Use of injectable progestin contraception and risk of STI among South African women

Objective

This study was conducted to determine the association between the use of injectable progestin contraception (IPC) and the risk of infection with Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), bacterial vaginosis (BV) and Trichomonas vaginalis (TV) among women in South Africa.

Methods

From August 1999 through May 2001, 643 HIV-1-negative women were recruited from family planning clinics in Orange Farm, South Africa. IPC [norethisterone enanthate (NET-EN) and depot medroxyprogesterone acetate (DMPA)] users and nonhormonal contraception users were recruited in approximately equal numbers. Eligible participants were seen at enrolment and on four follow-up visits over a 12-month period; 567 returned for at least one follow-up visit. Multivariable Poisson regression models with generalized estimating equations were used to compute the incidence rate ratios (IRRs) for infections with GC, CT, BV and TV by use of NET-EN or DMPA relative to nonuse during follow-up.

Results

In multivariable models, the use of DMPA slightly increased the risk of infection with CT [IRR=1.24; 95% confidence interval (95% CI)=0.80–1.94] and GC (IRR=1.30; 95% CI=0.58–2.98), although these associations were not statistically significant. In contrast, DMPA appeared to be protective for TV (IRR=0.35; 95% CI=0.12–1.01), although this estimate was very imprecise. The use of both DMPA and NET-EN was associated with a decreased risk of BV.

Conclusions

The use of DMPA among women in this study population was associated with an increased — but not statistically significant — risk of cervical infection with chlamydia and gonorrhea, and a decreased risk of TV and BV. Given the inconsistencies and limitations of the data describing an increased risk of CT and GC with IPC use, the potential risk of sexually transmitted infections (STIs) must be balanced against the risk of unintended pregnancy and its health consequences, especially in developing countries. Women opting to use IPC should be counseled to use condoms to protect against STIs and HIV.     

Predictors of dual method use for pregnancy and HIV prevention among adolescent South African women

INTRODUCTION: Dual contraceptive method use is advocated for adolescent women to prevent pregnancy, sexually transmitted diseases and HIV. METHODS: We examined data from a nationally representative sample of South African women aged 15-24 years to establish factors associated with dual method use. RESULTS: Only 7% of current contraceptive users reported using dual methods, although this percentage increased to 28.1% when women reporting hormonal contraception and condom use at last sex were included. In multivariate analyses, having talked about condoms with a partner was most strongly associated with dual method use (adjusted odds ratio (AOR), 12.3; 95% confidence interval (CI), 6.1-25.1) and suggests that communication skills might be the most effective way of increasing dual method use. Difficulty in accessing condoms was associated with lower odds of dual method use (AOR, 0.5; 95% CI, 0.2-1.0). CONCLUSION: We conclude with recommendations to increase male involvement and encourage communication between partners for the integration of HIV prevention and other reproductive health care services.     

Predictors of alcohol use prior to pregnancy recognition among township women in Cape Town, South Africa

South Africa has the highest prevalence of Fetal Alcohol Spectrum Disorders (FASDs) in the world. The purpose of this study was to identify high risk factors associated with drinking alcohol prior to pregnancy recognition in 24 neighborhoods in the Cape Flats outside Cape Town, South Africa. An interviewer assessed risk among 619 pregnant Black/African women between the ages of 18 and 41 years. Logistic regression analyses explored factors associated with drinking alcohol post conception but prior to pregnancy recognition. Forced multiple logistic regression analysis revealed that drinking prior to pregnancy recognition was associated with being younger, single, having better living conditions, smoking, having a longer gestation prior to pregnancy recognition, having a greater number of sexual partners, and a higher incidence of intimate partner violence. Depressive symptoms tended to be higher among alcohol users. These risk factors were consistent with other research on the characteristics of South African women having children with a diagnosis of Fetal Alcohol Spectrum Disorders and/or of non pregnant women at high risk for an alcohol-exposed pregnancy. These findings highlight the need for women of child-bearing age to be routinely screened for alcohol use and its associated risk factors. Intervention efforts could be integrated into health initiatives already present in South Africa including the prevention and treatment of HIV/AIDS, tuberculosis, and malnutrition. Preconception care is particularly important since pregnancy recognition often occurs several weeks to months following conception and could be implemented by South African community health workers. These endeavors should facilitate national goals of healthier pregnancies and the elimination of FASDs in South Africa.     

Scaling up postabortion contraceptive service--results from a study conducted among women having unwanted pregnancies in urban and rural Tanzania

INTRODUCTION: It is well recognized that unwanted pregnancies and unsafe abortion are significant public health problems in sub-Saharan Africa. At the International Conference on Population and Development held in Cairo in 1994, postabortion care was prioritized as a means to reduce maternal morbidity and mortality associated with unsafe abortion. However, only a few postabortion care programs have been implemented and most of them have been confined to urban settings. The present study describes the magnitude of the problem of unwanted pregnancies among women with incomplete abortion in urban and rural Tanzania and evaluates the outcome of a postabortion care intervention. METHODS: Data were collected among 781 women admitted with incomplete abortion in Dar es Salaam region (urban Tanzania) and 575 women in Kagera region (rural Tanzania). RESULTS: Sixty-seven percent of the women in urban Tanzania and 42% in rural Tanzania stated that their pregnancy was unwanted. Contraceptive acceptance among women with unwanted pregnancies was high; 93% in urban Tanzania and 71% in rural Tanzania left with a contraceptive method. CONCLUSION: The high proportion of women with unwanted pregnancies in urban and rural Tanzania underlines the need of scaling up postabortion contraceptive service.     

Uptake of permanent contraception among women in sub-Saharan Africa: a literature review of barriers and facilitators

Objective

Uptake of permanent contraception among women remains low in sub-Saharan Africa compared to other regions. We aimed to synthesize available evidence on barriers to, and facilitators of permanent contraception with regards to tubal ligation among women in sub-Saharan Africa.

HIV-status disclosure and depression in the context of unintended pregnancy among South African women

Depressive symptoms are common among pregnant women living with HIV, and an unintended pregnancy may heighten vulnerability. HIV-status disclosure is thought to improve psychological well-being, but few quantitative studies have explored the relationships among disclosure, pregnancy intention and depression. Using multivariable linear regression models, we examined the impact of disclosure on depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) during pregnancy and postpartum among women who tested HIV-positive during the pregnancy in South Africa; and explored the role of pregnancy intention in this relationship. Among 350 women (median age: 27 years; 70% reporting that their current pregnancy was unintended), neither disclosure to a male partner nor disclosure to ≥1 family/community member had a consistent effect on depressive symptoms. However, pregnancy intention modified the association between disclosure to a male partner and depression during pregnancy: disclosure was associated with higher depression scores among women who reported that their current pregnancy was unintended but was associated with lower depression scores among women who reported that their pregnancy was intended. During the early postpartum period, disclosure to ≥1 family/community member was associated with higher depression scores. Counselling around disclosure in pregnancy should consider the heightened vulnerability that women face when experiencing an unintended pregnancy.     

Disabled people in rural South Africa talk about sexuality

Disability is emerging as a human rights issue of public concern, rather than an individual tragedy requiring medical attention. The issue of sexuality remains relatively neglected in this agenda, particularly as regards the exploration of the complexities of sexuality encountered by disabled people themselves. This paper focuses on the experiences of sexuality of disabled people and parents of disabled children in settings of poverty in the Eastern Cape Province of South Africa. Three individual interviews and two focus groups were conducted with disabled adults and parents of disabled children. Thematic analysis of the interviews identified three principal themes (1) sexuality development in the family of origin, (2) sexuality in the community and (3) adult sexuality and creating families. Each of these larger themes encompasses various sub-themes that are discussed in the findings. The paper concludes that while sexuality is a very difficult aspect of life for a disabled person due to myths and discrimination against disabled people, it is also an important arena for affirmation and establishing self-worth. It is therefore critical to consider the development of a healthy sexuality amongst disabled people and the promotion of their sexual rights.     

Perceptions of anal sex in rural South Africa

As part of the Microbicides Development Programme, we conducted formative research to explore perceptions of anal sex at a site in rural KwaZulu‐Natal. We were interested in the practice of anal sex because of its potential role in HIV transmission. Eleven focus group discussions were conducted with men and women from rural areas and in a semi‐urban township. Participants were asked about their knowledge of and attitudes towards anal sex, and its practice in the local population. Findings indicate that in discussion anal sex was confused with other non‐traditional sexual practices like vaginal sex ‘dog‐style’ and with oral sex. Discussion of anal sex among those who had heard about it linked it to socially marginal groups and asymmetrical power relations.     

Contraception use and effectiveness among women in a trial of the diaphragm for HIV prevention

Background

There is little data on contraceptive effectiveness or use patterns from sub-Saharan Africa.

Study Design

We analyzed data from women at risk of pregnancy (n=4905) in the Methods for Improving Reproductive Health in Africa trial of the diaphragm for HIV prevention. We described reported contraceptive method use and calculated rates of pregnancy by contraceptive method. We compared time to first pregnancy by study arm (condoms or condoms plus diaphragm), and estimated a Cox proportional hazards model to identify predictors of pregnancy.

Results

Condoms (25.8%), injectables (25.4%) and OC (21.6%) were the most commonly used methods; long-acting method use was rare. During the trial, 51.6% of women used the same method, 27.4% switched to a more effective method and 20.9% switched to a less effective method; 21.4% of women became pregnant. Pregnancy rates by contraceptive group mirrored published estimates; frequency of study product use was not associated with pregnancy.

Conclusion

Long-acting methods of contraception should be made available in HIV prevention trials and to women in Southern Africa.     

The acceptability of reuse of the female condom among urban South African women

This study assessed whether reuse of the female condom was acceptable among two groups of women in central Johannesburg, South Africa, who were taking part in two separate studies of female condom reuse. The first group consisted of women (aged 17 to 43years) attending a family planning/sexually transmitted infections (STIs) clinic who were participating in a cross-sectional survey of the acceptability of female condoms reuse (n=100). The second group included women (aged 18–40 years) at high risk for STI (80% self-declared sex workers) who were taking part in an ongoing cohort study to investigate the safety of reuse of the female condom through a structural integrity and microbial retention study (n=50). Among women participating in the acceptability study, 83% said that they would be willing to reuse the female condom, and 91% thought the idea of reuse, of the female condom was acceptable. All women taking part in the safety of reuse study and who reused the female condom up to seven time (n=49) reported that the steps involved in reusing the device were easy to perform and acceptable. All 49 women said they would reuse the female condom at least once, while 45% said they would use it a maximum of seven or eight times. From the results of the interviews with both study groups, it can be concluded that, among women in a South African urban environment who have used a male and/or female condom, the concept of reuse of the female condom is acceptable and thought to be a good idea.     

Gender norms in South Africa: implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution

In post‐Apartheid South Africa, women are constitutionally guaranteed protections and freedoms that were previously unknown to them. These freedoms may have positive implications for women's ability to negotiate sexual protection with partners and hence prevent unintended pregnancy and decrease their risk of HIV. Among tertiary institution students, who are a relatively ‘privileged’ group, there is little information on gender norms that might shape responses to HIV‐prevention programmes. To elicit gender norms regarding women's and men's roles, condom and contraceptive use, sexual communication and sexual pleasure, we conducted 10 semi‐structured focus group discussions with African and Indian female tertiary institution students in order to understand how norms might be used to buttress HIV‐ and pregnancy‐prevention. Participants reported dramatic changes in the structure of gender norms and relations with the formal recognition of women's rights in the post‐Apartheid context. These generational shifts in norms are supported by other research in South Africa. At the same time, women recognized the co‐existence of traditional constructions of gender that operate to constrain women's freedom. The perceived changes that have taken place provide an entry point for intervention, particularly for reinforcing emerging gender norms that promote women's protection against unintended pregnancy and HIV/STIs.     

Price and availability of healthy food: A study in rural South Africa

Objective

We investigated the availability of healthier food choices and whether a healthier diet costs more than a diet commonly eaten by low-income families in South Africa.

Methods

We visited 21 food stores in 14 rural towns of the Western Cape province of South Africa. We recorded the price and availability of 66 food items, including both commonly consumed foods as well as healthy options.

Results

Healthier food choices are available in supermarkets. However, many towns only have small food stores with a limited selection of healthy foods. We compared the prices of six commonly consumed foods with healthier versions of those foods (e.g., whole-wheat bread in place of white bread). Healthier foods typically cost between 10% and 60% more when compared on a weight basis (Rand per 100 g), and between 30% and 110% more when compared based on the cost of food energy (Rand per 100 kJ). Next, we compared the extra cost of a healthier diet compared to a typical South African menu. On average, for an adult male, the healthier diet costs Rand 10.2 (US$1.22) per day more (69% more). For a household with five occupants, the increased expenditure on food by eating a healthier diet is approximately Rand 1090 per month (US$140); this represents a high proportion (>30%) of the total household income for most of the population.

Conclusion

Healthier food choices are, in general, considerably more expensive than commonly consumed foods. As a result, a healthy diet is unaffordable for the large majority of the population.     

Breast and bottle feeding in rural and urban South African children

We studied breast and bottle feeding in 1264 children aged 1–4 years from five South African communities using a questionnaire on feeding habits completed by trained interviewers. The proportion of infants breast feeding ranged from 73% to 94% for mean periods of 9–16 months. The group with the most consistent and prolonged breast feeding habits were rural black children. Different bottle feeding practices were used within the various communities. At the ages studied the types of infant feeding practice varied little within the groups although each group differed significantly from the others for the preferred feeding method.     

Identifying factors that influence pregnancy intentions: evidence from South Africa and Malawi

In developing-country settings, pregnancy intentions are often assessed using a series of questions from the Demographic and Health Surveys, yet research conducted in several countries yields conflicting results regarding these questions' ability to predict pregnancy. Conducted in Malawi and South Africa, this study identified individual, partner and societal factors that influence desire for pregnancy, and women's ability to achieve their intentions. Data come from interviews and focus-group discussions conducted prior to the FEM-PrEP HIV-prevention trial with women from communities at high risk of HIV infection. Cultural norms regarding contraceptive use and childbearing influenced both women's desire for pregnancy and ability to achieve those goals. Partner's expectations for pregnancy, financial concerns, family composition and contraceptive experiences were additional influences. Actively planning for pregnancy was not a salient concept to the majority of participants. Results support the call for a multidimensional measure of pregnancy intention that reflects the variety of factors that influence intentions, highlight the fluid nature of many women's reproductive health decision making and challenge the notion that all fertility decisions are the result of conscious action. Additional work on how women's plans for pregnancy are achieved would be programmatically more useful than current measures of intention.     

Healthcare experiences of lesbian and bisexual women in Cape Town,South Africa

Understanding the health needs and experiences of South African lesbian and bisexual women is imperative for implementing effective and inclusive public health strategies. Such understanding, however, is limited due to the exclusion of these women from most existing research on healthcare access in the region. This paper bridges that gap by investigating the healthcare experiences of lesbian and bisexual women in Cape Town. Data were gathered from 22 interviews with self-identified lesbian and bisexual community members and university students in the Cape Town area. Interviews explored obstacles women face in accessing affirming services, different experiences with public and private healthcare, fear of stigma/discrimination, availability of relevant sexual health information and suggestions to improve existing programmes. Findings suggest that South African lesbians and bisexual women may have a range of both positive and negative experiences in public and private health services, that they use protective strategies when ‘coming out’ and that they find that sexual health information pertinent to them is largely unavailable. These discussions contribute to a more inclusive understanding of the experiences of lesbian and bisexual women accessing healthcare and other services and help to inform providers, thereby enabling them to deliver more meaningful care to lesbian, gay, bisexual and transgender persons in South Africa.