As we approach 2015—the Millennium Development Goal deadline for a 75% reduction in maternal mortality since 1990—Sub-Saharan Africa lags behind other regions, in part because of low use of maternal health care in many countries. In a study including 317 households in rural Mali, Darcy White and colleagues conducted interviews with recent mothers, their husband and their mother-in-law to determine the role of intrafamilial dynamics in women’s receipt of maternal care [page 58]. In multivariable analyses, the preferences and attitudes of the woman and her mother-in-law were associated with the woman’s likelihood of having received four or more prenatal care visits, having begun prenatal care in the first trimester, having delivered her last birth at a health facility and having received postnatal care. For example, women who perceived their self-efficacy as higher were more likely to have had their last birth at a health facility, and those whose mother-in-law perceived them as having higher self-efficacy were more likely to have had four or more prenatal visits. In contrast, women whose mother-in-law had a higher level of agreement with traditional practices were less likely to have had an institutional delivery or to have had postnatal care. The preferences and attitudes of the husband were not associated with receipt of health care.

Female sex workers have a heightened risk of both unwanted pregnancy and HIV infection. In interviews with 325 sex workers in Swaziland, Eileen Yam and colleagues found that 8% used both condoms and nonbarrier methods, 16% consistently used condoms alone, and 39% relied on nonbarrier methods (alone or with inconsistent use of condoms); the remaining 38% used condoms inconsistently, used other methods or used no method [page 69]. Respondents who reported recent condom slippage or breakage were less likely than others to be consistent users of condoms (alone or with another method), while consistent use of condoms alone was more common among women who had had no noncommercial partners in the previous month than among those who had had at least two such partners. In addition, women who had children were more likely than those who had none to report use of nonbarrier methods alone. The researchers recommend that HIV prevention be incorporated into family planning interventions for female sex workers, especially those who have children and those who have noncommercial partners.

In Bangladesh, where the abortion law is highly restrictive, more than 700,000 women a year have a menstrual regulation (MR), or uterine evacuation by vacuum aspiration without pregnancy testing; many more resort to unsafe abortion. Because high levels of morbidity are associated with both procedures, Anadil Alam and colleagues explored the acceptability and feasibility of using a mifepristone-misoprostol regimen for uterine evacuation among women who were no more than 63 days past their last menstrual period [page 79]. The mifepristone was administered at the clinic; most women had the choice of taking misoprostol at the clinic or at home. Of 651 eligible women at 10 facilities who agreed to use the medication regimen for MR, 93% of those with known outcomes had a uterine evacuation without surgical intervention and 92% were satisfied with the regimen. Providers initially expressed concerns, but grew more confident as their experience with the regimen increased.

In Malawi, abortion is legal only when performed to save a pregnant woman’s life. The incidence of induced abortion is unknown, but thought to be high; the maternal mortality ratio was 675 in 2010, with the estimated proportion of deaths attributed to unsafe abortion as high as one in four. Using an adaptation of an existing indirect methodology, Brooke Levandowski and colleagues estimated abortion incidence in 2009 at 67,300; they calculated an abortion rate of 23 per 1,000 women aged 15–44 and an abortion ratio of 12 per 100 live births [page 88]. Noting that an estimated 52% of all pregnancies occurring in Malawi in 2010 were unintended, the authors conclude that interventions are needed to help women and couples avoid unwanted pregnancy, reduce unsafe abortion and decrease maternal mortality.

Official data on sex ratios at birth in some post-Soviet states suggest a rise in sex-selective abortions following the introduction of ultrasonography. Using vital registration data for 12 post-Soviet states, Marc Michael and colleagues examined trends from 1985 to 2009 [page 97], and found elevated sex ratios at birth for Armenia (117), Azerbaijan (116) and Georgia (121). Sex ratios at birth according to birth order could be calculated for Armenia, Azerbaijan and Moldova, the three countries that had had a Demographic and Health Survey between 2005 and 2010. Sex ratios were elevated in Armenia and Azerbaijan for first births (138 and 113, respectively); if the first child was a girl, the sex ratio in Armenia was even higher for the second birth (154). Overall, the number of girls born in these countries in 2010 was 10% lower than expected, consistent with the performance of nearly 2,000 sex-selective abortions in Armenia and of nearly 8,400 in Azerbaijan. Sex ratios did not vary by birth order in Moldova.—The Editors