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Objectives: Family planning (FP) is essential in achieving the United Nations Millennium Development Goals. We critically review the evidence on HIV acquisition among women using hormonal contraception, and discuss the policy and operational implications., Methods: Longitudinal studies conducted in sub-Saharan Africa published between 2008 and 2012, as well as key policy documents related to contraception and HIV were reviewed., Results: Findings on hormonal contraception and HIV acquisition conducted in sub- Saharan Africa are inconsistent. While in the large scale studies no statistically significant association between oral contraceptive use and HIV acquisition was found, results for injectables were mixed. Potential biases, such as those resulting from self-selection, related to the observational study design and main confounders such as condom use, sexual activity and contraceptive use are discussed., Conclusions: It is currently not possible to conclude whether the use of hormonal contraceptives is associated with a greater risk of acquiring HIV, or not. The use of male or female condoms for dual protection should be promoted in FP programmes. While there is need for further research on a broader range of contraceptive methods and HIV transmission, studies documenting acceptability of currently less used/more recent contraceptive methods are also warranted.

A qualitative assessment was made of service provider and user perceptions of the quality of integrated reproductive health services established through a pilot intervention in Cambodia. The intervention aimed to promote pregnant women's HIV testing and general utilization of reproductive health facilities as well as improve the follow-up of HIV-positive women and exposed infants through strengthened referral and operational linkages amongst health facilities/services and community-based support interventions for PLHIV. The study was conducted in one operational district where the intervention was piloted and for comparative purposes in a district where integrated services had yet to be implemented. Service providers in the pilot district reported improved collaboration and coordination of services, more effective referral, and the positive impact of improved proximity of HIV testing through integrated local level facilities. Community-based support teams for PLHIV embraced their expanded role, were valued by families receiving their assistance, and were understood to have had an important role in referral, PMTCT follow-up and countering PLHIV stigmatization; findings which underscore the potential role of community support in integrated service provision. Challenges identified included stigmatization of PLHIV by health staff at district hospital level and a lack of confidence amongst non-specialized health staff when managing deliveries by HIV-positive women, partly due to fear of HIV transmission.

Obstetric fistula is the presence of a hole between a woman's genital tract and either the urinary or the intestinal tract. Better knowledge of the risk factors for obstetric fistula could help in preventing its occurrence. The purpose of this study was to assess the characteristics of obstetric fistula patients. We conducted a search of the literature to identify all relevant articles published during the period from 1987-2008. Among the 19 selected studies, 15 were reports from sub-Saharan Africa and 4 from the Middle East. Among the reported fistula cases, 79.4% to 100% were obstetrical while the remaining cases were from other causes. Rectovaginal fistulae accounted for 1% to 8%, vesicovaginal fistulae for 79% to 100% of cases, and combined vesicovaginal and rectovaginal fistulae were reported in 1% to 23% of cases. Teenagers accounted for 8.9% to 86% of the obstetrical fistulae patients at the time of treatment. Thirty-one to 67% of these women were primiparas. Among the obstetric fistula patients, 57.6% to 94.8% of women labor at home and are secondarily transferred to health facilities. Nine to 84% percent of these women delivered at home. Many of the fistula patients were shorter than 150 cm tall (40-79.4%). The mean duration of labor among the fistula patients ranged from 2.5 to 4 days. Twenty to 95.7% of patients labored for more than 24 h. Operative delivery was eventually performed in 11% to 60% of cases. Obstetric fistula was associated with several risk factors, and they appear to be preventable. This knowledge should be used in strengthening the preventive strategy both at the health facility and at the community level.

This paper addresses the challenges faced in mainstreaming the teaching of sexual and reproductive health and rights into public health education. For this paper, we define sexual and reproductive health and rights education as including not only its biomedical aspects but also an understanding of its history, values and politics, grounded in gender politics and social justice, addressing sexuality, and placed within a broader context of health systems and global health. Using a case study approach with an opportunistically selected sample of schools of public health within our regional contexts, we examine the status of sexual and reproductive health and rights education and some of the drivers and obstacles to the development and delivery of sexual and reproductive health and rights curricula. Despite diverse national and institutional contexts, there are many commonalities. Teaching of sexual and reproductive health and rights is not fully integrated into core curricula. Existing initiatives rely on personal faculty interest or short-term courses, neither of which are truly sustainable or replicable. We call for a multidisciplinary and more comprehensive integration of sexual and reproductive health and rights in public health education. The education of tomorrow's public health leaders is critical, and a strategy is needed to ensure that they understand and are prepared to engage with the range of sexual and reproductive health and rights issues within their historical and political contexts., (Copyright © 2011 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.)

The Millennium Development Goals (MDGs) were defined in 2001, making poverty the central focus of the global political agenda. In response to MDG targets for health, new funding instruments called Global Health Initiatives were set up to target specific diseases, with an emphasis on "quick win" interventions, in order to show improvements by 2015. In 2005 the UN Millennium Project defined quick wins as simple, proven interventions with "very high potential short-term impact that can be immediately implemented", in contrast to "other interventions which are more complicated and will take a decade of effort or have delayed benefits". Although the terminology has evolved from "quick wins" to "quick impact initiatives" and then to "high impact interventions", the short-termism of the approach remains. This paper examines the merits and limitations of MDG indicators for assessing progress and their relationship to quick impact interventions. It then assesses specific health interventions through both the lens of time and their integration into health care services, and examines the role of health systems strengthening in support of the MDGs. We argue that fast-track interventions promoted by donors and Global Health Initiatives need to be complemented by mid- and long-term strategies, cutting across specific health problems. Implementing the MDGs is more than a process of "money changing hands". Combating poverty needs a radical overhaul of the partnership between rich and poor countries and between rich and poor people within countries., (Copyright © 2011 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.)

Objectives: To describe the implementation and results of the linked response (LR) in Cambodia after 18 months of follow-up., Methods: The main objectives of the LR are to increase access to sexually transmitted infection/HIV prevention, testing, care, and treatment and to strengthen existing reproductive health services through increased linkages within and between public health facilities and community-based services. The LR was piloted in Cambodia in 2008, in 2 demonstration projects, covering 5 operational districts. Routine data were collected and analyzed before (2007), during (2008), and after (2009) the implementation of the LR., Results: Overall in the 5 operational districts, the proportion of pregnant women, tested for HIV increased from 6% (1261 of 21,376) in 2007 to 86% (18394 of 21,478) in 2009. Syphilis testing, introduced early 2009, reached similar (85%) coverage as HIV by the end of 2009. Between 2007 and 2009, reproductive indicators also increased: antenatal care coverage (at least 1 visit) from 80% to 100%, public health facility delivery rates from 26% to 46%, and contraceptive prevalence from 24% to 28%. Antiretroviral uptake was high among HIV-positive mothers and exposed infants, 84% and 95% respectively, and 3 of 36 (8%) infants tested so far for HIV were diagnosed positive. However, 6 maternal (HIV-positive women) and 7 child deaths (1 tested positive) occurred during the pregnancy or the 30-week postpartum follow-up period., Conclusions: Sexually transmitted infection/HIV indicators and follow-up dramatically improved after the LR was implemented. Efforts should be pursued to further improve quality of health care services.

Objective: To understand pregnancy intentions and contraception knowledge and use among HIV-positive and negative women in the national prevention of mother-to-child transmission (PMTCT) program in Rwanda., Design: A cross-sectional survey of 236 HIV-positive and 162 HIV-negative postpartum women interviewed within 12 months of their expected delivery date in 12 randomly selected public-sector health facilities providing PMTCT services., Methods: : Bivariate analyses explored fertility intentions, and family planning knowledge and use by HIV status. Multivariate analysis identified socio-demographic and service delivery-related predictors of reporting a desire for additional children and modern family planning use., Results: HIV-positive women were less likely to report wanting additional children than HIV-negative women (8 vs. 49%, P < 0.001), and although a majority of women reported discussing family planning with a health worker during their last pregnancy (HIV-positive 79% vs. HIV-negative 69%, P = 0.057), modern family planning use remained low in both groups (HIV-positive 43% vs. HIV-negative 12%, P < 0.001). Condoms were the most commonly used method among HIV-positive women (31%), whereas withdrawal was most frequently reported among HIV-negative women (19%). In multivariate analysis, HIV-negative women were 16 times more likely to report wanting additional children and nearly 85% less likely to use modern family planning. Women who reported making two or less antenatal care visits were 77% less likely to use modern family planning., Conclusion: Our results highlight success in provision of family planning counseling in PMTCT services in Rwanda. As family planning use was low among HIV-positive and negative women, further efforts are needed to improve uptake of modern methods, including dual protection, in Rwandan PMTCT settings.

Objective: To describe the circumstances of occurrence and identify potential risk factors for obstetric fistula in northern Cameroon., Methods: A case series study of 42 obstetric fistula patients seeking services at the Provincial Hospital of Maroua, Cameroon, between May 2005 and August 2007. Structured interviews were conducted prior to surgical intervention., Results: Among obstetric fistula patients, 60% had lived with obstetric fistula for more than 5 years at the time of surgery. Eighty-one percent of patients had received no formal education and 86% were teenagers at their first delivery. Regarding the pregnancy and delivery preceding the occurrence of the fistula, 50% of women reported that they had received no prenatal care and 76% were in labor for more than 12 hours. The majority (83%) of women delivered a stillborn baby., Conclusions: Obstetric fistula patients in the Far North Province of Cameroon had a low level of education, were married at a young age, and had poor access to quality maternal healthcare services.

Objectives: To describe experiences, and identify factors associated with nonadherence to a single-dose nevirapine (SD-NVP) regimen for the prevention of mother-to-child transmission (PMTCT) of HIV in Rwanda., Methods: In April to May 2006, using a case-control design at 12 PMTCT sites, we interviewed HIV-infected women who did not adhere (n = 111) and who adhered (n = 125) to the PMTCT prophylaxis regimen. Nonadherence was defined as mother and/or infant not ingesting SD-NVP at the recommended time or not at all and adherence as mother-infant pairs who ingested it as recommended., Results: Only 61% of nonadherent women had received SD-NVP during pregnancy or delivery. Among nonadherent women who received SD-NVP, 80% ingested it at the recommended time, representing 49% of all nonadherent women. Only 7% of their newborns ingested SD-NVP. Multivariate logistic regression showed that unmarried women, less educated women, women who made 2 or less antenatal care visits, and those offered HIV testing after their first antenatal care visit were more likely to be nonadherent to PMTCT prophylaxis. Not disclosing one's HIV status to someone aside from a partner was also associated with nonadherence in mother-infant pairs., Conclusions: Sociodemographic factors, health services delivery factors, and a lack of communication and social support contributed to nonadherence to PMTCT prophylaxis in Rwanda.

Objectives: To document the pilot experience of provision of safe abortion/post-abortion services implemented in 2002 at the Mother Child Health clinic in Sihanoukville, Cambodia, and to profile clients and assess their uptake of post-abortion contraception., Methods: The initial package of safe abortion/post-abortion clinics (SAPAC) services included counselling on family planning and prevention of sexually transmitted infections, pain management, Manual Vacuum Aspiration procedure and standard universal precautions at an affordable price (US$12.5). SAPAC services became operational in August 2002. The data of medical records from 1 August 2002 to 31 December 2005 (2224 clients) were analysed., Results: The mean number of clients per month attending SAPAC services ranged from 26 in 2002 to 64 in 2005. Fifty-three per cent were housewives, 24% worked in sales or services, 8% in factories, 11% in bars or karaoke lounges and 3% were brothel-based sex workers. Ninety-three per cent of clients came for induced abortion and 7% sought post-abortion care. Pain management was used in 99% of cases. The overall rate of complications during intervention was 2.1% and dropped from 9.4% in 2002 to 1.3% in 2005. After SAPAC implementation, fewer women in Sihanoukville sought abortion services without any quality control and a safer technique was used. On average, 40% of patients took up contraception after the abortion., Conclusions: Integrating comprehensive abortion-care services at a peripheral government health facility is feasible. There is a demand for such services provided at an affordable price in Sihanoukville, Cambodia.

Background: Infants of North African immigrants are reported to have higher birthweights than their Belgian counterparts. It is unclear what mechanism contributes to this difference., Methods: Analyses were based on a hospital-based cohort of 1,162 women., Results: Infants of North African immigrants were less likely to be born preterm, compared to infants of Belgian women. After adjusting for sociodemographic and maternal factors, the estimated difference in mean birthweight was 74 g (p=0.05). When limited to term births, this difference was 28 g (p=0.42)., Conclusion: The difference in mean birthweight between North African and Belgian infants was explained by differences in preterm birth and other risk factors.

Objectives: Unsafe abortion is a public health concern because of its impact on maternal morbidity and mortality. The objective of this study was to document on induced abortion in Yaounde, Cameroon., Design: Cross-sectional study., Setting: Six antenatal clinics in Yaounde, Cameroon., Methods: Women attending antenatal clinics between October and December 1998 were included in the study and interviewed. Nulliparous were women with no previous delivery and multiparous were defined as women who had at least one previous delivery., Results: Out of the 1532 women, five hundred seventy-two were nulliparous and 960 were multiparous. Of the nulliparous women 17% reported a previous abortion ever; this proportion exceeded 35% in those over 24 years. For multiparous women, the proportion who reported an abortion (between the last birth and present pregnancy) was 22%. In multivariate analysis on the group of nulliparous women, older age, having used modern contraception and having spent more than two years in the city were significantly associated with induced abortion. In the multiparous group, older age, having a full time job and antenatal clinic were significantly associated with induced abortion., Conclusions: This study shows that induced abortion is a common practice in urban Cameroon. Because of restrictive laws, a substantial proportion of these abortions are likely to be unsafe, with the risk of associated complications. There is a need for expanded comprehensive sexual and reproductive health services.

Objective: Despite their low socioeconomic status, infants of North African immigrants have been reported to have high birth weights in Belgium. The aim of the study was to further explore potential mechanisms explaining this high birth weight., Study Design: Venous umbilical cord blood samples and perinatal characteristics of live-born infants from mothers of North African and Belgian nationality were collected in 1997 through 1998 at the University Hospital La Citadelle, Liège, Belgium., Results: The median connecting peptide (C-peptide) concentration was significantly higher among North African than Belgian neonates (0.125 vs 0.110 pmol/mL, P=.04). However, the median insulin-like growth factor-I concentrations among North African and Belgian newborn infants were, respectively, 74.0 and 69.6 ng/mL (P=.45). Nationality remained significantly associated with C-peptide after adjusting for age and parity. C-peptide, insulin-like growth factor-I correlated positively with birth weight and remained significant factors for birth weight after adjusting for confounders in multiple regression., Conclusion: These results suggest a link between higher C-peptide levels and birth weights among North African neonates in Belgium.

Objectives: To evaluate the quality and usefulness of integrated sexually transmitted infection (STI) care at non-governmental family planning (FP) clinics in Côte d'Ivoire., Methods: Evaluation components included: (1) a survey measuring the prevalence of STI and the predictive value of the Ivorian vaginal discharge treatment algorithm, (2) client exit interviews, (3) direct observations of client-provider contacts, (4) the monitoring of the clinics' workload and available equipment and supplies and (5) interviews of programme managers and FP providers., Results: Among 368 FP clients surveyed, the prevalence of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, B. vaginosis and Candida albicans were respectively 1.6, 5.7, 7.1, 44.8 and 5.2%. The positive predictive value of the national algorithm for the detection of cervicitis was only 6.3%, and was 17.9% among a subgroup of young, single women. Of 200 clients interviewed, 96% were satisfied with the services and 95% would return to the FP clinic if they had genital problems. In 215 observed client-provider contacts, 88% of 94 STI cases were correctly managed. Programme managers and providers reported no substantial work overload as a result of the integration of STI services., Conclusions: The prevalence of cervical infections is relatively low in this population and the Ivorian algorithm that treats all women with vaginal discharge performs poorly. Over-treatment of cervicitis can be reduced by modifying the algorithm, although improved diagnostic tools are urgently needed to detect cervicitis in this population. Continued STI case management at the FP clinics is nevertheless justified because there exists an easily identifiable group of higher risk women who need STI care; and because of the demand by a large proportion of clients, the high prevalence of vaginal pathogens, and the limited costs to the FP programme.

Objective: The purpose of the study was to compare prenatal care attendance in European Union countries, Hungary and Norway., Study Design: We analysed live births or deliveries from national registers in five countries, national surveys in five countries, and regional register or surveys in three countries., Results: The frequency of no prenatal care was lower than 0.5% in 10 countries, 0.9% in Hungary, 2.1% in Greece and 2.6% in Portugal. Late prenatal care varied from 3.1% in Finland to 29.2% in Ireland. Late care among women with parity 4 and more varied from 7.7% in Finland to 41.5% in Hungary. Among women under 20 years old, late care varied from 11.8% in Finland to 39.5% in Portugal. The median number of prenatal visits varied from seven in Greece to 14 in Finland., Conclusion: Prenatal care attendance varies widely among European countries. Late attendance is frequent in many countries.

The purpose of the study was to identify prenatal care incentives and benefits in 17 European countries. All participating countries completed a questionnaire on their prenatal care delivery system, incentives and benefits. Results were analyzed according to their direct or indirect relationship with prenatal care attendance. Direct incentives require a prenatal care visit to be eligible for the benefit. Indirect incentives support the pregnant woman but do not require a prenatal care visit to be eligible for the benefit. All 17 countries offer direct incentives, such as paid maternity leave. In 9 countries, pregnant women receive direct financial incentives. Eleven countries offer indirect incentives, such as transportation benefits. Prenatal care incentives such as financial benefits and social supports are widespread in Europe. The combination of incentives superimposed upon an inclusive health care system create a supportive environment which encourages prenatal care attendance.

The adult respiratory distress syndrome (ARDS) developed in 2 patients with blastomycosis. In one, ARDS apparently followed the rupture of an infected subcarinal lymph node into a bronchus. Extensive involvement of alveoli with Blastomyces dermatitidis was noted at autopsy in both patients. Four additional cases of blastomycosis with definite or presumed ARDS are reviewed. The clinical course of these 6 patients was characterized by a prolonged prodrome (median, 36 days), consistent with pulmonary blastomycosis, and a rapid demise (median, 5 days) associated with ARDS.