CONTRACEPTIVE USE AROUND THE GLOBE
Worldwide, 61% of married women of childbearing age are practicing contraception—69% in developed countries and 59% in developing ones.1 According to a wall chart produced by the United Nations Population Division, the level of contraceptive use among married women aged 15-49 is lowest in Africa (27%) and highest in Latin America and the Caribbean (71%). Overall, the most commonly used methods are female sterilization (21%), the IUD (14%) and the pill (7%). Women in developed countries most commonly rely on the pill (16%) and condoms (13%), whereas those in developing countries most commonly rely on sterilization (23%) and the IUD (15%). Traditional methods are used more widely in developed countries than in developing ones (13% vs. 6%). However, despite an increase in the level of contraceptive use during the past decade in developing regions, the unmet need for family planning remains high: For example, in Sub-Saharan Africa, roughly one-quarter of married women aged 15-49 want to end or delay childbearing, but are not using a method.
1. United Nations, Population Division, Department of Economic and Social Affairs, World Contraceptive Use 2003, 2004,
CHILD SEX RATIOS CONTINUE TO DECLINE IN INDIA
Between 1991 and 2001, the number of girls per 1,000 boys aged six or younger in India decreased, from 945 to 927, according to a report by the Indian government and the United Nations Population Fund.1 The decline in child sex ratios was particularly dramatic in the states of Punjab (from 875 to 793 girls per 1,000 boys), Haryana (from 879 to 820 per 1,000), Gujarat (from 928 to 878 per 1,000) and Delhi (from 915 to 865 per 1,000). Even in some of the country's most prosperous regions, child sex ratios in 2001 were low—only 770 per 1,000 in Kurukshetra, Haryana; 814 per 1,000 in Ahmedabad, Gujarat; and 845 per 1,000 in the southwest district of Delhi. The report concludes that the sex imbalance in India results from sex-selective abortion and infanticide, driven by the continued preference for sons. The authors warn that it may soon "become extremely difficult, if not impossible, to make up for the missing girls"—a problem that could "destroy the social and human fabric as we know it."
1. United Nations Population Fund, Office of the Registrar General and Census Commissioner, India, and Ministry of Health and Family Welfare, India, Missing: Mapping the Adverse Child Sex Ratio in India, 2003,
CIRCUMCISION LOWERS RISK OF HIV, NOT OTHER STIs
Circumcised men have a lower risk of HIV infection than do uncircumcised men; however, the two groups have a similar risk of contracting certain other sexually transmitted infections (STIs), according to a study conducted among 2,298 HIV-negative men who attended three STI clinics in Pune, India, between 1993 and 2000.1 At the first visit and at regular follow-ups, researchers tested the men for HIV-1, herpes simplex virus type 2, syphilis and gonorrhea, and collected information on sexual behavior. Circumcision status was assessed by physical examination. The HIV infection rate was lower among circumcised men than among uncircumcised men (0.7 vs. 5.5 cases per 100 person-years). After adjustment for social, demographic and behavioral risk factors (including condom use), Cox proportional hazards analysis revealed that men who had been circumcised were 85% less likely than those who had not to contract HIV (relative risk, 0.15), and that the two groups were equally likely to acquire the other STIs included in the study. The researchers conclude that circumcision has a "specific protective effect" against HIV infection, and suggest that "the foreskin has an important role in the biology of sexual transmission of HIV."
1. Reynolds SJ et al., Male circumcision and risk of HIV-1 and other sexually transmitted infections in India, Lancet, 2004, 363(5):1039-1040.
HERPES RISK FACTORS IN RURAL COSTA RICA
The prevalence of herpes simplex virus type 2 (HSV-2) infection among women in rural Costa Rica is high, even among those who report being monogamous.1 Using antibody test results from an age-stratified subsample of women, researchers estimated that 39% of a random sample of about 10,000 women from Guanacaste had the infection. A sizable proportion of women who had had only one lifetime partner tested positive (28%)—a finding the analysts attribute to high-risk sexual behavior of partners. The proportion was even higher among women with 2-3 partners (57%) and those with four or more partners (75%). In a multivariate logistic regression limited to sexually active women and adjusted for age and number of partners, HSV-2 infection was positively associated with age (odds ratios, 1.5-7.9), number of partners (3.6-21.4), former IUD use (1.7) and the presence of antibodies to human papillomavirus (1.6). In contrast, infection was negatively associated with former or current use of barrier contraceptives (0.5-0.6). The analysts conclude that until a vaccine is found, the "use of condoms and education of adolescents, women of reproductive age, and health-related personnel on the importance of diagnosis, treatment, and prevention may help control the spread of HSV-2 infections."
1. Rodríguez AC et al., A population based study of herpes simplex virus 2 seroprevalence in rural Costa Rica, Sexually Transmitted Infections, 2003, 79(6):460-465.
FATHERS MAKE A DIFFERENCE
Teenage females living in slums in Nairobi, Kenya, have reduced odds of having poor adverse reproductive health outcomes if they live with their father, according to an analysis of data from 788 never-married women aged 12-19 who participated in a cross-sectional survey of slum residents between February and June 2000.1 Among these teenagers, 44% said they lived with neither parent, 30% with both parents, 19% with their mother only and 7% with their father only. Overall, 27% of the teenagers had ever had sex, 7% had had an unwanted pregnancy and 9% had been sexually active in the previous four weeks. Multivariate analyses that controlled for various background factors (e.g., age, duration of residence in the household, primary education and poverty status) showed that teenagers who lived with their father (whether or not their mother was present) were less likely than those who did not to have ever had sex (odds ratio, 0.6), to have had an unwanted pregnancy (0.4) or to have had sex in the previous four weeks (0.5). The odds of having had an unwanted pregnancy remained significant (0.4) after adjustment for respondents' reports that they would use contraceptives against their parents' will—an indication of "disorderly behavior," according to the analysts. The investigators conclude that "fathers' presence constitutes a protective factor for adolescents," and call for a "segmented approach to adolescent programming aimed at involving or targeting parents."
1. Ngom P, Magadi MA and Owuor T, Parental presence and adolescent reproductive health among the Nairobi poor, Journal of Adolescent Health, 2003, 33(5):369-377.
INFANT MORTALITY IN CHINA RISES WITH PARITY
In rural China, perinatal mortality is high—69 of every 1,000 infants delivered are stillborn or die within one week—and the risk of death increases with birth order.1 Of the 3,697 pregnancies registered by the civil family planning system of 20 townships during 1999, 84% ended in live birth, 8% in induced abortion, 7% in miscarriage and 2% in stillbirth. Stillbirth and death within a week of birth were more likely outcomes for second pregnancies than for first pregnancies (relative risks, 3.8 and 2.5, respectively). As a consequence, the overall perinatal mortality rate for parity two was about three times that for parity one (121 vs. 44 per 1,000 births). Girls more commonly died in the first week of birth than did boys (69 vs. 29 per 1,000 live births), mainly because of the higher risk of mortality among second-born girls than among first-born girls (relative risk, 5.9), the researchers note. Commenting that the perinatal mortality rate in rural China is higher than that documented for urban areas, as well as for other developing countries, the authors conclude that the increased mortality among second-born girls is probably "a result of both the family planning policy and the preference for sons" in China.
1. Wu Z et al., Perinatal mortality in rural China: retrospective cohort study, British Medical Journal, 2003, 327(7427):1319-1322.
REPRODUCTIVE HEALTH AMONG CARIBBEAN YOUTH
More than one-third of Caribbean students participating in a multinational health survey reported ever having had sex.1 Among the respondents—15,695 students aged 10-18 in nine countries—34% were sexually experienced (52% of males and 22% of females), of whom 43% were younger than 11 at first sex and 38% said the first episode of intercourse had been forced. Although 33% of sexually experienced respondents reported only one partner, 16% reported two partners, 14% three, 7% four, 6% five and 24% at least six. Overall, 10% of respondents had been involved in a pregnancy and 30% said they were worried about becoming or making someone pregnant. However, only one-quarter of sexually experienced youth consistently practiced contraception. Noting that only 28-39% of students were concerned about getting AIDS, the researchers comment that there is "a need for sexual health education" in the Caribbean.
1. Halcón L et al., Adolescent health in the Caribbean: a regional portrait, American Journal of Public Health, 2003, 93(11):1851-1857.
IN BRIEF
• The government of China plans to provide free HIV tests nationwide and to pay for treatment for patients who cannot afford it. According to the health ministry, about 840,000 people were HIV-positive in 2003, some 80,000 of whom had full-blown AIDS; however, fewer than one in 10 of those infected had been tested for the virus. [Watts J, China offers free AIDS test for all in policy shift, Guardian, April 15, 2004,
• In its Review of Potential Interventions to Reduce Child Mortality in Iraq, the United Nations Agency for International Development describes programs—such as promotion of breast-feeding and improvement of care of newborns—that could cut child death rates in Iraq by half within 12-18 months. The current under-five mortality rate is an estimated 90-100 per 1,000 live births. The report, which also identifies obstacles to program implementation, is available at
• A CD-ROM from the United Nations Population Fund offers lessons learned from reproductive health projects targeting men in the armed forces in nine countries (Benin, Botswana, Ecuador, Madagascar, Mongolia, Namibia, Nicaragua, Paraguay and the Ukraine).