Volume 8, Number 26
30 June 2008

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ADOLESCENT HEALTH RESEARCH

Sexual and reproductive health service needs of university / college students: Updates from a survey in Shanghai, China
(Abstract; subscription needed for full text; Asia)
Asian Journal of Andrology. 2008 July;10(4):607-615.
Chen B | Lu YN | Wang HX | Ma QL | Zhao XM
The aim of the study was to promote the provision of reproductive health services to young people by exploring the attitudes and perceptions of university students in Shanghai, China, toward reproductive health. From July 2004 to May 2006, 5 243 students from 14 universities in Shanghai took part in our survey. Topics covered the demands of reproductive health-care services, attitudes towards and experience with sex, exposure to pornographic material, and knowledge on sexual health and sexually transmitted infections (STIs)/AIDS. Of the 5 067 students who provided valid answer sheets, 50.05% were female and 49.95% were male, 14.86% were medical students, and 85.14% had non-medical backgrounds. A total of 38.4% of respondents had received reproductive health education previously. The majority of students supported school-based reproductive health education, and also acquired information about sex predominantly from books, schoolmates, and the Internet. Premarital sexual behavior was opposed by 17.7% of survey participants, and 37.5% could identify all the three types of STIs listed in the questionnaire. Although 83.7% knew how HIV is transmitted, only 55.7% knew when to use a condom and 57.8% knew that the use of condoms could reduce the risk of HIV infection. The reproductive health service is lagging behind current attitudes and demands of university students. Although students' attitudes towards sexual matters are liberal, their knowledge about reproductive health and STIs/AIDS is still limited. It is therefore necessary to provide effective and confidential reproductive health services to young people.

Adolescent maternity in a low income community: Experiences revealed by oral history
(Abstract; subscription needed for full text; South America)
Revista Latino-Americana de Enfermagem. 2008 Mar-Apr;16(2):280-286.
Hoga LA
Adolescent maternity involves relevant factors associated with each family, culture and society. This research aimed to describe the experiences in the trajectory of adolescent maternity. The oral history method was used, obtaining the narratives of 21 adolescent mothers living in a low income community located in Sao Paulo City, Brazil. The following descriptive categories emerged from the narratives: Pregnancy: an event in the initial phase of the relationship; Insufficient knowledge and access to contraceptives, gender inferiority and God's will: the ways to look at pregnancy; To escape from family problems and define the life course: the personal meanings attributed to pregnancy; More gain than pain: the balance of adolescent maternity. Adolescent maternity in low income contexts involves very complex factors and requires an integral, integrated, personal and family centered care.

FAMILY PLANNING RESEARCH

Ensuring a wide range of family planning choices
(Policy Brief; Global)
Washington, D.C., Population Reference Bureau [PRB], BRinging Information to Decisionmakers for Global Effectiveness [BRIDGE], 2008. [4] p. (USAID Cooperative Agreement No. GPO-A-00-03-00004-)
Ashford L
The use of contraception varies widely around the world, both in terms of total use and the types of methods used. In many countries, women and couples rely largely on one or two contraceptive methods, because of government policies, the way that national family planning programs have evolved, and cultural or social preferences (see box below). Understanding why people prefer some contraceptive methods over others can be useful for strengthening family planning programs. Having a broad range of methods available is a key element of the quality of family planning services and raises the overall level of contraceptive use. Family planning programs ideally should offer choices of methods for all stages of people's reproductive lives, so that they can have the number of children they want, when they want them.

Contraceptive effectiveness of two insertions of quinacrine: Results from 10-year follow-up in Vietnam
(Abstract; subscription needed for full text; Asia)
Contraception. 2008 Jul;78(1):61-65.
Sokal DC | Do Trong Hieu | Nguyen Dinh Loan | Hubacher D | Nanda K
This study was conducted to evaluate the long-term effectiveness of two insertions of quinacrine pellets for nonsurgical sterilization among women in northern Vietnam. The study design was an observational cohort study of 1335 women who received two quinacrine insertions between 1989 and 1993. About 90% of the study population participated in the last round of interviews. Cumulative follow-up time for this cohort was 14,294 person-years. The 1-, 5- and 10-year cumulative pregnancy probabilities for quinacrine were 3.3% (95% CI, 2.4-4.3), 10.0% (95% CI, 8.4-11.6) and 12.1% (95% CI, 10.4-13.9), respectively. Pregnancy estimates with quinacrine in this cohort were higher than that reported from US-based research on surgical tubal sterilization and higher than results of quinacrine sterilization in Chile. Quinacrine effectiveness was better among older women. The effectiveness of quinacrine in Vietnam was lower than other forms of sterilization. Factors such as inconsistent training and use of various insertion techniques may have contributed to the relatively high failure rate.

Unintended pregnancy in sub-Saharan Africa: Magnitude of the problem and potential role of contraceptive implants to alleviate it
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Contraception. 2008 Jul;78(1):73-78.
Hubacher D | Mavranezouli I | McGinn E
Unintended pregnancies continue to burden many countries in sub-Saharan Africa. Our aim was to estimate the number of unintended pregnancies in the region and model the impact of expanding use of contraceptive implants at the expense of short-term hormonal birth control methods. For the 42 countries in mainland sub-Saharan Africa, we estimated current levels of unintended pregnancy, prevalence of hormonal contraceptive use and number of unintended pregnancies stemming from early discontinuation and typical method failure rates. Using a decision-analytic model, we estimated the potential impact of more widespread use of the contraceptive implant. Every year in sub-Saharan Africa, approximately 14 million unintended pregnancies occur and a sizeable proportion is due to poor use of short-term hormonal methods. If 20% of the 17.6 million women using oral contraceptives or injectables wanted long-term protection and switched to the contraceptive implant, over 1.8 million unintended pregnancies could be averted over a 5-year period. Poor patterns of short-term hormonal contraceptive use (high discontinuation rates and incorrect use) contribute significantly to the problem of unintended pregnancy in sub-Saharan Africa. More availability and widespread use of highly effective methods, such as the contraceptive implant, will improve reproductive health in the region.

GENDER and HEALTH RESEARCH

Correspondence analysis: A method for classifying similar patterns of violence against women
(Abstract; subscription needed for full text; South America)
Cadernos de Saude Publica. 2008 Jun;24(6):1397-1406.
da Mota JC | Vasconcelos AG | de Assis SG
Violence against woman has received relatively little debate in society. It includes physical, psychological, and sexual abuse that jeopardizes the victim's health. Multivariate correspondence analysis and cluster analysis were applied to crimes reported to the Integrated Women's Aid Center in Rio de Janeiro, Brazil, to investigate associations between injury and define criteria for classifying the aggressions. Three groups of abuse were identified, differing according to the nature (physical, psychological, or sexual) and severity of the crimes. Less serious crimes consisted of threats and moderate physical injuries. The intermediate severity group included serious physical assault and threats. More serious crimes included death threats, rape, and sexual assault. The method thus allowed classification of the crimes in three groups according to severity.

Marital violence: Is it a factor affecting the reproductive health status of women?
(Abstract; subscription needed for full text; Europe)
Journal of Family Violence. 2008 Aug;23(6):437-445.
Akyuz A | Sahiner G | Bakir B
The aim of this study is to determine the effects of violence on the reproductive health of women and utilization of reproductive health services. The study population consisted of 250 married women aged 15 to 49, selected from patients at two different hospitals' obstetrics and gynecology clinics in Ankara, Turkey. A data collection form and the "Scale of Marital Violence Against Women" were used to obtain data. According to the study, women who have lower education levels and who first experience marriage and sexual intercourse at a younger age suffer from violence more frequently. Women experiencing violence have higher gravida and para numbers. The majority of these women has not undergone appropriate prenatal care and delivered their babies under the supervision of a health care professional. These women have been using traditional and ineffective contraceptive methods. Marital violence has led to unfavorable effects on these women's reproductive health and utilization of reproductive health services.

'Boys will be boys': Traditional Xhosa male circumcision, HIV and sexual socialisation in contemporary South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Culture, Health and Sexuality. 2008 Jun;10(5):431-446.
Vincent L
Ritual male circumcision is among the most secretive and sacred of rites practiced by the Xhosa of South Africa. Recently, the alarming rate of death and injury among initiates has led to the spotlight of media attention and government regulation being focused on traditional circumcision. While many of the physical components of the ritual have been little altered by the centuries, its cultural and social meanings have not remained unchanged. This paper attempts to understand how some of these cultural and social meanings have shifted, particularly with respect to attitudes towards sex and the role that circumcision schools traditionally played in the sexual socialisation of Xhosa youth. Ritual circumcision is often defended on the basis of its usefulness as a mechanism for the maintenance of social order, particularly in relation to the perceived crisis in youth sexuality marked by extremely high levels of gender-based violence as well as HIV infection. However, the paper suggests two key ways in which traditional Xhosa circumcision has changed. These include the erosion of the role which circumcision schools once played in the sexual socialisation of young men and the emergence of the idea that initiation gives men the unlimited and unquestionable right to access to sex rather than marking the point at which sexual responsibility and restraint is introduced into the lifestyle of young men.

Women, war, and violence: Surviving the experience
(Abstract; subscription needed for full text; Middle East)
Journal of Women's Health. 2008;17(5):793-804.
Usta J | Farver JA | Zein L
The objective of this study was to investigate how Lebanese women were affected by the July 2006 conflict that erupted between the Hezbollah and the State of Israel, with a specific focus on their personal violence exposure and how they coped with these circumstances. Participants were 310 women at Ministry of Social Affairs Centers (MOSA) located in six geographic areas with varying exposure to the conflict. A questionnaire was administered in interview format to collect information about the participants' demographic characteristics, experiences of the conflict, perceived psychological functioning, exposure to violence associated with the conflict, exposure to domestic violence during and after the conflict, and their coping strategies. Of the women, 89% had to leave their homes during the conflict because of fear or worry about safety. Of the 310 participants, 39% reported at least one encounter with violence perpetrated by soldiers, 27% reported at least one incident of domestic abuse during the conflict, and 13% reported at least one incident after the conflict perpetrated by their husbands or other family members. Women's self-reported negative mental health scores were positively correlated with the violence associated with the conflict and with domestic violence during and after the conflict. Women who reported that they did not know how to cope or had just tried to forget about their experiences reported more frequent domestic violence exposure during the conflict and had higher negative mental health outcomes associated with the conflict than did those who reported using active strategies. During armed conflict, domestic violence is also likely to increase. Therefore, when investigating the psychological impact of war on women, both forms of violence exposure should be considered. The use of active coping strategies may help in reducing psychological distress.

What matters most: An investigation of predictors of perceived stress among young mothers in Khayelitsha
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Health Care for Women International. 2008 Jul;29(6):638-648.
BeLue R | Schreiner AS | Taylor-Richardson K | Murray-Kolb LE | Beard JL
Our purpose in the present study was to examine how two different sets of stressors, one representing the physical environment and the other representing the social environment, related to perceived stress among new mothers served by a health clinic in Khayelitsha, South Africa. We found that among the chronic urban poverty-environmental stressors related to water, housing, transportation, toileting, and lack of food, that lack of drinkable water in the home had the strongest correlation with perceived stress. In terms of social stressors we found that 60% of new mothers had no partner, and 43% of those with a partner reported that they currently were not coresiding. In terms of the social stressors, the inability to depend on a partner in times of trouble had the strongest relationship to perceived stress. Other findings relating to partner support are discussed as well as sample and community characteristics. Given the importance of partner support, it is argued that the conditions of poverty itself serve to destabilize relationships, which in turn contributes to the cycle of poverty experienced by many residents of periurban settlements like Khayelitsha.

HIV/AIDS and STIs RESEARCH

Risk compensation is not associated with male circumcision in Kisumu, Kenya: A multi-faceted assessment of men enrolled in a randomized controlled trial
(Abstract; subscription needed for full text; Sub-Saharan Africa)
PLoS One. 2008 Jun;3(6):[9] p.
Mattson CL | Campbell RT | Bailey RC | Agot K | Ndinya-Achola JO
Three randomized controlled trials (RCTs) have confirmed that male circumcision (MC) significantly reduces acquisition of HIV-1 infection among men. The objective of this study was to perform a comprehensive, prospective evaluation of risk compensation, comparing circumcised versus uncircumcised controls in a sample of RCT participants. Between March 2004 and September 2005, we systematically recruited men enrolled in a RCT of MC in Kenya. Detailed sexual histories were taken using a modified Timeline Follow-back approach at baseline, 6, and 12 months. Participants provided permission to obtain circumcision status and laboratory results from the RCT. We evaluated circumcised and uncircumcised men's sexual behavior using an 18-item risk propensity score and acquisition of incident infections of gonorrhea, chlamydia, and trichomoniasis. Of 1780 eligible RCT participants, 1319 enrolled (response rate = 74%). At the baseline RCT visit, men who enrolled in the sub-study reported the same sexual behaviors as men who did not. We found a significant reduction in sexual risk behavior among both circumcised and uncircumcised men from baseline to 6 (p less than 0.01) and 12 (p = 0.05) months post-enrollment. Longitudinal analyses indicated no statistically significant differences between sexual risk propensity scores or in incident infections of gonorrhea, chlamydia, and trichomoniasis between circumcised and uncircumcised men. These results are based on the most comprehensive analysis of risk compensation yet done. In the context of a RCT, circumcision did not result in increased HIV risk behavior. Continued monitoring and evaluation of risk compensation associated with circumcision is needed as evidence supporting its' efficacy is disseminated and MC is widely promoted for HIV prevention.

An outcome assessment of an ABC-based HIV peer education intervention among Kenyan university students
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Journal of Health Communication. 2008 Jun;13(4):345-356.
Miller AN | Mutungi M | Facchini E | Barasa B | Ondieki W
This study reports an outcome assessment on an HIV peer education intervention at the main campus of Kenyatta University in Nairobi, Kenya. A quasiexperimental separate sample pretest-posttest design was used. Campus-wide baseline and endline surveys were conducted with 632 and 746 students, respectively, soliciting information on HIV-related knowledge, attitudes, and behavior. After 2 years of on-campus intervention, no changes in behavior were evident with respect to either abstinence or number of sexual partners. Small but statistically significant changes were found in condom attitudes and behavior, and a large increase in HIV testing was evident. It is recommended that future research more specifically compare abstinence versus multiple option peer education programs, giving special attention to the role of peer educators as models.

Community action for preventing HIV in Cambodia: Evaluation of a 3-year project
(Abstract; subscription needed for full text; Asia)
Health Policy and Planning. 2008;23(4):277-287.
Sopheab H | Fylkesnes K | Lim Y | Godwin P
The 'Community Action for Preventing HIV/AIDS Project' was implemented in four provinces in Cambodia (2001-04) to support a comprehensive set of HIV prevention efforts. Implementation was strictly monitored in terms of inputs, outputs and outcomes. We examine changes in these variables during the project period to assess the extent to which they were related to the project. Inputs and outputs were monitored regularly by supervision and quarterly project reports. Baseline and follow-up surveys were conducted on 10 target groups to measure changes in outcome indicators related to sexual risk behaviours, uses of HIV voluntary counselling and testing (VCT), self-reported sexually transmitted infections (STIs) and other indicators. The analyses use data from surveys and from project monitoring. Spending on HIV-related work at provincial level increased markedly, including investments in VCT, STI facilities and staff training. Yearly expenditure increased about 7-fold compared with years immediately preceding the project. VCT centres increased from 3 to 12, numbers of counsellors from 10 to 27, and numbers of client visits more than doubled. STI laboratory facilities increased from 0 to 6 with coverage of STI check-ups among sex workers increasing from 70% to 93% and a decline in men attending STI clinics. The survey results indicate significant changes in a number of major outcome indicators such as consistent condom use related to sex work (greater than 80%), HIV testing and counselling after HIV tests, especially among police (42 to 72%, P less than 0.001) and brothel-based sex workers (48 to 89%, P less than 0.001). Self-reported STIs declined in most groups. Finally, the programmatic systems for planning, managing and monitoring implementation of activities at both central and provincial level, as well as technical guidelines, developed under the project have become the standard for the national programme. In conclusion, the project appears to have been comprehensive and a number of favourable changes in output and outcome indicators occurred. It seems likely that the project made a substantial contribution to these positive outcomes, though the extent is not clear. The project is likely to have powerful long-term effects through strengthening of capacity and establishment of systems for the national programme.

Second-line antiretroviral therapy in resource-limited settings: The experience of Medecins Sans Frontieres
(Abstract; subscription needed for full text; Global)
AIDS. 2008 Jul;22(11):1305-1312.
Pujades-Rodriguez M | O'Brien D | Humblet P | Calmy A
The objectives were to describe the use of second-line protease-inhibitor regimens in Medecins Sans Frontieres HIV programmes, and determine switch rates, clinical outcomes, and factors associated with survival. We used patient data from 62 Medecins Sans Frontieres programmes and included all antiretroviral therapy-naive adults (greater than 15 years) at the start of antiretroviral therapy and switched to a protease inhibitor-containing regimen with at least one nucleoside reverse transcriptase inhibitor change after more than 6 months of nonnucleoside reverse transcriptase inhibitor first-line use. Cumulative switch rates and survival curves were estimated using Kaplan-Meier methods, and mortality predictors were investigated using Poisson regression. Of 48 338 adults followed on antiretroviral therapy, 370 switched to a second-line regimen after a median of 20 months (switch rate 4.8/1000 person-years). Median CD4 cell count at switch was 99 cells/ml (interquartile ratio 39-200; n = 244). A lopinavir/ritonavir-based regimen was given to 51% of patients and nelfinavir-based regimen to 43%; 29% changed one nucleoside reverse transcriptase inhibitor and 71% changed two nucleoside reverse transcriptase inhibitors. Median follow-up on second-line antiretroviral therapy was 8 months, and probability of remaining in care at 12 months was 0.86. Median CD4 gains were 90 at 6 months and 135 at 12 months. Death rates were higher in patients in World Health Organization stage 4 at antiretroviral therapy initiation and in those with CD4 nadir count less than 50 cells/ml. The rate of switch to second-line treatment in antiretroviral therapy-naive adults on non-nucleoside reverse transcriptase inhibitor-based first-line antiretroviral therapy was relatively low, with good early outcomes observed in protease inhibitor-based second-line regimens. Severe immunosuppression was associated with increased mortality on second-line treatment.

MATERNAL AND CHILD HEALTH RESEARCH

Early mixed feeding and breastfeeding beyond 6 months increase the risk of postnatal HIV transmission: ANRS 1201/1202 Ditrame Plus, Abidjan, Cote d'Ivoire
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Preventive Medicine. 2008 Jul;47(1):27-33.
Becquet R | Ekouevi DK | Menan H | Amani-Bosse C | Bequet L
The objective was to evaluate the risk of postnatal HIV transmission among women in Abidjan, Cote d'Ivoire offered alternatives to prolonged breastfeeding, and to assess the impact of the breastfeeding pattern and duration on this risk. In 2001-2003, HIV-infected pregnant women received peri-partum antiretroviral prophylaxis and were counselled antenatally regarding infant feeding options: formula feeding or exclusive breastfeeding with early cessation from 4 months of age. The primary outcome was HIV postnatal transmission by 18 months of age, defined by a positive HIV test after a negative test greater than or equal to 30 days. The effect of the pattern (mixed feeding, defined as breastmilk plus food-based fluid, solid food or non-human milk) and duration (less vs. more than 6 months) of breastfeeding on postnatal transmission was assessed. Of 622 live-born infants who were HIV uninfected at or after 30 days, 15 were infected postnatally, 13/324 among breastfed, and 2/ 298 among formula-fed infants. The 18-month probability of remaining free from HIV infection was 0.95 [95% CI, 0.92-0.97] and 0.99 [95% CI, 0.97-1.00] in the breastfeeding and formula-feeding groups respectively (p less than 0.001). In adjusted analysis, breastfeeding for more than 6 months and mixed feeding during the first month of life were independently associated with a 7.5 (AOR 95% CI, 2.0-28.2, p=0.003)- and a 6.3 (95% CI, 1.1-36.4, p=0.04)-fold increase of postnatal transmission among breastfed children. Mixed feeding during the first month of life and breastfeeding beyond 6 months are strong determinants of HIV transmission and should be avoided when replacement feeding after breastfeeding cessation can be safely and sustainably provided.

Effect of 50,000 IU vitamin A given with BCG vaccine on mortality in infants in Guinea-Bissau: Randomised placebo controlled trial
(Abstract; subscription needed for full text; Sub-Saharan Africa)
BMJ. British Medical Journal. 2008 Jun 21;336(7658):1416-1420.
Benn CS | Diness BR | Roth A | Nante E | Fisker AB
The objective of this study was to investigate the effect of high dose vitamin A supplementation given with BCG vaccine at birth in an African setting with high infant mortality. The study design was a randomised placebo controlled trial in Bandim Health Project's demographic surveillance system in Guinea-Bissau, covering approximately 90 000 inhabitants. Participants were 4345 infants due to receive BCG. Infants were randomised to 50 000IU vitamin A or placebo and followed until age 12 months. The main outcome measure was mortality rate ratios. 174 children died during follow-up (mortality = 47/1000 person-years). Vitamin A supplementation was not significantly associated with mortality; the mortality rate ratio was 1.07 (95% confidence interval 0.79 to 1.44). The effect was 1.00 (0.65 to 1.56) during the first four months and 1.13 (0.75 to 1.68) from 4 to 12 months of age. The mortality rate ratio in boyswas0.84 (0.55 to 1.27) compared with 1.39 (0.90 to 2.14) in girls (P for interaction = 0.10). An explorative analysis revealed a strong interaction between vitamin A and season of administration. Vitamin A supplementation given with BCG vaccine at birth had no significant benefit in this African setting. Although little doubt exists that vitamin A supplementation reduces mortality in older children, a global recommendation of supplementation for all newborn infants may not contribute to better survival.

NGO facilitation of a government community-based maternal and neonatal health programme in rural India: Improvements in equity
(Abstract; subscription needed for full text; Asia)
Health Policy and Planning. 2008;23(4):234-243.
Baqui AH | Rosecrans AM | Williams EK | Agrawal PK | Ahmed S
Socio-economic disparities in health have been well documented around the world. This study examines whether NGO facilitation of the government's community-based health programme improved the equity of maternal and newborn health in rural Uttar Pradesh, India. A quasi-experimental study design included one intervention district and one comparison district of rural Uttar Pradesh. A household survey conducted between January and June 2003 established baseline rates of programme coverage, maternal and newborn care practices, and health care utilization during 2001-02. An endline household survey was conducted after 30 months of programme implementation between January and March 2006 to measure the same indicators during 2004-05. The changes in the indicators from baseline to endline in the intervention and comparison districts were calculated by socio-economic quintiles, and concentration indices were constructed to measure the equity of programme indicators. The equity of programme coverage and antenatal and newborn care practices improved from baseline to endline in the intervention district while showing little change in the comparison district. Equity in health care utilization for mothers and newborns also showed some improvements in the intervention district, but notable socio-economic differentials remained, with the poor demonstrating less ability to access health services. NGO facilitation of government programmes is a feasible strategy to improve equity of maternal and neonatal health programmes. Improvements in equity were most pronounced for household practices, and inequities were still apparent in health care utilization. Furthermore, overall programme coverage remained low, limiting the ability to address equity. Programmes need to identify and address barriers to universal coverage and care utilization, particularly in the poorest segments of the population.

Maternal mortality in Nepal: Unraveling the complexity
(Abstract; subscription needed for full text; Asia)
Canadian Studies in Population. 2008;35(1):1-26.
Suwal JV
Maternal mortality has been recognised as a public health problem in the developing countries. The situation concerning maternal mortality in Nepal remained unexplored and vague until the early 1990s. By using 1996 Nepal Family Health Survey, this study discusses the maternal mortality situation in Nepal and analyses the differentials in maternal mortality by place of residence, region, ethnic and religious groups, age at death, and parity. Almost 28 percent of deaths of women in reproductive age was accountable to maternal causes. Logistic regression analysis shows 'ethnicity,' 'age of women,' and 'number of births' as strong predictors of maternal mortality. A number of policy recommendations are suggested to help lower maternal mortality.

Scaling-up exclusive breastfeeding support programmes: The example of KwaZulu-Natal
(Research Article; Sub-Saharan Africa)
PLoS One. 2008 Jun;3(6):[9] p.
Desmond C | Bland RM | Boyce G | Coovadia HM | Coutsoudis A
Exclusive breastfeeding (EBF) for six months is the mainstay of global child health and the preferred feeding option for HIV-infected mothers for whom replacement feeding is inappropriate. Promotion of community-level EBF requires effective personnel and management to ensure quality counselling and support for women. We present a costing and cost effectiveness analysis of a successful intervention to promote EBF in high HIV prevalence area in South Africa, and implications for scale-up in the province of KwaZulu-Natal. The costing of the intervention as implemented was calculated, in addition to the modelling of the costs and outcomes associated with running the intervention at provincial level under three different scenarios: full intervention (per protocol), simplified version (half the number of visits compared to the full intervention; more clinic compared to home visits) and basic version (one third the number of visits compared to the full intervention; all clinic and no home visits). Implementation of the full scenario costs R95 million ($14 million) per annum; the simplified version R47 million ($7 million) and the basic version R4 million ($2 million). Although the cost of the basic scenario is less than one tenth of the cost of the simplified scenario, modelled effectiveness of the full and simplified versions suggest they would be 10 times more effective compared to the basic intervention. A further analysis modelled the costs per increased month of EBF due to each intervention: R337 ($48), R206 ($29), and R616 ($88) for the full, simplified and basic scenarios respectively. In addition to the average cost effectiveness the incremental cost effectiveness ratios associated with moving from the less effective scenarios to the more effective scenarios were calculated and reported: Nothing - Basic R616 ($88), Basic - Simplified R162 ($23) and Simplified - Full R879 ($126). The simplified scenario, with a combination of clinic and home visits, is the most efficient in terms of cost per increased month of EBF and has the lowest incremental cost effectiveness ratio.

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Stages of the demographic transition from a child's perspective: Family size, cohort size, and children's resources
(Abstract; subscription needed for full text; Global)
Population and Development Review. 2008 Jun;34(2):225-252.
Lam D | Marteleto L
The demographic transition has played itself out with great regularity in developing countries over the last 50 years. Looking at a broad set of countries, a stylized version of the demographic transition is consistent with the empirical experience of most of the developing world. The transition begins with large and sustained declines in death rates, especially infant and child mortality. The immediate effect of this mortality decline is an increase in the number of surviving children at the family level and an increase in the total number of children at the population level. Mortality decline is eventually followed by the second key element of the transition, a decline in fertility, which in turn has effects on both family size and cohort size. These changes in family size and cohort size over the course of the demographic transition are the focus of this article. We develop a new characterization of stages of the transition, viewing the demographic changes from a child's perspective. As we show, dramatic changes in the numbers of siblings and the size of cohorts can occur during the demographic transition, changes with important implications for children's resources at the family level and the population level. These changes do not always move in the same direction, however, owing to the complex interaction of population momentum with falling fertility and mortality.

Swaziland Demographic and Health Survey 2006-07
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Mbabane, Swaziland, Central Statistical Office, 2008 May. [506] p.
This detailed report presents the major findings of the 2006-07 Swaziland Demographic and Health Survey (2006-07 SDHS). The 2006-07 SDHS is the first survey of its kind to be undertaken in Swaziland. It was a nationwide survey aimed at generating estimates at the country level, regional level, and for urban and rural areas. The survey was commissioned by the Ministry of Health and Social Welfare and implemented by the Central Statistical Office. Fieldwork was carried out between July 2006 and March 2007. The primary objective of the 2006-07 SDHS was to collect up-to-date information for policymakers, planners, researchers, and programme managers that would provide guidance in the planning, implementation, monitoring and evaluation of population and health programmes in Swaziland. Specifically, the 2006-07 SDHS collected information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood and maternal mortality, care and protection of youth, and awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections (STIs). In addition, it collected information on malaria, the use of mosquito nets, and the prevalence of HIV in the population age two years and above.

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