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The study analysed the HIV/AIDS situation in Zambia six years after the onset of mass campaigns of Voluntary Medical Male Circumcision (VMMC). The analysis was based on data from Demographic and Health Surveys (DHS) conducted in 2001, 2007 and 2013. Results show that HIV prevalence among men aged 15–29 (the target group for VMMC) did not decrease over the period, despite a decline in HIV prevalence among women of the same age group (most of their partners). Correlations between male circumcision and HIV prevalence were positive for a variety of socioeconomic groups (urban residence, province of residence, level of education, ethnicity). In a multivariate analysis, based on the 2013 DHS survey, circumcised men were found to have the same level of infection as uncircumcised men, after controlling for age, sexual behaviour and socioeconomic status. Lastly, circumcised men tended to have somewhat riskier sexual behaviour than uncircumcised men. This study, based on large representative samples of the Zambian population, questions the current strategy of mass circumcision campaigns in southern and eastern Africa.

The study describes the patterns of concurrent wasting and stunting (WaSt) among children age 6–59 months living in the 1980s in Niakhar a rural area of Senegal under demographic surveillance. Wasting and stunting were defined by z scores lower than -2 in weight for height and height for age. Both conditions were found to be highly prevalent wasting more so before age 30 months stunting more so after age 30 months. As a result concurrent WaSt peaked around age 18 months and its prevalence (6.2%) was primarily the product of the two conditions with an interaction term of 1.57 (p < 10-6). The interaction was due to the correlation between both conditions (more stunting if wasted more wasting if stunted). Before age 30 months boys were more likely to be concurrently wasted and stunted than girls (RR = 1.61) but the sex difference disappeared after 30 months of age. The excess susceptibility of younger boys could not be explained by muscle mass or fat mass measured by arm or muscle circumference triceps or subscapular skinfold. Concurrent WaSt was a strong risk factor for child mortality and its effect was the product of the independent effect of each component with no significant interaction. Key messages: 1) Prevalence of concurrent wasting and stunting (WaSt) among under-five children is the product of independent wasting and stunting plus an interaction term of 57%. Prevalence of WaSt peaks around age 18 months; 2) Prevalence of WaSt is about 50% higher among boys than among girls before age 30 months largely because their higher susceptibility to stunting but not higher thereafter; and 3) Excess mortality associated with WaSt is the product of that associated with wasting and that associated with stunting.

SummaryThis study analysed sex ratios at birth (defined as the number of male births per 100 female births) using data on children ever-born from three censuses conducted in Ethiopia in 1984, 1994 and 2007. The results showed very high values by any standard, with an average of 108.4 for a sample of some 8.2 million births, with somewhat lower values in urban areas. Analysis of socioeconomic correlates revealed that the sex ratio varied very much by household wealth, from about 110 for very poor women to about 102 for wealthier women. The high value of the sex ratio at birth in Ethiopia could be explained by poverty, used as a proxy for poor nutritional status. In multivariate analysis, the effects of living in urban areas and of maternal education were less important than household wealth. Among the many ethno-linguistic groups, the Nilotic family had higher sex ratios than other groups. The results were confirmed using data from DHS surveys conducted in the country, and by the analysis of children still living at time of census.

Background : Completeness of vital registration remains very low in sub-Saharan Africa, especially in rural areas. Objectives : To investigate trends and factors in completeness of birth and death registration in Agincourt, a rural area of South Africa covering a population of about 110,000 persons, under demographic surveillance since 1992. The population belongs to the Shangaan ethnic group and hosts a sizeable community of Mozambican refugees. Design : Statistical analysis of birth and death registration over time in a 22-year perspective (1992–2014). Over this period, major efforts were made by the government of South Africa to improve vital registration. Factors associated with completeness of registration were investigated using univariate and multivariate analysis. Results : Birth registration was very incomplete at onset (7.8% in 1992) and reached high values at end point (90.5% in 2014). Likewise, death registration was low at onset (51.4% in 1992), also reaching high values at end point (97.1% in 2014). For births, the main factors were mother’s age (much lower completeness among births to adolescent mothers), refugee status, and household wealth. For deaths, the major factors were age at death (lower completeness among under-five children), refugee status, and household wealth. Completeness increased for all demographic and socioeconomic categories studied and is likely to approach 100% in the future if trends continue at this speed. Conclusion : Reaching high values in the completeness of birth and death registration was achieved by excellent organization of the civil registration and vital statistics, a variety of financial incentives, strong involvement of health personnel, and wide-scale information and advocacy campaigns by the South African government. Keywords: completeness of vital registration; demographic surveillance system; socioeconomic factors; level of education; household wealth; Mozambican refugee; South Africa; Agincourt (Published: 24 October 2016) Citation: Glob Health Action 2016, 9 : 32795 - http://dx.doi.org/10.3402/gha.v9.32795

The study uses data from eight censuses conducted between 1970 and 2011 to reconstruct long term trends in terminal celibacy in South Africa. The cohort analysis covers those born between 1870 and 1971. Results show a quasi-stable prevalence of terminal celibacy for cohorts born before 1920, followed by a steep rise. Levels and trends were notably different for the four population groups. Black/Africans had the highest level at endpoint (50% celibate), despite lower levels at onset, followed by Coloured (34%). Indian/Asian had the lowest level at endpoint (14%). White/European had highest levels at onset, and intermediate values at endpoint (17%). Differences were large by ethnicity, Zulu and Swazi having the highest prevalence of terminal celibacy (60%). Correlations with development were complex, with higher values among persons with lower education, and those living in urban areas, and lower values among those who were employed. Overall, cultural factors dominated the rise in terminal celibacy in South Africa.

Demographic surveys and censuses often record pregnancy-related deaths, defined as those occurring during the maternal risk period (pregnancy, delivery, and six weeks postpartum), but do not include cause of death. This study presents a method for estimating obstetric mortality from pregnancy-related deaths data. Calculations are based on multiple-decrement life tables, and data needed are simply age-specific fertility and mortality rates that are commonly available in Demographic and Health Survey (DHS) or census data, and an estimate of the relative risk of death from nonobstetric causes during the maternal risk period. The method is tested on 59 DHS surveys from Africa. Results show that, on average, less than half of the pregnancy-related deaths are attributable to obstetric causes. This proportion varies with the level of mortality and fertility, and in particular with the prevalence of HIV in the population.

SummaryIn this study, sex ratios at birth (male/female births) were found to vary according to family composition. Using Demographic and Health Survey (DHS) maternity histories from sub-Saharan Africa, the study shows that the sex ratio at birth increases with the number of previous male births and decreases with the number of previous female births. For families with only males, the sex ratio increases from 1·046 for the first birth to 1·083 for the 8th birth. For families with only females, the sex ratio decreases from 1·046 for the first birth to 0·942 for the 8th birth. The differences were highly significant when tested with a linear logistic model (p=0·018 for males; p=1·85✕10−11 for females). The effect was not symmetrical, and was found to be significantly stronger for females. These effects could be reproduced assuming a strong heterogeneity between couples. The distribution of sex ratios was fitted with an asymmetrical log-gamma function, which revealed a wide range of variation in the sex ratio between 0·50 and 1·30, and a peak around 1·14. The results and their implications are discussed in the light of former findings in France and in the United States of America.

This paper examines the complex relationship between male circumcision and HIV prevalence and incidence in sub-Saharan African countries that have generalised epidemics. In South Africa, the mean yearly HIV incidence and an estimate of the net reproduction rate of the epidemic (R0) (in this case, the ratio of the number of HIV-infected persons between 1994 and 2004 to the number of persons infected in 1994 from which they were presumed to have become infected) were computed from antenatal clinic data for the period 1994–2004, and then compared, by province, to prevailing levels of male circumcision (high, medium and low). In South Africa, mean yearly HIV incidence and net reproduction rate of the epidemic were not lower in provinces with higher levels of male circumcision. For thirteen other countries where Demographic and Health Survey data were available, male HIV prevalence in circumcised and non-circumcised groups was compared. A meta-analysis of that data, contrasting male HIV seroprevalence according to circumcision status, showed no difference between the two groups (combined risk ratio [RR] = 0.99, 95% CI = 0.94–1.05). Individual case study analysis of eight of those countries showed no significant difference in seroprevalence in circumcised and uncircumcised groups, while two countries (Kenya and Uganda) showed lower HIV prevalence among circumcised groups, and three countries (Cameroon, Lesotho and Malawi) showed higher HIV prevalence among circumcised groups. In most countries with a complex ethnic fabric, the relationship between men's circumcision status and HIV seroprevalence was not straightforward, with the exception of the Luo in Kenya and a few groups in Uganda. These observations put into question the potential long-term effect of voluntary circumcision programmes in countries with generalised HIV epidemics. Keywords: demography; epidemiology; HIV infection; household surveys; meta-analysis; prevention and control; quantitative data; statistical analysisAfrican Journal of AIDS Research 2008, 7(1): 1–8

Background The HIV seroprevalence among women aged 15–24 years was compared according to their pattern of contraceptive use in four African countries: Kenya, Lesotho, Malawi and Zimbabwe. Study Design Data were derived from Demographic and Health Surveys (DHS) conducted between 2003 and 2006 on representative samples, totaling 4549 women. Results It is indicated that users of depo-medroxyprogesterone acetate (DMPA) have a significantly higher seroprevalence than nonusers [odds ratio (OR)=1.82, 95% CI=1.63–2.03] and higher than users of oral contraceptives and users of traditional methods. The results were confirmed in a multivariate analysis including as controls, age, duration since first intercourse, urban residence, education, number of sexual partners in the last 12 months and marital status. A somewhat smaller net effect (OR=1.34, 95% CI=1.10–1.63) was found. In contrast, oral contraceptives and traditional methods did not show any risk for HIV (OR=0.96 and 0.92, respectively). Conclusion The increased risk of DMPA was present in three of the four countries investigated, and significant in Zimbabwe and Lesotho, the countries with the highest HIV seroprevalence. The HIV risk attributable to DMPA remained small altogether and was estimated as 6% in the four countries combined.

Rationale for study: Vital registration is generally lacking in infrastructurally weak areas where health and development problems are most pressing. Health and demographic surveillance is a response to the lack of a valid information base that can provide high-quality longitudinal data on population dynamics, health, and social change to inform policy and practice. Design and measurement procedures: Continuous demographic monitoring of an entire geographically defined population involves a multi-round, prospective community study, with annual recording of all vital events (births, deaths, migrations). Status observations and special modules add value to particular research areas. A verbal autopsy is conducted on every death to determine its probable cause. A geographic surveillance system supports spatial analyses, and strengthens field management. Population and sample size considerations: Health and demographic surveillance covers the Agincourt sub-district population, sited in rural north-eastern South Africa, of some 70,000 people (nearly a third are Mozambican immigrants) in 21 villages and 11,700 households. Data enumerated are consistent or more detailed when compared with national sources; strategies to improve incomplete data, such as counts of perinatal deaths, have been introduced with positive effect. Basic characteristics: A major health and demographic transition was documented over a 12-year period with marked changes in population structure, escalating mortality, declining fertility, and high levels of temporary migration increasing particularly amongst women. A dual burden of infectious and non-communicable disease exists against a background of dramatically progressing HIV/AIDS. Potential and research questions: Health and demographic surveillance sites — fundamental to the INDEPTH Network — generate research questions and hypotheses from empirical data, highlight health, social and population priorities, provide cost-effective support for diverse study designs, and track population change and the impact of interventions over time.

Objectives: To study the different responses by sex to zinc supplementation among young children. Study Children and Methods: Double-blind randomized controlled trial of zinc supplementation in 686 children aged 6‐30 months, conducted in Nouna, a rural area of Burkina Faso. Children received either a 12.5-mg zinc sulfate tablet or a placebo every day for about 6 months. Outcomes were morbidity, nutritional status, and mortality. Results: Results revealed significant differences between boys and girls in their responses to zinc supplementation. Boys who received the zinc preparation had fewer days with diarrhea than did control boys (RR ¼ 0.88, P ¼ 0.05), especially less nonfebrile diarrhea (RR ¼ 0.72, P < 0.001) and less dysentery (RR ¼ 0.65, P ¼ 0.05), but more ear infections (RR ¼ 4.00, P < 0.001). By contrast, girls who received the zinc supplement had the same prevalence of diarrhea as did control girls, but more dysentery (RR ¼ 3.70, P < 0.001), fewer ear infections (RR ¼ 0.39, P < 0.001), and fewer eye infections (RR ¼ 0.41, P < 0.001). The effect of supplementation on nutritional status was not detectable in boys, but girls who received supplementation experienced a faster growth velocity in height than did control girls (P ¼ 0.004) and a faster growth velocity for weight and height if they were wasted and not stunted at baseline (P ¼ 0.003). Conclusions: Zinc supplementation had positive, nil, or negative effects depending on pathological condition, and the effects were different for boys than for girls. JPGN 44:619–628, 2007. Key Words: Zinc supplementation—Morbidity— Diarrhea—Dysentery—Malaria—Nutritional status— Immunity—Sex differences—Burkina Faso. # 2007 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

To analyse the effects of zinc supplementation on growth parameters in a representative sample of young children in rural Burkina Faso. Design Randomized, double-blind, placebo-controlled efficacy trial. Setting Eighteen villages in rural northwestern Burkina Faso. Subjects In all, 709 children aged 6-31 months were enrolled; 685 completed the trial. Intervention Supplementation with zinc (12.5 mg zinc sulphate) or placebo daily for 6 days a week for 6 months. Outcomes Weight, length/height, mid-arm circumference, and serum zinc.In a representative subsample of study children, 72% were zinc-deficient at baseline. After supplementation, serum zinc increased in zinc-supplemented but not in control children of the subsample. No significant differences between groups were observed during follow-up regarding length/height, weight, mid-arm circumference, and z scores for height-for-age, weight-for-age, and weight-for-height.We conclude that zinc supplementation does not have an effect of public health importance on growth in West African populations of young children with a high prevalence of malnutrition. Multinutrient interventions are likely to be more effective.

Using data collected by the Agincourt Health and Population Programme in a rural sub-district of South Africa's Northern Province, this paper describes the residential arrangements of a population in rural South Africa, and analyses the impact of these arrangements on children's educational attainment. Children with co-resident parents generally have higher levels of schooling than those who have one or no co-resident parents. However, having a father who is away from home as a migrant appears to benefit older children whereas, for girls aged 11 to 15, having a mother who is a migrant lowers educational attainment. Children who live in households headed by Mozambican refugees have lower levels of schooling than those who live in non-refugee households. Living in a household headed by a woman is not associated with lower levels of education and, for some age-sex groups, appears to be an advantage.

The paper proposes a socioeconomic framework of supply, demand, and regulation to explain the development of sex-selective abortion in several parts of the world. The framework is then applied to three countries of southern Caucasus (Armenia, Azerbaijan, and Georgia) where sex-selective abortion has developed since the collapse of the Soviet Union. The authors argue that sex-selective abortion cannot be explained simply by patriarchal social systems, sex discrimination, or son preference. The emphasis is put on the long-term acceptability of abortion in the region, on acceptability of sex-screening by both the medical establishment and by the population, on newly imported techniques of sex-screening, and on the changing demand for children associated with the major economic and social changes that followed the dismantlement of the Soviet Union., Video abstract

SummaryThe study investigates the complex relationships between sex-selective abortion and family composition in two countries of the Southern Caucasus: Armenia and Azerbaijan. Data were drawn from maternity histories recorded in Demographic and Health Surveys (DHSs). In both countries, the relationship between the sex ratio of the next birth and the number of girls already born changed from negative to positive after 1992, when sex-selective abortion became prevalent. In Azerbaijan, but not in Armenia, a similar change was noticed for the relationship between the sex ratio of the next birth and the number of boys already born, this time from positive to negative. All changes in slopes were highly statistically significant. These findings indicate that sex-selective abortion was prevalent in both countries, and could work both ways in Azerbaijan. The results are interpreted in terms of ‘gender saturation’, that is a desire of families to better balance the composition of the family when too many children of the same sex are already born, which is consistent with opinion surveys indicating a preference for balanced families.

Summaryobjective To validate the causes of death determined with a single verbal autopsy instrument covering all age groups in the Agincourt subdistrict of rural South Africa. methods Verbal autopsies (VAs) were conducted on all deaths recorded during annual demographic and health surveillance over a 3-year period (1992–95) in a population of about 63 000 people. Trained fieldworkers elicited signs and symptoms of the terminal illness from a close caregiver, using a comprehensive questionnaire written in the local language. Questionnaires were assessed blind by three clinicians who assigned a probable cause of death using a stepwise consensus process. Validation involved comparison of VA diagnoses with hospital reference diagnoses obtained for those who died in a district hospital; and calculation of sensitivity, specificity and positive predictive value (PPV) for children under 5 years, and adults 15 years and older. results A total of 127 hospital diagnoses satisfied the criteria for inclusion as reference diagnoses. For communicable diseases, sensitivity of VA diagnoses among children was 69%, specificity 96%, and PPV 90%; among adults the values were 89, 93 and 76%. Lower values were found for non-communicable diseases: 75, 91 and 86% among children; and 64, 50 and 80% among adults. Most misclassification occurred within the category itself. For deaths due to accidents or violence, sensitivity was 100%, specificity 97%, and PPV 80% among children; and 75, 98 and 60% among adults. Since causes of death were largely age-specific, few differences in sensitivity, specificity and PPV were found for adults and children. The frequency distribution of causes of death based on VAs closely approximated that of the hospital records used for validation. conclusion VA findings need to be validated before they can be applied to district health planning. In Agincourt, a single verbal autopsy instrument provided a reasonable estimate of the frequency of causes of death among adults and children. Findings can be reliably used to inform local health planning and evaluation.

The study compares the cause of death profile in a rural area of South Africa (Agincourt), with that in a rural area of West Africa (Niakhar), and in a developed country with the same life expectancy (France, 1951) in order to determine causes with high and low mortality and priorities for future health interventions. In the two African sites, causes of death were assessed by verbal autopsies, whereas they were derived from regular cause of death registration in France. Age-standardized death rates were used to compare cause-specific mortality in the three studies. Life expectancy in Agincourt was estimated at 66 years, similar to that of France in 1951, and much higher than that of Niakhar. Causes of death with outstandingly high mortality in Agincourt were violent deaths (homicide and suicide), accidents (road traffic accidents and household accidents), certain infectious diseases (HIV/AIDS, tuberculosis, diarrhea and dysentery), certain chronic diseases (cancer of genital organs, liver cirrhosis, gastrointestinal hemorrhage, maternal mortality, epilepsy, acute rheumatic fever, and pneumoconiosis) and malnutrition of young children (kwashiorkor). Causes of death with lower mortality than expected were primarily respiratory diseases (pneumonia, bronchitis, influenza, lung cancer), other cancers, vaccine preventable diseases (measles, whooping cough, tetanus), and marasmus. Verbal autopsies could be used in a rural area of a developing country without formal cause of death registration to identify the most salient health problems of the population, and could be compared with a formal cause of death registration system of a developed country.

Information on cause of death is essential for rational public health planning, yet mortality data in South Africa is limited. In the Agincourt subdistrict, verbal autopsies (VA) have been used to determine cause of death. A VA is conducted on all deaths recorded during annual demographic and health surveillance. Trained lay fieldworkers interview a close caregiver to elicit signs and symptoms of the terminal illness. Each questionnaire is reviewed by three medical practitioners blind to each other's assessment, who assign a 'probable cause of death' where possible. Of 1001 deaths of adults and children identified between 1992 and 1995, 932 VAs were completed. The profile of deaths reflects a mixed picture: the 'unfinished agenda' of communicable disease and malnutrition (diarrhoea and kwashiorkor predominantly) are responsible for over half of deaths in under-fives, accidents are prominent in the 5-14 age-group, while the 'emerging agenda' of violence and chronic degenerative disease (particularly circulatory disease) is pronounced among the middle-aged and elderly. This profile shows the social and demographic transition to be well underway within a rural, underdeveloped population. Validation of VA findings demonstrate that the cause of death profile derived from VA can be used with confidence for planning purposes. Findings of note include the high death rates from kwashiorkor and violence, emerging AIDS and pulmonary tuberculosis, and circulatory deaths in the middle-aged and young elderly. A deeper understanding of the causal factors underlying these critical health problems is needed to strengthen policy and better target interventions.

Background: Measurement of the level and composition of maternal mortality depends on the definition used, with inconsistencies leading to inflated rates and invalid comparisons across settings. This study investigates the differences in risk of death for women in their reproductive years during and outside the maternal risk period (pregnancy, delivery, puerperium), focusing on specific causes of infectious, non-communicable and external causes of death after separating out direct obstetrical causes. Methods: Data on all deaths of women aged 15-49 years that occurred in the Agincourt sub-district between 1992 and 2010 were obtained from the Agincourt health and socio-demographic surveillance system (HDSS) located in rural South Africa. Causes of death were assessed using a validated verbal autopsy instrument. Analysis included 2170 deaths, of which 137 occurred during the maternal risk period. Findings: Overall, women had significantly lower mortality during the maternal risk period than outside it (age-standardized RR = 0.75; 95% CI = 0.63-0.89). This was true in most age groups with the exception of adolescents aged 15-19 years where the risk of death was higher. Mortality from most causes, other than obstetric causes, was lower during the maternal risk period except for malaria, cardiovascular diseases and violence where there were no differences. Lower mortality was significant for HIV/AIDS (RR = 0.29, P

Background Uncertainty in the levels of global maternal mortality reflects data deficiencies, as well as differences in methods and definitions. This study presents levels and trends in maternal mortality in Agincourt, a rural subdistrict of South Africa, under long-term health and sociodemographic surveillance. Methods All deaths of women aged 15 years–49 years occurring in the study area between 1992 and 2010 were investigated, and causes of death were assessed by verbal autopsy. Two case definitions were used: “obstetrical” (direct) causes, defined as deaths caused by conditions listed under O00–O95 in International Classification of Diseases-10; and “pregnancy-related deaths”, defined as any death occurring during the maternal risk period (pregnancy, delivery, 6 weeks postpartum), irrespective of cause. Results The case definition had a major impact on levels and trends in maternal mortality. The obstetric mortality ratio averaged 185 per 100,000 live births over the period (60 deaths), whereas the pregnancy-related mortality ratio averaged 423 per 100,000 live births (137 deaths). Results from both calculations increased over the period, with a peak around 2006, followed by a decline coincident with the national roll-out of Prevention of Mother-to-Child Transmission of HIV and antiretroviral treatment programs. Mortality increase from direct causes was mainly due to hypertension or sepsis. Mortality increase from other causes was primarily due to the rise in deaths from HIV/AIDS and pulmonary tuberculosis. Conclusion These trends underline the major fluctuations induced by emerging infectious diseases in South Africa, a country undergoing rapid and complex health transitions. Findings also pose questions about the most appropriate case definition for maternal mortality and emphasize the need for a consistent definition in order to better monitor and compare trends over time and across settings., Video abstract

The Agincourt health and socio-demographic surveillance system (HDSS), located in rural northeast South Africa close to the Mozambique border, was established in 1992 to support district health systems development led by the post-apartheid ministry of health. The HDSS (90 000 people), based on an annual update of resident status and vital events, now supports multiple investigations into the causes and consequences of complex health, population and social transitions. Observational work includes cohorts focusing on different stages along the life course, evaluation of national policy at population, household and individual levels and examination of household responses to shocks and stresses and the resulting pathways influencing health and well-being. Trials target children and adolescents, including promoting psycho-social well-being, preventing HIV transmission and reducing metabolic disease risk. Efforts to enhance the research platform include using automated measurement techniques to estimate cause of death by verbal autopsy, full 'reconciliation' of in- and out-migrations, follow-up of migrants departing the study area, recording of extra-household social connections and linkage of individual HDSS records with those from sub-district clinics. Fostering effective collaborations (including INDEPTH multi-centre work in adult health and ageing and migration and urbanization), ensuring cross-site compatibility of common variables and optimizing public access to HDSS data are priorities.

The paper presents and discusses the progress in knowledge of African populations and their dynamics over the past 50 years. It takes as a starting point the landmark series of studies published in The Demography of Tropical Africa. Since then major progresses in data collection and data analysis were made, which are reviewed and discussed, with special reference to direct and indirect methods of demographic estimation. A major change occurred about 25 years ago with the development of DHS surveys and the focus on epidemiology and public health issues. Demographic research had to change its paradigms, and major advances were made in our understanding of population dynamics in relation with health issues. In a last part, the paper addresses special topics, unforeseeable events such as the HIV/AIDS epidemics which had major consequences for many demographic processes, and new fields for research around environmental issues. Keywords: Demography; public health; demographic methods; history; sub-Saharan Africa Resume en francais Cette communication presente et discute les progres faits depuis un demi-siecle sur la connaissance des populations africaines et leurs dynamiques. Elle part d’une serie d’etudes pionnieres publiees dans l’ouvrage intitule : The Demography of Tropical Africa. Depuis cette epoque, de nombreux progres ont ete faits en matiere de collecte et d’analyse des donnees, qui sont presentes et discutes, en mettant l’accent sur les methodes directes et indirectes d’estimation demographique. Un changement majeur se produit 25 ans plus tard avec le developpement des enquetes demographiques et sanitaires (EDS), l’interet se portant alors sur les questions epidemiologiques et de sante publique. La recherche demographique a du changer ses paradigmes, permettant de realiser des avancees majeures sur la comprehension des dynamiques de population en relation avec les questions de sante. Dans une derniere partie, la communication traite de sujets speciaux, d’evenements imprevisibles comme l’emergence du VIH/sida, qui a eu d’enormes consequences sur les phenomenes demographiques, et de nouvelles questions comme celles qui ont trait aux questions d’environnement. Mots cle: Demographie; Sante publique; Methodes d’estimation; Histoire; Afrique sub-Saharienne.

This article is a discussion of the design and methods of program impact surveys conducted as part of the Combatting Childhood Communicable Diseases (CCCD) program. Independent reviews are given of the analysis of results from Liberia and Zaire. The CCCD evaluations aim to examine the performance of routine technologies in national programs rather than to test the efficacy of new technologies and demonstrate the impact on mortality and morbidity. The argument is presented that mortality and morbidity are insufficient indicators of improvements in quality of life of reductions in suffering or of short-term changes in health status. Short-term changes are best measured as mortality based on a full reporting of births and deaths as occurs in a vital registration system over a number of years. Retrospective surveys are considered to be flawed by systematic biases problems of omission and misdating of events. The widely used Brass method is viewed as not producing estimates for exact time periods and data from aged 15-29 years are affected by selection effects. Field conditions have an important effect on results. Sometimes the quality of field work is assessed on the basis of plausibility of results. Interseasonal and interannual variations in death rates can be substantial. Outcomes are unpredictable. Randomized control trials with or without controls for community level factors require large sample sizes but are argued by some researchers to be more successful. Cause specific changes in mortality offer a more useful measure of impact and increase the level of significance of the impact. Limitations are the interaction between causes of death and the unreliability in the identification of causes. Ideally evaluation should involve an estimation of longterm mortality trends documentation of mortality change pre/post-intervention a control group and data on causes of death targeted by the intervention. The surveys in Liberia and Zaire are noteworthy for attempting to rigorously measure program impact but the impact of service delivery and mortality is limited. Concern is raised that poor assessment measures will lead to poor future policy choices.

The health of children improved dramatically worldwide during the 20th century, although with major contrasts between developed and developing countries, and urban and rural areas. The quantitative evidence on urban child health from a broad historical and comparative perspective is briefly reviewed here. Before the sanitary revolution, urban mortality tended to be higher than rural mortality. However, after World War I, improvements in water, sanitation, hygiene, nutrition and child care resulted in lower urban child mortality in Europe. Despite a similar mortality decline, urban mortality in developing countries since World War II has been generally lower than rural mortality, probably because of better medical care, higher socio-economic status and better nutrition in urban areas. However, higher urban mortality has recently been seen in the slums of large cities in developing countries as a result of extreme poverty, family disintegration, lack of hygiene, sanitation and medical care, low nutritional status, emerging diseases (HIV/AIDS and tuberculosis) and other health hazards (environmental hazards, accidents, violence). These emerging threats need to be addressed by appropriate policies and programmes.

This paper reviews the demographic evidence for the relationship between male circumcision and HIV infection in national or sub-national African populations. A meta-analysis based on 18 countries, representing more than half of the population of sub-Saharan Africa, shows no relationship [standardized odds ratio = 1.00; 95% CI: 0.96–1.05]. There were even more countries in which HIV prevalence was higher among circumcised persons than countries where it was lower. In only five countries, the odds ratio of HIV prevalence (circumcised/intact) was significantly different from 1.0; three countries where it was higher, and two countries where it was lower. The contrast between lack of demographic impact and results from clinical trial is striking, and can probably be explained by the low clinical efficacy in situations of intense and repeated exposure, and by the interactions with the many other determinants of HIV spread. This paper also addresses some ethical and political issues, and in particular raises the question of power abuse, which may lie in the practice of genital mutilations and relevant international recommendations.

The study investigates the magnitude of differences in child and adult mortality by wealth in Uzbekistan, a former soviet country of Central Asia, and compares it with similar indicators from sub-Saharan Africa. Data were derived from Demographic and Health Surveys. An “Absolute Wealth Index” was built from data on goods owned by households and quality of housing, and scaled from 0 to 12. Wealth was distributed evenly in Uzbekistan, with a symmetric distribution around a mean of 5.5 modern goods. In sub-Saharan Africa, on the contrary, the wealth distribution had a lower mean (2.5) and was highly skewed towards the left, revealing a high proportion of very poor people. Adult and child mortality levels were lower in Uzbekistan. Despite these major differences, the relationships between mortality indicators and the wealth index were similar in the two cases. The magnitude of mortality differentials by wealth was of the same order in both cases, with gradients ranging from 2.5 to 1 for child mortality and 1.5 to 1 for adult mortality (poorest versus richest). However, mortality levels remained lower in Uzbekistan than in sub-Saharan Africa at the same level of wealth for both children and adults. A similar relationship was found between nutritional status and wealth index in both cases. On the contrary, there were no differences by wealth in use of health services and level of education in Uzbekistan, whereas wealth gradients were steep for the same variables in sub-Saharan Africa. The study suggests that mortality differentials were primarily due to nutritional status, and not to access and use of health services or to education. The discussion focuses on health and social policies during the colonial and post-colonial period that have produced these patterns.

Variations of the sex ratio at birth (SRB) were investigated using maternity history data collected in demographic surveys conducted in sub-Saharan Africa. Thirty-three countries were covered, totaling about 2.0 million births. The average SRB was 1.034 and varied by ethnicity, birth order, and maternal age. The effect of maternal age was significant for younger mothers (12–19 years old) and older mothers (40–49 years old), with a decline in sex ratios with increasing maternal age in both cases. The effect of birth order was significant only for the 20–39-year-old women, with a decline in sex ratio with increasing birth order. These two effects were similar for the three main population groups identified: populations from southern, eastern, and central Africa (SRB = 1.015), populations from West Africa and Sahelian countries (SRB = 1.040), and populations from Nigeria and Ethiopia (SRB = 1.087). In contrast, no effect of marital duration was found.

A comparative study of fertility trends since 1950 in 30 countries from sub-Saharan Africa revealed several cases of “fertility stall”, that is a change from downward fertility trends to flat- or even slightly rising- trends for some time, usually a few years: Ghana (1998-2003), Kenya (1995-2003), Madagascar in urban areas (1987-1993), Nigeria (1999-2003), Rwanda in rural areas (1999-2005), Tanzania in rural areas (1995-2004). In a first part, the paper presents the statistical evidence of changes in fertility trends. In a second part, the analysis focuses on possible causes of these changes. Fertility stalls were often associated with changes in two proximate determinants (contraceptive use and age at marriage) and in two socio-economic correlates (income and labour force participation). The paper concludes to a variety of situations leading to different causality in the various countries, including one case (Ghana) for which no reasonable explanation could be found from the available data.

The study compares the association between using the services of commercial sex workers and male HIV seroprevalence in five African countries: Ghana, Kenya, Lesotho, Malawi and Rwanda. The HIV seroprevalence among men who ‘ever paid for sex’ was compared with controls who ‘never paid for sex’. Results were based on 12,929 eligible men, aged 15–59 years, interviewed in Demographic and Health Surveys. The odds ratio of HIV seroprevalence associated with ever paying for sex was 1.89 (95% confidence interval = 1.57–2.28), with only minor differences by country. The results were stable in multivariate analysis after controlling for available potential cofactors (data on non-sexual routes of transmission were not available). Given the relatively small proportion of men involved, the risk attributable to ‘ever paying for sex’ remained low: 7.1% in univariate analysis and 4.4% after adjustment, and it varied among countries (range 1.3–9.4%). These results match previous observations that commercial sex seems to play a minor role in the spread of HIV in mature epidemics.

Background Maternal mortality remains poorly researched in Africa, and is likely to worsen dramatically as a consequence of HIV/AIDS. Methods The 2001 census of South Africa included a question on deaths in the previous 12 months, and two questions on external causes and maternal mortality, defined as "pregnancy-related deaths". A microdata sample from the census permits researchers to assess levels and differentials in maternal mortality, in a country severely affected by high death rates from HIV/AIDS and from external causes. Results After correcting for several minor biases, our estimate of the Maternal Mortality Ratio (MMR) in 2001 was 542 per 100,000 live births. This level is much higher than previous estimates dating from pre-HIV/AIDS times. This high level occurred despite a relatively low proportion of maternal deaths (6.4%) among deaths of women aged 15–49 years, and was due to the astonishingly high level of adult mortality, some 4.7 times higher than expected from mortality below age 15 or above age 50. The main reasons for these excessive levels were HIV/AIDS and external causes of deaths. Our regional estimates of MMR were found to be consistent with other findings in the Cape Town area, and with the Agincourt DSS. The differentials in MMR were considerable: 1 to 9.2 for population groups (race), 1 to 3.2 for provinces, and 1 to 2.4 for levels of education. Relationship with income and wealth were complex, with highest values for middle income and middle wealth index. The effect of urbanization was small, and reversed in a multivariate analysis. Higher risks in provinces were not necessarily associated with lower income, lower education or higher proportions of home delivery, but correlated primarily with the prevalence of HIV/AIDS. Conclusion Demographic census microdata offer the opportunity to conduct an epidemiologic analysis of maternal mortality. In the case of South Africa, the level of MMR increased dramatically over the past 10 years, most likely because of HIV/AIDS. Indirect causes of maternal deaths appear much more important than direct obstetric causes. The MMR appears no longer to be a reliable measure of the quality of obstetric care or a measure of safe motherhood.

In a rural area of Senegal, 1500 cases of measles and 98 deaths (6.5%) were registered during a 4-year period (1983-1986). For children less than 5 years old, the acute case fatality ratio (CFR) was 9.6%. Compared with index cases who contracted measles in the village, secondary cases infected within the compound had a significantly higher mortality (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.3-6.1). The CFR of secondary cases increased with the closeness of contact with the index cases; the ORs were 1.9 (CI, 0.6-6.0) for children living in the same compound but not the same household, 2.3 (CI, 1.0-5.7) for children living in the same household but not in the same hut, and 3.8 (CI, 1.7-8.4) for children living in the same hut. In large compounds with many cases, the CFR increased exponentially through the succession of generations; the ORs were 2.3 (CI, 1.0-5.2) in the second generation, 3.7 (CI, 1.1-3.0) in the third generation, 5.5 (CI, 1.7-18.1) in the fourth generation, and 16.1 (CI, 5.6-46.3) in the fifth or later generations. Postmeasles mortality through the year following measles infection was also significantly related to the intensity of exposure. Differences in exposure may be a major determinant of child survival, both at time of acute disease and for the long term impact of measles infection.

Aims: To analyse trends in fertility rates and net reproduction rates in Agincourt, a rural area of South Africa located in the former homeland of Gazankulu near the Mozambican border. Trends are analysed in the context of widely available modern contraceptive methods and increasing HIV/AIDS. Methods: A health and demographic surveillance system has been in place since 1992, covering a population of approximately 70,000 persons, with an annual census update and comprehensive recording of births and deaths. It was complemented by a retrospective study of fertility at baseline. Retrospective and prospective data were used to calculate trends in fertility, survival, and net reproduction. When possible, they were compared with data from other censuses and surveys in the same ethnic group. Results: The fertility transition has almost ended over a course of 25 years in Agincourt. The total fertility rate (TFR) averaged 6.0 in 1979 and 2.3 in 2004. Fertility declined in proportionate fashion in all age groups including adolescents in the recent period. The net reproduction rate (NRR) declined from 1.8 to 1.0 during the prospective period (1992—2004). At current rates of change in fertility and mortality, the NRR can be expected to reach 0.63 by the year 2010. Conclusions: The situation of a below-replacement fertility level is new for rural Africa, and is likely to have many demographic, economic and social implications. The population could decline in the country as a whole, and is nearly static in Agincourt because of negative migration flows balancing the small excess from natural increase.

A two-sex compartmental model of the dynamics of HIV infection was developed and applied to the case of Zambia. Parameters included age specific rates of fertility mortality entry into sexual life number of partners and age of partners. They were all derived from empirical data from Demographic and Health Surveys and applied by single year of age. The model was unable to fit age and sex patterns of infection observed in 2001. Current knowledge of HIV transmission does not allow fitting the dynamics of HIV epidemics. Further research is needed to understand the dynamics of HIV heterosexual epidemics in Africa. (authors)

This study investigates trends and age-and-sex patterns of mortality in pulmonary tuberculosis (PTB) and PTB/HIV co-infection in a rural population of South Africa. The PTB/HIV mortality emerged in 1994 and has been rising ever since (men: P = 0.001; women: P = 0.020 test for trend). In the last 2 years for both sexes combined 63% (95% CI 51-74%) of PTB deaths were attributable to HIV/AIDS. PTB/HIV death rate was higher in men than in women for all ages combined (RRMH = 2.48 95% CI 1.53-4.04 P less than 0.001). PTB/HIV death rate was also higher in younger individuals (less than 25 years) compared with PTB without HIV/AIDS (P = 0.033) and the median age at death from PTB/HIV in women (28 years) was lower than in men (38 years P = 0.002). While mortality from PTB without HIV remained constant over time HIV/AIDS explained the rise in PTB mortality. In the last 3 years the HIV/AIDS epidemic has caused the number of persons dying of PTB to increase by +117% with the mortality excess being higher in women (+164%) than in men (+103% P = 0.001). Combined PTB and HIV programme activities need to be reinforced to respond to the increase in PTB mortality particularly in women. (authors)

OBJECTIVE: To reconstruct and analyse mortality trends in children younger than 5 years in sub-Saharan Africa between 1950 and 2000. METHODS: We selected 66 Demographic and Health Surveys and World Fertility Surveys from 32 African countries for analysis. Death rates were calculated by yearly periods for each survey. When several surveys were available for the same country, overlapping years were combined. Country-specific time series were analysed to identify periods of monotonic trends, whether declining, steady or increasing. We tested changes in trends using a linear logistic model. FINDINGS: A quarter of the countries studied had monotonic declining mortality trends: i.e. a smooth health transition. Another quarter had long-term declines with some minor rises over short periods of time. Eight countries had periods of major increases in mortality due to political or economic crises, and in seven countries mortality stopped declining for several years. In eight other countries mortality has risen in recent years as a result of paediatric AIDS. Reconstructed levels and trends were compared with other estimates made by international organizations, usually based on indirect methods. CONCLUSION: Overall, major progress in child survival was achieved in sub-Saharan Africa during the second half of the twentieth century. However, transition has occurred more slowly than expected, with an average decline of 1.8% per year. Additionally, transition was chaotic in many countries. The main causes of mortality increase were political instability, serious economic downturns, and emerging diseases.

Premarital fertility, defined as fertility before first marriage, was found to be highly prevalent in Namibia. According to data from the 1992 and 2000 DHS surveys, the proportion of premarital births was 43% for all births, and 60% for the first birth. This seemed to be primarily due to a late mean age at first marriage (26·4 years) and low levels of contraception before first marriage. Data were analysed using a variety of demographic methods, including multiple decrement life table and multivariate logistic models. Major variations were found by ethno-linguistic groups: Herero and Nama/Damara had the highest levels of premarital fertility (above 60%); Ovambo and Lozi had intermediate levels of premarital fertility (around 40%); Kavongo and San appeared to have kept a more traditional behaviour of early marriage and low levels of premarital fertility (around 20%). The largest ethno-linguistic group, the Ovambo, were in a special situation, with fast increasing age at marriage and average level of premarital fertility. Whites and mixed races also differed, with Afrikaans-speaking groups having a behaviour closer to the average, whereas other Europeans had less premarital fertility despite an average age at marriage. Ethnic differences remained stable after controlling for various socioeconomic factors, such as urbanization, level of education, wealth, access to mass media, and religion. Results are discussed in light of the population dynamics and political history of Namibia in the 20th century.

In a provocative series of statements published in the March 2003 issue of the International Journal of STD & AIDS Gisselquist Potterat and colleagues argued that the spread of HIV in Africa was more closely linked to medical care (injections and blood transfusion in particular) than to sexual transmission. If some of their arguments deserve serious consideration the available population-based evidence remains strongly against their main hypothesis. (excerpt)

Both malaria and protein-energy malnutrition (PEM) are highly prevalent in young children of sub-Saharan Africa, and the association between PEM and malaria continues to be discussed controversially. We analysed the association between PEM, malaria morbidity and all-cause mortality in a cohort of 709 children aged 6-30 months in a malaria holoendemic rural area of Burkina Faso. Study children were followed over the main malaria transmission period (June-December) in 1999 through longitudinal malaria surveillance complemented by three cross-sectional clinical surveys. There was no association between PEM and malaria morbidity, but malnourished children had a more than two-fold higher risk of dying than non-malnourished children.

If demographic and health surveys have underlined declining fertility trends in many countries of sub-Saharan Africa, little is known on the precise timing and the speed of the fertility transition in the continent. This study attempts to fill this gap, by using an innovative approach to the analysis of DHS data and other relevant surveys. The method utilizes fine tuning of fertility trends year by year, for urban and rural areas separately. The paper starts by a case study of the fertility transition in Kenya. The same method is later applied to more than 20 countries. Results indicate that in many countries, fertility started to decline in the late 1960s and 1970s in urban areas, and about 10 years later in rural areas, much earlier than usually thought. Placing a time frame at the onset of the fertility transition allows one to develop further analysis of the key determinants of the fertility transition. Emphasis is on the role of family planning programs, as well as on emerging independent individual behavior such as delayed marriage and induced abortions. Comparison is made with the situations of other developing countries, and with the possible role of mass media, in particular television.

Objective: To study the effects of zinc supplementation on malaria and other causes of morbidity in young children living in an area holoendemic for malaria in west Africa. Design: Randomised, double blind, placebo controlled efficacy trial. Setting: 18 villages in rural northwestern Burkina Faso. Participants: 709 children were enrolled; 685 completed the trial. Intervention: Supplementation with zinc (12.5 mg zinc sulphate) or placebo daily for six days a week for six months. Main outcome measures: The primary outcome was the incidence of symptomatic falciparum malaria. Secondary outcomes were the severity of malaria episodes, prevalence of malaria parasite, mean parasite densities, mean packed cell volume, prevalence of other morbidity, and all cause mortality. Results: The mean number of malaria episodes per child (defined as a temperature ≥37.5°C with ≥5000 parasites/μl) was 1.7, 99.7% due to infection with Plasmodium falciparum. No difference was found between the zinc and placebo groups in the incidence of falciparum malaria (relative risk 0.98, 95% confidence interval 0.86 to 1.11), mean temperature, and mean parasite densities during malaria episodes, nor in malaria parasite rates, mean parasite densities, and mean packed cell volume during cross sectional surveys. Zinc supplementation was significantly associated with a reduced prevalence of diarrhoea (0.87, 0.79 to 0.95). All cause mortality was non-significantly lower in children given zinc compared with those given placebo (5 v 12, P=0.1). Conclusions: Zinc supplementation has no effect on morbidity from falciparum malaria in children in rural west Africa, but it does reduce morbidity associated with diarrhoea. What is already known on this topic Zinc deficiency is common in infants in developing countries Zinc supplementation has been shown to reduce morbidity from infectious disease in such populations, particularly through reductions in morbidity from diarrhoea and respiratory infections Limited evidence exists for zinc supplementation being effective in reducing morbidity from malaria What this study adds Zinc supplementation has no effect on falciparum malaria in children in rural west Africa It is effective in reducing morbidity from diarrhoea and may help to reduce mortality from all causes

The age pattern of fertility in a rural area of South Africa under health and demographic surveillance (Agincourt subdistrict) was investigated over the 1992–1997 period. The total fertility rate (number of children born, on average, to the women of this population) averaged 3.3 over the period, a major drop from earlier estimates in the same area (6.0 in 1970–1974). Age-specific fertility rates showed an atypical bimodal pattern composed of two components of similar magnitude: premarital fertility (ages 12–26) and marital fertility (ages 15–49). These two components demonstrate a peak of premarital fertility (around age 18–20 years) and a peak of marital fertility (around age 28–30 years). Premarital fertility accounted for 21 per cent of all births, and for 47 per cent of births to women aged 12–26 years. Thus, in the Northern Province of South Africa at least, premarital fertility is a significant demographic and social phenomenon that contributes to a deeper understanding of both teenage and adolescen...

The age pattern of fertility in a rural area of South Africa under demographic surveillance (Agincourt subdistrict) was investigated over the 1992-97 period. The total fertility rate (TFR) averaged 3.3 births per woman of reproductive age over the period, a major drop from earlier estimates in the same area (6.0 births in 1970-74). Age-specific fertility rates showed an atypical bimodal pattern. They were decomposed into two components of similar magnitude: premarital fertility (among women aged 12-26) and marital fertility (among women aged 15-49). The decomposition revealed the two underlying modes: a mode of premarital fertility (among women aged 18-20) and a mode of marital fertility (among women aged 28-30). Premarital fertility accounted for 21 percent of all births and for 47 percent of births among women aged 12-26. This pattern of high premarital fertility appears to reflect a low incidence of contraceptive use before the first birth, especially among adolescents, a low prevalence of abortion, and a high contraceptive prevalence thereafter. This finding calls for a reorientation of the family planning policy, which until now has targeted married women and women who have been pregnant once, but has failed to address the contraceptive needs of young women before their first pregnancy, especially adolescents.

Although the 1918 influenza epidemic was a major demographic event in the US and worldwide it has not been the major focus of studies by demographers. Some of its salient features include the enormity of the number of people who were affected; estimates indicate that one-quarter of the American population had clinically recognizable cases of flu during the epidemic. Also noteworthy is the fact that the 1918 influenza epidemic was associated with exceptionally high mortality both qualitatively and quantitatively. This study presents a relevant finding in the reexamination of published statistics on death: that the 1918 influenza had a strong and fairly long-lasting effect on differential mortality by sex diminishing the earlier female advantage. Specifically it is noted that the mechanism posited is a selection effect whereby those with tuberculosis (TB) in 1918 were more likely than others to die of influenza. This possible outcome affected males more than females because TB morbidity disproportionately affected males. However the reduction of the pool of male TB cases lowered the male TB death rate in the 2 years following 1918 thereby bringing males life expectancy closer to the longer female life expectancy.

To examine changes in mortality in rural South Africa over the period 1992-1995 by age, sex and cause of death.As with much of sub-Saharan Africa, South Africa lacks effective vital registration and information on mortality is lacking. The Agincourt demographic and health surveillance system was established to inform health policy and practice with regard to rural subdistrict populations.Prospective community-based study involving annual update of a household census with enquiry into all birth, death and migration events. All reported deaths (n = 1001) are the subject of a verbal autopsy.An increasing trend in overall mortality relative to general population growth in the study area is apparent. There is evidence for a reversal in the previously declining trend in mortality among women 20-44 years. A comparison of 1992-1993 with 1994-1995 shows that most of the increase in mortality is concentrated in the younger adult (20-49 year) age group. AIDS and related diseases, particularly tuberculosis, appear primarily responsible. Injuries and violence (especially homicide) and circulatory disease are important, under-recognized causes of death, although their levels have remained constant over the period.Mortality from AIDS and related diseases appears responsible for the probable reversal in mortality emerging in South Africa's rural northeast. Findings carry implications for the emerging system of decentralized health care.

To the Editor: The comments made by Gisselquist on our paper focus on the risk associated with unsafe injections rather than with DMPA per se. Our study was not designed to separate the effects of unsafe injections from the effects of using DMPA in an HIV environment. Note however that similar effects were found in Thailand where injections are assumed to be safe and that the biological plausibility for an effect of hormonal contraception is quite strong. This leads us to think that in this case the effect is more likely to be due to the interactions with hormones than to the injection per se. What we showed is that in real life of an African population injectable contraception was associated with a minor increase in risk of HIV infection whatever the reason. Of course for the individual woman the issue is whether she is at risk of Ivory not. If her partner is infected with HIV she should be using condoms and not any other form of contraception. Even if she is not exposed to HIV she should use only safe injections whether for contraception or for other purpose and be protected from any type of contamination such as HIV HBV HCV or other germs. Gisselquist is right in emphasizing the need for safe injections in Africa for any type of therapy or prevention. For us recommending DMPA still appears legitimate for women who are not exposed to HIV and assuming that injections are safe. The control of HIV is likely to be efficient if such policies are followed and unlikely to be enough by just shifting from injectable contraceptives to other types beyond condoms. (full text)

Sunil Sazawal and colleagues did a large randomised controlled trial of zinc supplementation in a malaria holoendemic area of east Africa which showed no significant effect on mortality among children younger than 5 years. However in subgroup analyses Sazawal and colleagues showed a significant effect of the intervention on mortality in children older than 12 months and this effect was significant for boys (relative risk 0.71) but not for girls (0.95). We did a similar study on the effects of zinc supplementation in a malaria holoendemic area of west Africa. Here zinc supplementation had no effect on malaria morbidity but significantly reduced diarrhoea morbidity in children younger than 3 years. A subgroup analysis showed that this effect was also significant for boys (relative risk 0.67) but not for girls (1.03) a finding that needs further explanation. Finally we showed a significant association between malnutrition and mortality but not between malnutrition and malaria in this cohort. (excerpt)

A simulation model was developed to test the accuracy of indirect estimates of maternal mortality (the sisterhood method). The model generated a first generation of grandmothers, a second generation of mothers (with brothers and sisters), and a third generation of children (births). In the second generation, maternal mortality was introduced. Empirical values for the parameters of fertility and mortality were taken from a prospective survey in Senegal (Niakhar). Results based on 100 simulations of the same situation revealed several limitations of the sisterhood method: The indirect estimates could fall as far as 33 percent from the true values on individual cases; the indirect estimates tended to be systematically higher than the direct estimates; their range was wider, as were their confidence intervals; and biases were particularly strong for the younger age groups of respondents. Reasons for these biases are explored.A simulation method was used to assess the accuracy of indirect estimates of maternal mortality (sisterhood method). The model generated a first generation of grandmothers, a second generation of mothers (with brothers and sisters), and a third generation of children (births). Maternal mortality was introduced in the second generation. Fertility and mortality parameters for the simulations were derived from a prospective study conducted in Niakhar, Senegal, in 1983-89. Results based on 100 simulations of the same situation revealed several limitations of the sisterhood method. The indirect estimates were as far as 33% from the true values on individual cases, despite the assumed perfect quality of the data. The indirect estimates tended to be systematically higher than the direct estimates, with wider ranges and confidence intervals. Biases were especially marked for the younger age group (15-39 years). The only justification for use of indirect rather than direct estimates seems to be the avoidance of questions about age differences between the respondent and the sister and the age of the sister at time of death, when applicable. Recommended, instead of indirect estimates, are two methods of computing direct estimates of maternal mortality: 1) direct computation of the maternal mortality quotient, followed by conversion to the maternal mortality rate through use of the total fertility rate, and 2) use of information on parity by age from maternity histories to compute the maternal mortality rate in each age group directly.

This study was conducted in the three main hospitals of Dakar, the capital city of Senegal. Each case of 152 maternal deaths identified over a 12-month period was matched with two controls: a safe delivery in the same clinic, and a safe delivery in the same neighbourhood of residence. Controls were matched on age, birth order, place, and time of delivery. The leading causes of death were : puerperal sepsis and other infections (51 cases), haemorrhage (32cases), eclampsia (29 cases), ruptured uterus (11 cases), and anaemia (7 cases). Results of the case-control study revealed the major risk factors associated with health system failures: medical equipment failure (odds ratio fOR] = 55.0), late referral (OR 23.2), lack of antenatal visit (OR = 16.9), and lack of available personnel at time of admission (OR = 6.6). Various indicators of maternal status at time of admission (complications, blood pressure, temperature, oedema, haemoglobin level) and of health history prior to admission (previous complications, previous C-section, lack of treatment) were also strong predictors of survival. Lastly, socio-demographic factors also appeared as correlates of maternal mortality, in particular: first pregnancy (OR = 2.3), pregnancy of high birth order (OR = 1.9), rainy season (OR = 2.4), being unmarried (OR 2.5), and low level of education (OR = 1.6). Implications for policy are discussed. (AfrJ Rep rod Health 1997;l(1):14—24) KEY WORDS: Maternal mortality, cause of death, risk factors, case-control study, health system, Senegal, Africa