REPRODUCTIVE HEALTH ADDED TO MILLENIUM DEVELOPMENT GOALS

In October 2006, the United Nations (UN) General Assembly agreed to amend the fifth Millennium Development Goal (MDG), which aims to reduce maternal mortality by three-quarters by 2015, to include a new target—achieving universal access to reproductive health by 2015.¹ Although the importance of reproductive health was recognized at the International Conference on Population and Development at Cairo in 1994, it was not among the 18 targets included when the MDGs—which form the global framework for poverty reduction—were adopted in 2000. However, after lobbying by many governments, nongovernmental organizations and others, world leaders at the September 2005 UN World Summit in New York endorsed incorporating universal access to reproductive health into the MDGs. Dr. Gill Greer, director general of the International Planned Parenthood Federation, commented: "Sexual and reproductive health is one of the most important aspects of health policy in general and is crucially important in the reduction of global poverty. …the UN General Assembly has made a decision that will save the lives and reduce the suffering of millions of women worldwide—especially the poorest women in the poorest countries, who bear a disproportionate level of maternal death and ill health."

1. International Planned Parenthood Federation Western Hemisphere Region, United Nations General Assembly adopts "universal access" target for reproductive health, October 2006, <http://www.ippfwhr.org/publications/serial_issue_e.asp?PubID=36&SerialI…;, accessed Nov. 15, 2006.

MALARIA TREATMENT FOR PREGNANT WOMEN

Amodiaquine may be an effective and safe treatment for pregnant women with malaria in areas where the disease is resistant to other commonly prescribed medications.¹ As part of a study conducted in Nkoranza, Ghana, between March 2003 and September 2004, 900 women with a pregnancy of at least 16 weeks who tested positive for malaria were divided into four treatment groups: chloroquine, sulphadoxine-pyrimethamine alone, amodiaquine alone or amodiaquine in combination with sulphadoxine- pyrimethamine. Overall, the rate of treatment failure after 28 days was lower among women treated with amodiaquine alone or with amodiaquine and sulphadoxine-pyrimethamine (3% and 0%, respectively) than among those treated with chloroquine or with sulphadoxine-pyrimethamine alone (14% and 11%, respectively). After three days of treatment, the proportion of women reporting minor side effects—such as weakness, dizziness and nausea—was greater among those given amodiaquine alone or amodiaquine and sulphadoxine-pyrimethamine (86% and 90%, respectively) than among those given one of the other treatment regimens (34–76%). However, there were no significant differences found between the treatment groups in terms of maternal outcomes at delivery or six weeks postpartum. In light of the high rate of treatment failure found among pregnant Ghanaian women treated with chloroquine, the authors comment that "a change in treatment is needed because any parasitameia in a pregnant woman…is a threat to the mother and her fetus."

1. Tagbor H et al., Efficacy, safety, and tolerability of amodiaquine plus sulphadoxine-pyrimethamine used alone or in combination for malaria treatment in pregnancy: a randomised trial, Lancet, 2006, 368(9544):1349–1356.

ATTITUDES OF JAMAICANS TOWARD PEOPLE WITH HIV

The level of sympathy Jamaican students feel for people living with HIV varies according to the students' characteristics and the subgroup of infected people.¹ Among 1,252 students interviewed at the University of the West Indies between June 2001 and February 2002, 98% expressed sympathy for children living with HIV, 81% for infected women who were not sex workers, 67% for infected heterosexual men, 44% for infected female sex workers and 40% for infected men who have sex with men. Regular church attendance and having had an HIV education class were associated with greater odds of feeling sympathy for homosexual men living with HIV (odds ratios, 1.4 and 1.5, respectively), whereas being male was associated with lower odds (0.6). Students who attended church regularly were more likely than others to feel sympathy for infected female sex workers (1.4), whereas those who were younger than 25 and those who had inaccurate knowledge about HIV were less likely to feel sympathetic (0.7 and 0.6, respectively). Having inaccurate knowledge about HIV was associated with lower odds of feeling sympathy for infected heterosexual men (0.6), and knowing someone living with HIV was associated with greater odds of feeling sympathy for infected female women who were not sex workers (1.5). The authors comment that programs should produce messages designed to reduce the stigmatization of specific subgroups of people living with HIV in Jamaica and should include members of those subgroups in the subsequent efforts.

1. Norman LR, Carr R and Jiménez J, Sexual stigma and sympathy: attitudes toward persons living with HIV in Jamaica, Culture, Health & Sexuality, 2006, 8(5):423–433.

OBEYING THE LAW, BREACHING CONFIDENCE, OR BOTH?

In El Salvador, where abortion is illegal, health care providers often report women seeking postabortion care to the legal authorities because they believe they are obligated by law to do so.¹ Among a random sample of 110 Salvadorian obstetricians and gynecologists surveyed between November 2003 and March 2004, 80% believed that they were legally required to report unlawful abortion. In fact, Salvadorian law does not explicitly mention reporting of suspected abortion, but instead requires providers to report injuries resulting from criminal acts perpetrated against their patients. However, the law also stipulates that providers are not obligated to report confidential information and that any information acquired through unlawful breach of confidentiality is invalid for legal purposes. Only 23% of physicians knew that Salvadorian law protects patient-provider confidentiality, and 38% that international law offers such protection. More than half of providers (56%) had reported a postabortion patient to the authorities; working for a public health institution and not knowing that international law mandates confidentiality were associated with greater odds of reporting (odds ratios, 5.1 and 3.3, respectively). Of physicians who had reported a woman to the authorities, 42% had done so out of perceived legal obligation, and 27% for fear of being prosecuted as an accomplice. Half of physicians reported that they had treated women who had delayed seeking postabortion care out of fear of being reported. In light of their findings, the authors comment that "disclosing the identity of patients suspected of having sought an unlawful abortion from an unsafe abortion practitioner does more harm than good and does not satisfy ethical and human rights conditions for the disclosure of confidential information."

1. MacNaughton HL et al., Patient privacy and conflicting legal and ethical obligations in El Salvador: reporting of unlawful abortions, American Journal of Public Health, 2006, 96(11):1927–1933.

INTERVENTIONS TO REDUCE CHILD DEATHS IN MIDDLE EAST

Increased implementation of 26 low-cost maternal and child health interventions in eastern Mediterranean countries could substantially reduce child mortality in the region, according to an analysis of World Health Organization and UNICEF data.¹ The 22 countries of the eastern Mediterranean region account for 1.4 million deaths among children younger than five each year—approximately one-seventh of all newborn and child deaths worldwide. The vast majority of such deaths in the region (1.2 million) occur in just seven countries: Afghanistan, Egypt, Iraq, Pakistan, Somalia, Sudan and Yemen. Increasing the coverage of 15 preventive care interventions (e.g., breastfeeding promotion, tetanus toxoid administration and skilled postnatal care) and 11 treatment interventions (e.g., oral rehydration therapy, zinc for diarrhea and emergency newborn care) to between 90% and 95% would prevent an estimated 52% of newborn and child deaths in the region. Child mortality for a country was closely related to its ratio of health spending to military spending and to its government's score on an index measuring ability to implement policies. The researchers comment that delivering interventions to all who need them "will require concerted efforts by public health policy makers, development agencies, and civic societies to garner resources for child health."

1. Bhutta ZA et al., Child health and survival in the Eastern Mediterranean region, BMJ, 2006, <http://www.bmj.com/cgi/content/full/333/7573/839&gt;, accessed Nov. 9, 2006.

COST-EFFECTIVENESS OF HIV THERAPIES IN CÔTE D’IVOIRE

Antiretroviral therapy combined with an antibiotic is a cost-effective strategy for the treatment of HIV in resource-poor settings, according to a computer-simulation analysis based on patient data from Côte d'Ivoire.¹ Twenty-two strategies were investigated, including no treatment, prophylactic treatment with only the antibiotic trimethoprim-sulfamethoxazole and various regimens of antiretroviral therapy with or without antibiotics. Compared with no treatment, treatment with antibiotic alone increased life expectancy by 1.6 months (from 33.6 to 35.2 months) at an estimated cost of $240 per year of life gained. Strategies that utilized antiretroviral therapy with prophylactic antibiotics were consistently more effective and more cost-effective than the comparable regimens without antibiotics. Treatment regimens that included antibiotics and antiretroviral therapy increased patient's life expectancy 10.8–46.0 months above treatment with antibiotics alone, depending on the clinical criteria used for starting and stopping antiretroviral treatment, at a cost of $590–1,180 per year of life gained. The researchers comment that "Strategies identified as cost-effective may be unaffordable in the poorest countries without assistance. The results of this analysis may be used, however, to motivate the global community to direct resources toward investments that have the greatest promise of providing gains in health."

1. Goldie SJ et al., Cost-effectiveness of HIV treatment in resource-poor settings—the case of Côte d'Ivoire, New England Journal of Medicine, 2006, 355(11):1141–1153.

MODIFIED TECHNIQUE ALLOWS SAFER, EARLIER ABORTIONS

A modified dilation and evacuation procedure may be safer and more effective than methods currently used to provide second-trimester abortions in settings that lack access to electric vacuum aspiration, according to results from a demonstration project conducted at the Hanoi Obstetrics and Gynecology Hospital in Vietnam.¹ Between June 1999 and January 2002, 439 women who requested pregnancy termination at 12–18 weeks of gestation were enrolled in the project. Typically, second-trimester abortion in Vietnam involves sharp curettage without cervical preparation; instead, each woman underwent manual vacuum aspiration after buccal (between the cheek and the gum) misoprostol to prepare the cervix. Ninety-one percent required only one dose of misoprostol, and 80% of procedures were finished in less than 20 minutes. The rate of major complications was 0.7%. The authors comment that using the modified procedure "enables the hospital and the health care system to avoid the gap in services that previously existed from 12 to 20 weeks of gestation," because of the lack of an appropriate second-trimester technique that could be used in that setting. Furthermore, the new procedure allows abortion patients to avoid an overnight hospital stay, which saves valuable resources in a resource-poor setting like Vietnam.

1. Castleman LD et al., Introduction of the dilation and evacuation procedure for second-trimester abortion in Vietnam using manual vacuum aspiration and buccal misoprostol, Contraception, 2006, 74(3):272–276.