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Objective: To quantify the influence of increasing use of health-care services on rising rates of caesarean section in China., Methods: We used data from a population-based survey conducted by the United Nations Population Fund during September 2003 in 30 selected counties in three regions of China. The study sample (derived from birth history schedule) consisted of 3803 births to mothers aged less than 40 years between 1993 and 2002. Multiple logistic regression models were used to estimate the effect of health-care factors on the odds of a caesarean section, controlling for time and selected variables., Findings: Institutional births increased from 53.5% in 1993-1994 to 82.2% in 2001-2002, while the corresponding increase in births by caesarean section was from 8.9% to 24.8%, respectively. Decomposition analysis showed that 69% of the increase in rates of caesarean section was driven by the increase in births within institutions. The adjusted odds of a caesarean section were 4.6 times (95% confidence interval, CI: 3.4-11.8) higher for recent births. The adjusted odds were also significantly higher for mothers who had at least one antenatal ultrasound test. Rates of caesarean section in secondary-level facilities markedly increased over the last decade to the same levels as in major hospitals (P < 0.001)., Conclusion: The upsurge in rates of births by caesarean section in this population cannot be fully explained by increases in institutional births alone, but is likely to be driven by medical practice within secondary-level hospitals and women's demand for the procedure.

This study examined the prevalence of dyspareunia, urinary sensory symptoms, and urinary incontinence and explored their associations among sexually active Chinese women aged 15-34 years. Data from 3,150 women were analyzed from a survey undertaken during 2003 in 30 counties in China as part of the United Nations Population Fund Country Program. The overall prevalence of dyspareunia was 4.7%. Urinary pain, burning or frequency was reported by 8.5%, 6.2% reported urinary incontinence, and 2.3% reported both sets of urinary symptoms. The prevalence of urinary incontinence, both alone and in combination with sensory symptoms, increased in a linear manner with age. Dyspareunia was associated with early sexual debut, primary level of education, and membership of minority ethnic communities. Urinary sensory symptoms and incontinence were more common among those reporting early sexual debut, those with less schooling, and women engaged in agricultural and manual unskilled occupations. Urinary incontinence was more common among women who had had a previous vaginal delivery compared to nulliparous women. Dyspareunia was strongly associated with the presence of urinary symptoms, particularly among those with both sensory symptoms and incontinence (26.8%). Nearly a quarter of women who had dyspareunia had sought treatment but fewer had done so for urinary incontinence. Dyspareunia and urinary symptoms show distinct but overlapping patterns of association with demographic variables. The findings indicate unmet need for assessment and advice about these symptoms in women's reproductive health programs.

Context: A cultural preference for sons may be a factor driving recourse to abortion in India, as women carrying female fetuses may decide to terminate their pregnancies. To assess this hypothesis, more information on the incidence of abortion, and on maternal and social correlates of the procedure, is needed., Methods: Birth order-specific abortion ratios were calculated using the birth histories of 90,303 ever-married women aged 15-49 who participated in India's 1998-1999 National Family Health Survey. For the first four births, the association between abortion and various maternal and social variables, including the sex of the respondent's last child, was assessed using logistic regression., Results: The overall abortion ratio was 17.0 per 1,000 pregnancies. The ratio increased from 5.3 per 1,000 pregnancies for first-order births to 25.8 per 1,000 pregnancies for third-order births and then declined. The strongest predictor of abortion was maternal education: Women with at least a primary education were more likely than those with no education to have had an abortion (odds ratios, 1.9-6.7). Rural residence was associated with a reduced likelihood of abortion (0.6). There was no association between the sex of a woman's previous child and the odds that she subsequently had an abortion., Conclusion: At the national level, it is likely that unintended pregnancy, rather than the sex of the previous child, underlies demand for abortion in India. Rising educational attainment among women may lead to an increase in the demand for abortion.

Objective: Chronic pelvic pain (CPP) is a common condition in women, and care experiences are distressing and unsatisfactory for many. Research suggests that elements of the initial hospital consultation influence clinical outcome. This study aimed to identify the dimensions through which initial consultations were subsequently recalled at follow-up., Method: A questionnaire study of 100 women, 6 months following a hospital gynaecology consultation for CPP, was conducted. Measures of pain and ratings of the medical consultation were completed at initial consultation and at follow-up., Results: Follow-up questionnaire items loaded to constructs of "affect", "expectation", and "cognition", forming three subscales. Patients' initial ratings of the consultation and scores on all three subscales measured at follow-up were correlated, remaining significant for both affect and expectation after controlling for current pain status., Conclusion: Doctor's affect and the appropriateness of information to meet expectations are important influences on experiences of care and contribute to the long-term therapeutic element of the consultation.

This study aimed to identify socio-cultural and reproductive health correlates of knowledge about AIDS among rural women using multivariate analysis of 1998-1999 National Family Health Survey (NFHS) data from two Indian states, Maharashtra and Tamil Nadu, where the urban HIV prevalence is relatively high. Analysis using multiple logistic regression was undertaken, modelling women's knowledge of AIDS, of whether the disease can be avoided, and of effective means of protection. Although 47% of all rural women in Maharashtra were aware of AIDS only about 28% knew that one can avoid it, and only about 16% possessed correct knowledge about its transmission. In Tamil Nadu, where overall 82% of rural women had awareness of AIDS, about 71% knew that one can avoid the disease but only about 31% possessed correct knowledge about its transmission. In both states, women from socially and economically backward groups had lower odds both of having awareness of AIDS and knowledge of ways to avoid getting the disease. Associations with socio-cultural and reproductive variables and the impact of contact with family planning services differed in the two states. The spread of the epidemic to rural areas presents a need actively to disseminate AIDS related knowledge for health protection rather than waiting for knowledge to follow the appearance of the disease in communities. Approaches to health promotion that do not consider differing contextual factors are unlikely to succeed. In particular, innovative strategies to disseminate knowledge among disadvantaged population groups are needed.

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children's care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations.

This study estimated birth order-specific miscarriage rates and characterized the influence of maternal age using the complete birth history of 90,303 ever-married women from the 1998-2000 Indian National Family Health Survey. Rates of miscarriage in India were low in association with early childbearing, whereas birth order as well as age substantially influenced miscarriage risk.

Objective: The interval between births is associated with child survival in the developing world. We aimed to investigate associations between use of depot-medroxyprogesterone acetate and other reversible contraception and short birth intervals in sub-Saharan Africa., Methods: Data from successive Demographic and Health Surveys undertaken in nine African countries were analyzed. Logistic regression was used to explain changes in the proportion of short birth intervals in four countries with relatively high use of reversible contraception., Findings: The overall odds ratio for the trend was 0.90 (95% CI 0.84 to 0.95) and this was unaffected by adjusting for the other variables. The odds of a short birth interval were reduced by exclusive breastfeeding (OR 0.67, 95% CI 0.58 to 0.78) and increased by use of injectable contraception (OR 1.23, 95% CI 1.11 to 1.38)., Conclusion: The proportion of short birth intervals has changed little over the last decade in a context of very low use of the intrauterine device. Widespread adoption of injectable contraception is associated with greater odds of a short birth interval, thus not contributing favorable conditions for improved child health.

The objectives of this paper are to examine factors associated with use of antenatal care in rural areas of north India, to investigate access to specific critical components of care and to study differences in the pattern of services received via health facilities versus home visits. We used the 1998-1999 Indian National Family Health Survey of ever-married women in the reproductive age group and analysed data from the states of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh (n = 11,369). Overall, about three-fifths of rural women did not receive any antenatal check-up during their last pregnancy. Services actually received were predominantly provision of tetanus toxoid vaccination and supply of iron and folic acid tablets. Only about 13% of pregnant women had their blood pressure checked and a blood test done at least once. Women visited by health workers received fewer services compared to women who visited a health facility. Home visits were biased towards households with a better standard of living. There was significant under-utilisation of nurse/midwives in the provision of antenatal services and doctors were often the lead providers. The average number of antenatal visits reported in this study was 2.4 and most visits were in the second trimester. Higher social and economic status was associated with increased chances of receiving an antenatal check-up, and of receiving specific components including blood pressure measurement, a blood test and urine testing but not the obstetric physical examination, which was however linked to ever-use of family planning and the education of women and their husbands. Thus, pregnant women from poor and uneducated backgrounds with at least one child were the least likely to receive antenatal check-ups and services in the four large north Indian states. Basic antenatal care components are effective means to prevent a range of pregnancy complications and reduce maternal mortality. The findings indicate substantial limitations of the health services in overcoming socio-economic and cultural barriers to access., (Copyright 2004 Elseiver Ltd.)

Objective: Developing country clinicians are aware of the discourse of evidence-based medicine but heavily constrained in their ability to access and apply new knowledge. This study aimed to obtain primary descriptive data about access to and application of reproductive health-related medical knowledge in developing countries., Design: Qualitative study using semi-structured interviews., Setting: India and Yemen., Sample: Forty-one doctors working in obstetrics, gynaecology, general practice and family planning services., Methods: Interviews were tape recorded and transcribed verbatim. A theory-driven approach was conducted to carry out thematic analysis., Main Outcome Measures: Descriptions of experiences, attitudes and needs., Results: Doctors felt the need to update their knowledge but this was not always achieved due to time and financial constraints. Alternative knowledge sources were described including the Internet, scientific meetings, medical family networks and speciality medical societies but access to these was limited by the expense of equipment, unfamiliarity with the technology and restricted advertisement of scientific meetings and conferences. Institutional hierarchy and conflict of generations were identified as barriers to change. Demoralisation was a common obstacle. On the positive side, involvement in medical education was a powerful driver for seeking new knowledge and applying research evidence to clinical practice., Conclusions: Priorities are to identify needs specific to different countries and medical settings in the developing world, access for all to full text journals and educational activities that fully engage practitioners in the early stages of their careers. Clinical teachers are the nodal group with the strongest incentive to obtain and use new knowledge.

Context: Family planning clinic in urban India., Objective: To assess the usefulness of a pelvic simulator for intimate examination and intrauterine device insertion training, and for enhancing reproductive education for women., Design: Observational study using evaluation forms completed by staff, and focus group interviews with women and girls participating in sexual health education. Content analysis of interview material., Results: Staff being trained in intimate examination found the simulator to be useful in increasing their level of skill. Participants in sexual health education reported an improved range and depth of knowledge following demonstrations with the simulator., Conclusion: Where working and training conditions are crowded and lacking in privacy, inappropriate examination practices are likely to be propagated. Training for intimate examinations can be enhanced by the use of pelvic simulators.