Every year, more than half a million women worldwide die of problems associated with pregnancy and childbirth, and some eight million infants are stillborn or die within their first week of life. Almost all of these deaths occur in developing countries, and most could be prevented by skilled maternal and neonatal care. Still more young children—and their mothers—die of diseases that could be prevented by routine vaccinations. Nevertheless, substantial proportions of women and children do not receive basic, low-cost interventions shown to save lives and protect health: According to the World Health Organization, 35% of women in developing countries receive no antenatal care, 47% give birth without a skilled attendant and 70% receive no postpartum care.

Pregnancy and childbirth are the leading causes of death among teenage women in many regions where childbearing commonly begins during adolescence and use of skilled maternal care is low. Using Demographic and Health Survey (DHS) data from 16 countries in Africa, Asia and Latin America, Heidi Reynolds and colleagues examine differences between women aged 15–18 and those aged 19–23 in use of skilled care during pregnancy and delivery and use of infant immunization services [see article]. Overall, they found significant age differences in use of both maternal and child health services in only four countries, three of which were in Southeast Asia. According to the authors, adolescent women may be particularly disadvantaged in Southeast Asia because women's status and decision-making power within their household tend to increase with age.

Women's status is at the heart of the next article, in which Marie Furuta and Sarah Salway examine the influence of Nepali women's household position on their use of maternal care [see article]. About half of women aged 15–49 had discussed family planning with their husband, one-quarter were involved in decision making on their own health care or on large household purchases, and fewer than one in 10 worked and had some control over use of their earnings. A minority had received skilled care during pregnancy (39%) or during delivery (13%). In multi-variate analyses, discussion of family planning was associated with receipt of each type of maternal care. Moreover, women who worked and had some control over their earnings were more likely to receive each type of care than women who worked and had no control, but were no more likely to receive care than nonworkers. Women's involvement in decision making on major household purchases (but not on their own health care) was associated with receipt of skilled antenatal care.

Also in This Issue

• Because condoms can be used for either contraception or disease prevention (or both), designing messages to promote effective use can be difficult. According to research by Pranitha Maharaj among sexually active young people in KwaZulu-Natal, South Africa, two-thirds of those who said they had used a condom at last intercourse cited protection against both pregnancy and HIV [see article]. Nevertheless, concern about pregnancy seemed more likely to lead to condom use: Young people who said that becoming or making someone pregnant in the next few weeks would be highly problematic were more likely to use condoms than those who said a pregnancy would be no problem, while respondents who believed they were at medium or high risk of HIV infection were less likely to use condoms than those who believed they were at no risk.

• It would be easy to assume that young people in culturally and religiously conservative countries such as Iran do not need reproductive health education because few have sexual experiences before marriage. As a study conducted in Tehran by Mohammad R. Mohammadi and colleagues shows, such an assumption would be a mistake [see article]. Twenty-eight percent of the 15–18-year-old males interviewed said they were sexually experienced. Knowledge about sexual and reproductive health, however, was relatively low: Only 17% knew that pregnancy is most likely to occur in midcycle, and just 21–34% recognized common symptoms of sexually transmitted infections.

• In cultures that value women for both sexual purity and accommodation of men's desires, trying to meet societal expectations can make women vulnerable to unwanted intercourse. In focus group research conducted by Ann Moore in two cities in Brazil, women expressed the beliefs that men have an urgent need for sex, and that they will abandon their partner or become violent if she says no [see article]. According to the participants, women are expected to act ignorant about sex the first time they have intercourse. They fear that taking any initiative—such as asking their partner to practice contraception—will expose them to accusations of previous sexual experience and to being classified as "girls to date" rather than "girls to marry." Women feel compelled to say no to sex whether or not they want it, to avoid losing their reputation and allow their partner to "conquer" their resistance, thus reinforcing the belief that their refusals need not be taken seriously.

—The Editors