely to be associated with failed abortion attempts, which may also shorten gestation. With unintended pregnancies, a high incidence of reporting errors on timing of pregnancy is likely to confound statistics. Accessibility of family planning and maternity care for pregnant adolescents.1 1. Magadi M. Poor pregnancy outcomes among adolescents in South Nyanza region of Kenya. African Journal of Reproductive Health 2006;10(1):26–38.
Weight gain increases pregnancy risks in Sweden This population-based, cohort study analysed the Swedish Birth Register records of 151,025 women who had their first two singleton births between 1992 and 2001, in order to establish whether there is a causal relationship between obesity and adverse pregnancy outcomes. Information was gathered on the interval between the two pregnancies, education level, height, whether a smoker or not, and change in body mass index between the two pregnancies. Maternal and perinatal complications in the second pregnancy were noted from records made at birth and at hospital discharge, including stillbirth and largefor-gestational-age infants, pre-eclampsia, gestational hypertension, gestational diabetes and 228
caesarean delivery. Weight gain was associated with the risk of major maternal and perinatal complications, whether or not the woman was overweight, with a small gain in body mass index of one unit increasing the risk of gestational diabetes by more than 30%. A dose–response was also found: an additional two body mass index units increased average risk by 100% and three units by 200%. Pre-eclampsia and large-forgestational-age birthweight fell significantly in women who had lost more than one body mass index unit. Stillbirth, particularly at term, was strongly associated with inter-pregnancy weight change after adjusting for maternal diabetes, pre-eclampsia and hypertension. The impact of weight gain on pregnancy outcomes, even in women who were not overweight and in the absence of obesity-related conditions, led to the following conclusion: there is a causal relationship between weight gain and poor pregnancy outcomes, independent of factors common both to obesity and to maternal and perinatal complications. The authors call for public health interventions to help women avoid post-partum weight retention.1 Randomised trials of weight loss interventions before pregnancy and postpartum weight loss are needed in the context of an increase in obesity in the developed world. Such interventions could affect women’s health in the long term as well as pregnancy outcomes. Further research should assess what level of body mass index reduction is necessary in obese and overweight women if they are to reduce their risks.2 1. Villamore E, Cnattingius S. Inter-pregnancy weight change and risk of adverse pregnancy outcomes: a population-based study. Lancet 2006;368:1164–70. 2. Caughey AB. Obesity, weight loss and pregnancy outcomes [Commentary]. Lancet 2006;368:1136–38.
Tackling maternal mortality Though some countries have reduced maternal mortality over the past 25 years, the lifetime risk of dying as a result of pregnancy or childbirth is still one in six in the poorest parts of the world. In order to achieve progress towards Millennium Development Goal 5 on reducing maternal mortality, efforts need to target those most at risk at the times and places they are most at risk. Those countries with the greatest burden of maternal mortality such as sub-Saharan Africa and South
Round Up: Research / Reproductive Health Matters 2007;15(29):225–229
that the impact on maternal mortality is not accurately understood. Deaths due to accident, murder or suicide during or after pregnancy need to be examined to understand whether they are related to or independent of pregnancy. Only by distinguishing between direct causes and the impact of background factors will strategies be effective in tackling maternal mortality. A further distinction needs to be made between those women who reach hospital in time, but die due to lack of adequate professional care, and those who are unable to reach a hospital at all or in time to access care. A country’s wealth alone is not an adequate indicator of likely risks. Great inequalities in risk exist within countries between rural and urban areas, and between rich and poor. Non-economic factors relating to culture, marital status, ethnicity, race and caste have their own impact. Specific strategies are needed; otherwise, resources will not be targeted accurately towards meeting the MDG goal.1 1. Ronsmans C, Graham WJ. Maternal mortality: who, when, where and why. Lancet 2006;368:1189–1200.
THOMAS HOEPKER / MAGNUM PHOTOS
Asia have the poorest data, but evidence shows that a substantial proportion of maternal deaths take place in hospital and mainly occur around labour, delivery and the immediate post-partum period. Inequalities in the risk of maternal death exist within as well as between countries. Progress in Thailand, Sri Lanka, Honduras and Egypt is attributable to more access to trained and supervised medical and midwifery staff. In Matlab, Bangladesh, in contrast, health and family planning services leading to better general health, lower fertility and fewer deaths from abortion have resulted in a substantial decrease in maternal mortality, even though most women still deliver at home without a professional attendant. Understanding the epidemiology of maternal mortality and the timing of deaths from different causes in different areas can help to identify the most useful interventions and inform strategies to dramatically reduce mortality rates. Reporting of deaths from complications of unsafe abortion varies hugely, especially the incidence at population level. Insufficient diagnosis of HIV and AIDS in pregnant women means
Welcome for Chile’s first woman president, 2006 229