January 2009 - Reproductive Health


HLT/056 - January 2009



BMC Pediatrics 9(2); January 2009

Fadnes, L.T. et al. Need to optimise infant feeding counselling: A cross-sectional survey among HIV-positive mothers in Eastern Uganda.

The choice of infant feeding method is important for HIV-positive mothers in order to optimise the chance of survival of their infants and to minimise the risk of HIV transmission. The aim of this study was to investigate feeding practices, including breastfeeding, in the context of PMTCT for infants and children under two years of age born to HIV-positive mothers in Uganda. In collaboration with The Aids Support Organisation Mbale, we conducted a cross-sectional survey involving 235 HIV-positive mothers in Uganda. Infant feeding practices, reasons for stopping breastfeeding, and breast health problems were studied. Breastfeeding duration was analysed using the Kaplan-Meier method based on retrospective recall. The main reasons for stopping breastfeeding were reported as: advice from health workers, maternal illness, and the HIV-positive status of the mother. Exclusive breastfeeding was uncommon. Exclusive replacement feeding was practised by few HIV-positive mothers. Well-educated mothers, mothers who were socio-economically better-off and PMTCT-attendees had the shortest durations of breastfeeding. Further efforts are needed to optimise infant feeding counselling and to increase the feasibility of the recommendations… http://www.biomedcentral.com/content/pdf/1471-2431-9-2.pdf


Child and Adolescent Psychiatry and Mental Health 3(1); January2009

Parens, E.; Johnston, J. Facts, values, and Attention-Deficit Hyperactivity Disorder (ADHD): an update on the controversies

The Hastings Center, a bioethics research institute, is holding a series of 5 workshops to examine the controversies surrounding the use of medication to treat emotional and behavioral disturbances in children. This commentary, which grows out of our second workshop, explains why informed people can disagree about ADHD diagnosis and treatment. Based on what workshop participants said and our understanding of the literature, we make 8 points. Because people hold competing views about the proper goals of psychiatry and parenting, some people will be more, and others less, concerned about treating children in the zone of ambiguity. To recognize that nature has written no bright line between impaired and unimpaired children, and that it is the responsibility of humans to choose who should receive a diagnosis, does not diminish the significance of ADHD.  Once ADHD is diagnosed, the facts surrounding the most effective treatment are complicated and incomplete; contrary to some popular wisdom, behavioral treatments, alone or in combination with low doses of medication, can be effective in the long-term reduction of core ADHD symptoms and at improving many aspects of overall functioning.  Especially when a child occupies the zone of ambiguity, different people will emphasize different values embedded in the pharmacological and behavioral approaches… http://www.capmh.com/content/pdf/1753-2000-3-1.pdf


Cost Effectiveness and Resource Allocation 7(2); January 2009

Bachmann, M. O. Cost effectiveness of community-based therapeutic care for children with severe acute malnutrition in Zambia: decision tree model

Children aged under five years with severe acute malnutrition (SAM) in Africa and Asia have high mortality rates without effective treatment. Primary care-based treatment of SAM can have good outcomes but its cost effectiveness is largely unknown. This study estimated the cost effectiveness of community-based therapeutic care (CTC) for children with severe acute malnutrition in government primary health care centres in Lusaka, Zambia, compared to no care. Outcomes and health service costs of CTC were obtained from the CTC programme, local health services and World Health Organization (WHO) estimates of unit costs. Outcomes of doing nothing were estimated from published African cohort studies. Probabilistic and deterministic sensitivity analyses were done. The mean cost of CTC per child was $203 (95% confidence interval (CI) $139-$274), of which ready to use therapeutic food (RUTF) cost 36%, health centre visits cost 13%, hospital admissions cost 17% and technical support while establishing the programme cost 34%. Expected death rates within one year of presentation were 9.2% with CTC and 20.8 % with no treatment (risk difference 11.5% (95% CI 0.4-23.0%). CTC is relatively cost effective compared to other priority health care interventions in developing countries, for a wide range of assumptions…http://www.resource-allocation.com/content/pdf/1478-7547-7-2.pdf


Pediatrics 123(1); January2009

Isanaka, S. et al. Assessing the impact of the introduction of the World Health Organization growth standards and weight-for-height z-score criterion on the response to treatment of severe acute malnutrition in children: secondary data analysis

The objective of our study was to assess the impact of adopting the World Health Organization growth standards and weight-for-height z-score criterion on the response to treatment of severe acute malnutrition in children compared with the use of the National Center for Health Statistics growth reference. We used data from children aged 6 to 59 months with acute malnutrition who were admitted to the Médecins sans Frontières nutrition program in Maradi, Niger, during 2006 (N = 56214).  A total of 8 times more children (n = 25754) were classified as severely malnourished according to the World Health Organization standards compared with the National Center for Health Statistics reference (n = 2989). The introduction of the World Health Organization standards with the z-score criterion to identify children for admission into severe acute malnutrition treatment programs would imply the inclusion of children who are younger but have relatively higher weight for height on admission compared with the National Center for Health Statistics reference. These children have fewer medical complications requiring inpatient care and are more likely to experience shorter durations of treatment and lower mortality rates. The World Health Organization standards with the z-score criterion might become a useful tool for the early detection of acute malnutrition in children, although additional research on the resource implications of this transition is required… http://pediatrics.aappublications.org/cgi/reprint/123/1/e54


The lancet 373(9660); January 2009

Reading, R. et al. Promotion of children's rights and prevention of child maltreatment. Pp 332-343

In medical literature, child maltreatment is considered as a public-health problem or an issue of harm to individuals, but less frequently as a violation of children's human rights. Public-health approaches emphasise monitoring, prevention, cost-effectiveness, and population strategies; protective approaches concentrate on the legal and professional response to cases of maltreatment. Both approaches have been associated with improvement in outcomes for children, yet maltreatment remains a major global problem. We describe how children's rights provide a different perspective on child maltreatment, and contribute to both public-health and protective responses. Rights of participation and provision are as important as rights of protection. The principles embodied in the UNCRC are concordant with those of medical ethics. The greatest strength of an approach based on the UNCRC is that it provides a legal instrument for implementing policy, accountability, and social justice, all of which enhance public-health responses. Incorporation of the principles of the UNCRC into laws, research, public-health policy, and professional training and practice will result in further progress in the area of child maltreatment… http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673608617092.pdf


The Lancet 373(9658); January 2009

Hyder, A. A.; Peden, M.; Krug, E. Child health must include injury prevention Pp 102-103

Injuries are currently a leading cause of death and disability in the world and account for more than 5 million deaths each year. Globally, injuries are among the ten leading causes of death and disease burden at ages 0–4, 5–14, and 15–29 years. Despite the size of this burden and the known potential for prevention, the lack of global attention to injuries in terms of both policies and resource investments in public health is surprising. Dec 10 saw the global launch of the World Report on Child Injury Prevention by WHO and UNICEF. This report should have an important role in highlighting the importance of injuries as a cause of death and disability in children, and will provide a valuable mix of data, interventions, and policy information on specific types of unintentional childhood injuries. The report shows that unintentional injuries in children account for around 830 000 deaths each year. Road-traffic injuries and drowning are the two leading causes of death, followed by burns, falls, and poisoning. In addition to the link with poverty, there is a strong association between unintentional childhood injuries and the child's age and development. The quality and availability of medical care influences the likelihood of survival and long-term consequences… http://www.thelancet.com/journals/lancet/issue/vol373no9658/PIIS0140-6736(09)X6056-3


The Lancet 373(9660); January 2009

Aynsley-Green, A.; Hall, D. Safeguarding children: a call to action Pp 280-281

Since Kempe's description, almost 50 years ago, of the “battered baby”, we have become all too familiar with sexual and emotional abuse of children, neglect, fabricated illness, bullying, and exposure to domestic violence. In many countries the catalogue of abuse and exploitation also includes female genital mutilation, child trafficking and prostitution, sweatshop labour, and coercive enrolment into military service. The Lancet's Series on child maltreatment describes the progress that has been made in recognising maltreatment and its effects in the short and long term, and in evaluating interventions once abuse has occurred. However, mental-health professionals and social services too often lack the resources to apply this knowledge…




BMC Pregnancy and Childbirth 9(2); January 2009

Kidney, E. et al. Systematic review of effect of community-level interventions to reduce maternal mortality

The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality.We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence.Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence…http://www.biomedcentral.com/content/pdf/1471-2393-9-2.pdf


Bulletin of the World Health Organization 87(1); January 2009

Fournier, P. et al. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali.Pp30-38

To evaluate the effect of a national referral system that aims to reduce maternal mortality rates through improving access to and the quality of emergency obstetric care in rural Mali (sub-Saharan Africa).A maternity referral system that included basic and comprehensive emergency obstetric care, transportation to obstetric health services and community cost-sharing schemes was implemented in six rural health districts in Kayes region between December 2002 and November 2005. The primary outcome was the risk of death among obstetric emergency patients, calculated with crude case fatality rates and crude odds ratios. Analyses were adjusted for confounding variables using logistic regression.The number of women receiving emergency obstetric care doubled between P–1 and P2, and the rate of major obstetric interventions (mainly Caesarean sections) performed for absolute maternal indications increased from 0.13% in P–1 to 0.46% in P2. The intervention showed rapid effects due to the availability of major obstetric interventions in district health centres, reduced transport time to such centres for treatment, and reduced financial barriers to care. Our results show that national programmes can be implemented in low-income countries without major external funding and that they can rapidly improve the coverage of obstetric services and significantly reduce the risk of death associated with obstetric complications…



The Lancet 373(9660); January 2009

Garcia-Moreno, C. Intimate-partner violence and fetal loss Pp 278-279

Violence against women by their male intimate partners is an important public-health problem worldwide. Such violence is associated with a wide range of negative physical and mental-health outcomes among women, including injuries, unwanted pregnancies, and other sexual and reproductive health problems. The violence often continues—and at times starts—during pregnancy, and is negatively associated with maternal and fetal health outcomes, including low birthweight, preterm labour, smaller gestational weight-gain, and reduced levels of breastfeeding. Despite much published work, knowledge about the association of intimate-partner violence with fetal loss is limited,possibly because of the difficulty in distinguishing between induced abortions and miscarriages… http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609600799.pdf


The Lancet 373(9660); January 2009

Alio, A.P.; Nana, P.N.; Salihu, H.M. Spousal violence and potentially preventable single and recurrent spontaneous fetal loss in an African setting: cross-sectional study Pp 318-324

Spousal violence is a global issue, with ramifi cations for the reproductive health of women. We aimed to investigate the eff ect of physical, sexual, and emotional violence on potentially preventable single and recurrent spontaneous fetal loss. We analysed data from the Cameroon Demographic Health Survey. In the violence module of this survey, women were questioned about their experience of physical, emotional, and sexual violence infl icted by their spouses. Respondents were also asked about any stillbirths and spontaneous abortions. We measured risk for single and recurrent fetal loss with odds ratios, with adjustment for intracluster correlations as appropriate. We also estimated the proportion of preventable excess fetal loss at various levels of violence reduction.  2562 women responded to the violence module.If the prevalence of spousal abuse could be reduced to 50%, 25%, or entirely eliminated, preventable excess recurrent fetal demise would be 17%, 25%, and 33%, respectively. Our fi ndings support the idea of routine prenatal screening for spousal violence in the African setting, a region with the highest rate of fetal death in the world…




BMC Health Services Research 9(11); January 2009

Kaplan-Marcusan, A.et al Perception of primary health professionals about Female Genital Mutilation: from healthcare to intercultural competence.

The practice of Female Genital Mutilation (FGM), a deeply-rooted tradition in 28 countries in Sub-Saharan Africa, carries important negative consequences for the health and quality of life of women and children. Migratory movements have brought this harmful traditional practice to our medical offices, with the subsequent conflicts related to how to approach this healthcare problem, involving not only a purely healthcare-related event but also questions of an ethical, cultural identity and human rights nature.The aim of this study was to analyse the perceptions, degree of knowledge, attitudes and practices of the primary healthcare professionals in relation to FGM. A transversal, descriptive study was performed with a self-administered questionnaire to family physicians, paediatricians, nurses, midwives and gynaecologists. Trends towards changes in the two periods studied (2001 and 2004) were analysed. Less than 40% correctly identified the typology, while less than 30% knew the countries in which the practice is carried out and 82% normally attended patients from these countries.Female genital mutilations are present in primary healthcare medical offices with paediatricians and gynaecologists having the closest contact with the problem. Preventive measures should be designed as should sensitization to promote stands against these practices…http://www.biomedcentral.com/content/pdf/1472-6963-9-11.pdf


Bulletin of the World Health Organization 87(1); January 2009

Berer, M. Provision of abortion by mid-level providers: international policy, practice and perspectives Pp 58-63

Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice…



Contemporary Clinical Trials 30(1); January 2009

van der Horst, C. et al. Modifications of a large HIV prevention clinical trial to fit changing realities: A case study of the Breastfeeding, Antiretroviral, and Nutrition (BAN) protocol in Lilongwe, Malawi. Pp 24-33

In order to evaluate strategies to reduce HIV transmission through breast milk and optimize both maternal and infant health among HIV-infected women and their infants, we designed and implemented a large, randomized clinical trial in Lilongwe, Malawi. The development of protocols for large, randomized clinical trials is a complicated and lengthy process often requiring alterations to the original research design. Many factors lead to delays and changes, including study site-specific priorities, new scientific information becoming available, the involvement of national and international human subject committees and monitoring boards, and alterations in medical practice and guidance at local, national, and international levels. When planning and implementing a clinical study in a resource-limited setting, additional factors must be taken into account, including local customs and program needs, language and socio-cultural barriers, high background rates of malnutrition and endemic diseases, extreme poverty, lack of personnel, and limited infrastructure. This paper describes the process of designing, implementing, and subsequently modifying the Breastfeeding, Antiretrovirals, and Nutrition, (BAN) Study, a large, on-going, randomized breastfeeding intervention trial of HIV-infected women and their infants conducted at a single-site in Lilongwe, Malawi. We highlight some of the successes, challenges, and lessons learned at different stages during the conduct of the trial… http://download.journals.elsevierhealth.com/pdfs/journals/1551-7144/PIIS1551714408001158.pdf


Reproductive Health 5(13); December 2008

Atuyambe, L. et al. Adolescent and adult first time mothers' health seeking practices during pregnancy and early motherhood in Wakiso district, central Uganda.

Maternal health services have a potentially critical role in the improvement of reproductive health. In order to get a better understanding of adolescent mothers' needs we compared health seeking practices of first time adolescent and adult mothers during pregnancy and early motherhood in Wakiso district, Uganda.This was a cross-sectional study conducted between May and August,2007 in Wakiso district. A total of 762 women (442 adolescents and 320 adult)were interviewed using a structured questionnaire. We calculated odds ratios with their 95% CI for antenatal and postnatal health care seeking, stigmatisation and violence experienced from parents comparing adolescents to adult first time mothers. STATA V.8 was used for data analysis. Adolescent mothers were more likely to have dropped out of school due to pregnancy (OR=3.61, 95% CI: 2.40-5.44), less likely to earn a salary (OR=0.43, Adolescents showed poorer health care seeking behaviour for themselves and their children, and experienced increased community stigmatization and violence, suggesting bigger challenges to the adolescent mothers in terms of social support.Adolescent friendly interventions such as pregnancy groups targeting to empower pregnant adolescents providing information on pregnancy, delivery and early childhood care need to be introduced and implemented…http://www.reproductive-health-journal.com/content/pdf/1742-4755-5-13.pdf


Social Science & Medicine 68(1); January 2009

Bove, R.; Valeggia, C. Polygyny and women's health in sub-Saharan Africa. Pp. 21-29

In this paper we review the literature on the association between polygyny and women's health in sub-Saharan Africa. We argue that polygyny is an example of “co-operative conflict” within households, with likely implications for the vulnerability of polygynous women to illness, and for their access to treatment. We begin with a review of polygyny and then examine vulnerability to sexually transmitted infections (STIs, including HIV) and differential reproductive outcomes. Polygyny is associated with an accelerated transmission of STIs, both because it permits a multiplication of sexual partners and because it correlates with low rates of condom use, poor communication between spouses, and age and power imbalances among other factors. Female fertility is affected by the interplay between marital rank, household status, and cultural norms in polygynous marriages. Finally, we present areas which have received only cursory attention: mental health and a premature, “social” menopause. Although data are scarce, polygyny seems to be associated with higher levels of anxiety and depression, particularly around stressful life events. It is our hope that the examples reviewed here will help build a framework for mixed method quality research, which in turn can inform decision makers on more appropriate, context-dependent health policies… http://www.elsevier.com/locate/socscimed

Featured Publications

Atlas of Health Statistics of the African Region 2011
[pdf 2.9Mb]



rds-report-2010-2011-en-tnThe Work of WHO in the African Region 2010 - 2011
Biennial Report of the Regional Director
[pdf 1.91Mb]


hsa-cpp-june2012-tnHealth Systems in Africa: Community Perceptions and Perspectives
The Report of a Multi-Country Study



Achieving Sustainable Health Development in the African Region
Strategic Directions for WHO 2010–2015
[pdf 1.1Mb]