Martha Campbell

Controlling postpartum hemorrhage after home births in Tanzania

Objectives: Determine safety of household management of postpartum hemorrhage (PPH) with 1000 μg of rectal misoprostol, and assess possible reduction in referrals and the need for additional interventions. Methods: Traditional birth attendants (TBAs) in Kigoma, Tanzania were trained to recognize PPH (500 ml of blood loss). Blood loss measurement was standardized by using a local garment, the “kanga”. TBAs in the intervention area gave 1000 μg of misoprostol rectally when PPH occurred. Those in the non‐intervention area referred the women to the nearest facility. Results: 454 women in the intervention and 395 in the non‐intervention areas were eligible. 111 in the intervention area and 73 in the non‐intervention had PPH. Fewer than 2% of the PPH women in the intervention area were referred, compared with 19% in the non‐intervention. Conclusion: Misoprostol is a low cost, easy to use technology that can control PPH even without a medically trained attendant.

Misoprostol and declining abortion-related morbidity in Santo Domingo, Dominican Republic: a temporal association

Objective  To validate anecdotal reports that abortion‐related complications decreased in the Dominican Republic after the introduction of misoprostol into the country.

Using the kanga to measure postpartum blood loss

Postpartum hemorrhage (PPH) represents a quarter of all pregnancy-related mortality worldwide and an even higher percentage in sub-Saharan Africa. The following observation was made during focus group discussions with traditional birth attendants (TBAs) in Kigoma Tanzania as part of a study using misoprostol to treat PPH. Such study is yielding encouraging results but even without misoprostol the ability to measure blood loss and to seek medical care at the correct moment can decrease PPH associated morbidity and mortality. Clinical observation of blood loss tends to underestimate the actual loss by 34—50%. The standard of 500 ml is the internationally accepted threshold for clinically dangerous PPH and more accurate measurement would permit women to be referred at the correct moment significantly decreasing PPH morbidity and mortality. (excerpt)

Misinformation and fear of side-effects of family planning

Fears about the side-effects from family planning are well-documented barriers to use. Many fears are misinformation, while others reflect real experience, and understanding of these is not complete. Using qualitative interviews with women in three countries, this study examines what women feared, how they acquired this knowledge, and how it impacted on decision-making. We aimed to understand whether women would be more likely to use family planning if they were counselled that the side-effects they feared were inaccurate. Across all countries, respondents had a similar host of fears and misinformation about family planning, which were comprised of a mixture of personal experience and rumour. Most fears were method-specific and respondents overwhelmingly stated that they would be more likely to use the family planning method they feared if counselled that there were no side-effects. This suggests programmes should focus on education about family planning methods and method mix.

History of Contraception

The factors controlling human fertility and the development of rational therapies to limit births are not necessarily more difficult to understand than the isolation and cure of bacterial diseases. The surgery of voluntary sterilization or early abortion is intrinsically simpler than the treatment of appendicitis or the forceps delivery of a baby. Yet fertility regulation has diffused less rapidly through society than the means to cure disease and prevent death. This imbalance has generated an explosion in global population that is difficult to accommodate, and it has contributed to great inequalities in wealth and untold personal misery. Useful insights into current problems can be gained by looking at the history of contraceptive practice.

The impact of vouchers on the use and quality of health care in developing countries: A systematic review

Abstract One approach to delivering healthcare in developing countries is through voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health care. Using inclusion/exclusion criteria, a search of databases, key journals and websites review was conducted in October 2010. A narrative synthesis approach was taken to summarise and analyse five outcome categories: targeting, utilisation, cost efficiency, quality and health outcomes. Sub-group and sensitivity analyses were also performed. A total of 24 studies evaluating 16 health voucher programmes were identified. The findings from 64 outcome variables indicates: modest evidence that vouchers effectively target specific populations; insufficient evidence to determine whether vouchers deliver healthcare efficiently; robust evidence that vouchers increase utilisation; modest evidence that vouchers improve quality; no evidence that vouchers have an impact on health outcomes; however, this last conclusion was found to be unstable in a sensitivity analysis. The results in the areas of targeting, utilisation and quality indicate that vouchers have a positive effect on health service delivery. The subsequent link that they improve health was found to be unstable from the data analysed; another finding of a positive effect would result in robust evidence. Vouchers are still new and the number of published studies is limiting.

The impact of freedom on fertility decline.

Although fertility decline often correlates with improvements in socioeconomic conditions, many demographers have found flaws in demographic transition theories that depend on changes in distal factors such as increased wealth or education. Human beings worldwide engage in sexual intercourse much more frequently than is needed to conceive the number of children they want, and for women who do not have access to the information and means they need to separate sex from childbearing, the default position is a large family. In many societies, male patriarchal drives to control female reproduction give rise to unnecessary medical rules constraining family planning (including safe abortion) or justifying child marriage. Widespread misinformation about contraception makes women afraid to adopt modern family planning. The barriers to family planning can be so deeply infused that for many women the idea of managing their fertility is not considered an option. Conversely, there is evidence that once family planning is introduced into a society, then it is normal consumer behaviour for individuals to welcome a new technology they had not wanted until it became realistically available. We contend that in societies free from child marriage, wherever women have access to a range of contraceptive methods, along with correct information and backed up by safe abortion, family size will always fall. Education and wealth can make the adoption of family planning easier, but they are not prerequisites for fertility decline. By contrast, access to family planning itself can accelerate economic development and the spread of education.

The origins and future of patriarchy: the biological background of gender politics

Those working in reproductive health are vividly aware of how much more time and energy a woman puts into pregnancy and lactation than a man puts into depositing sperm. Evolution predicts that the sex making most biological investment in the next generation will be cautious in their mating choices while the one that makes the least investment is likely to be more competitive less discriminating and more risk-taking. It is a generalisation borne out by the behaviour of all other species including our own. Evolutionary psychology posits that certain behaviours are universal because they helped the genes of a particular species to survive across the generations. In the case of human beings such behavioural predispositions evolved to adapt us to the Stone Age rather the modern world. Patriarchy we suggest has deep roots in human evolution. (excerpt)

Niger: Too Little, Too Late

In this article Niger is presented as the most extreme example of a catastrophe that is likely to overtake the Sahel. Niger is characterized by the world’s fastest growing population and its highest total fertility rate (TFR). The author cites demographic and family planning norms along with development and environmental issues as significant components of the problem posed by the country’s rapid population growth. The policies chosen by Niger’s government and the international community to reduce rapid population growth and the speed with which they are implemented are very important. The author discusses two existent policy options: emphasize socioeconomic improvement and emphasize fertility regulation.

Consumer behaviour and contraceptive decisions: resolving a decades-long puzzle.

Demographers theoretical explanations for fertility decline have been based for decades on an assumption that couples make family size decisions influenced by a changing balance between costs and benefits of childbearing resulting in parents reduced demand for children. It has been widely assumed that these decisions are based on changes in social or economic factors such as increased education wealth or economic opportunities or urbanisation or other related factors in their lives. However a number of situations in developing countries have been documented showing that contraceptive prevalence rose more rapidly than such theories could account for. In some instances desired family size changed when contraception became available and in others women who said they did not want to use contraception adopted a method when the option to use it arrived. We have reviewed the cases of this kind that are published in the demographic literature and we offer a plausible explanation grounded in research on consumer behaviour. (excerpt)