Temporal trends in sexually transmitted infection prevalence and condom use following introduction of the female condom to Madagascar sex workers.

We followed 1000 sex workers in Madagascar for 18 months to assess whether adding female condoms to male condom distribution led to increased protection levels and decreased sexually transmitted infections (STIs). For months 1-6, participants had access to male condoms only; in the final 12 months, they had access to male and female condoms. We interviewed participants about condom use every two months and tested for chlamydia, gonorrhoea and trichomoniasis every six months. Following six months of male condom distribution, participants used protection in 78% of sex acts with clients. Following female condom introduction, protection at months 12 and 18 rose to 83% and 88%, respectively. Aggregate STI prevalence declined from 52% at baseline to 50% at month 6. With the female condom added, STI prevalence dropped to 41% and 40% at months 12 and 18, respectively. We conclude female condom introduction is associated with increased use of protection to levels that reduce STI risk.

Results of a randomised trial of male condom promotion among Madagascar sex workers.

OBJECTIVES: To test the effect of supplementing peer promotion of male condom use with clinic based counselling, measured in terms of STI prevalence and reported male condom use. METHODS: 1000 female sex workers in Madagascar were randomised to two study arms: peer education supplemented by individual risk reduction counselling by a clinician (peer + clinic) versus condom promotion by peer educators only (peer only). STI testing was conducted at baseline and 6 months. Behavioural interviews were administered at baseline, 2, 4, and 6 months. RESULTS: At baseline, women in the peer only arm had prevalences of 16.0%, 23.6%, and 12.1% for chlamydia, gonorrhoea, and trichomoniasis respectively, with an aggregate prevalence of 38.2%. Baseline STI prevalences for the peer + clinic arm were slightly lower and 34.1% in aggregate. At 6 months, aggregate STI prevalence increased in the peer only arm to 41.4%, whereas the aggregate prevalence diminished slightly to 32.1% in the peer + clinic arm. In logistic regression analyses, the estimated odds ratios (ORs) for chlamydia, gonorrhoea, trichomoniasis, and aggregate STI were 0.7 (95% confidence interval 0.4 to 1.0), 0.7 (0.5 to 1.0), 0.8 (0.6 to 1.2), and 0.7 (0.5 to 0.9) respectively, comparing the peer + clinic arm with the peer only arm. The logistic regression OR for reported condom use with clients in the past 30 days increased from 1.1 at 2 months to 1.8 at 6 months, comparing the peer + clinic arm with the peer only arm, and was 1.4 overall (1.1 to 1.8). Adjustment for baseline factors changed the regression results little. CONCLUSIONS: The impact of male condom promotion on behaviour can be heightened through more concentrated counselling on risk reduction. Persistently high STI prevalence despite increases in reported condom use by sex workers supports the need for multidimensional control programmes.

The impact of traditional birth attendant training on delivery complications in Ghana.

OBJECTIVES: In their efforts to reduce maternal and neonatal morbidity and mortality, many national and international agencies make considerable investments in training traditional birth attendants (TBAs). The value of TBA training is controversial, and plausible arguments are made both for and against. Numerous process evaluations are reported in the literature and the results are mixed, though generally positive. Outcome evaluations, however, are scarce. This article describes an outcome evaluation of TBA training conducted in two districts of Brong-Ahafo Region, Ghana, during 1996. DESIGN AND METHODS: Data from a random sample survey of 1961 clients of TBAs were subjected to logistic regression modelling to determine the effect of training on maternal outcomes, controlling for other independent variables. RESULTS: Of eight outcomes modelled, three were associated with training and five were not. Three additional outcomes were not modelled, primarily due to low prevalence. CONCLUSIONS: Despite some inherent design limitations, this study found that the evidence for a beneficial impact of TBA training was not compelling. Training sponsors should consider alternative health investments and, where TBA training remains the intervention of choice, be realistic about expectations of impact.

Twin delivery and neonatal and infant mortality: a population-based study.

OBJECTIVE: To examine the effect of mode of delivery on twin survival, especially among very premature twin births, in a population-based historical cohort study. METHODS: A total of 4428 pairs of live-born twins, birth weight 500 g or greater, were included based on data from vital records of the entire state of North Carolina for the period 1988-1991. The main outcome measures were Apgar score at 5 minutes (less than 7 versus 7 or greater), neonatal death, and infant death. RESULTS: After controlling for birth weight, twin order, fetal presentation, ethnicity, maternal age, marital status, and adequacy of prenatal care, we found that cesarean delivery was associated with reduced risks (by 50-60%) of low 5-minute Apgar score and neonatal and infant deaths among infants born weighing 500-749 g (P < .05). The cesarean delivery benefited the second twins more than the first twins. Among infants weighing more than 1000 g, the mode of delivery was not associated with either low Apgar score or neonatal and infant mortality. CONCLUSION: Our study suggests that cesarean delivery for twins with estimated fetal weights less than 1000 g together with a more liberal use of vaginal delivery for twins with estimated fetal weights more than 1000 g would have a net effect of increasing perinatal survival while lowering the overall cesarean delivery rate.