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The vast majority of births in the world occur within marriages or stable partnerships. Yet family planning programs have largely ignored the male partner. One justification for this nearly exclusive focus on women has been that almost all of the modern contraceptive methods are female-oriented. In contrast, studies of fertility preferences within couples that included a later follow-up have shown that men’s fertility preferences are important for predicting subsequent births. Interspousal communication can be key to resolving differences in desired family size and for promoting open contraceptive use. Experimental studies with couples on family planning education and/or counseling show higher contraceptive prevalence or continuation in the couples groups than in the women-only groups, though the differences are not always significant statistically. Other intervention studies have varying designs and mixed results. The purpose of this systematic review is to summarize the research findings on interventions with couples on reproductive health from experimental and pre–post observational studies. An important conclusion is that couples education and counseling are critical components for involving male partners. There is a need for systematic research on couples using a standardized intervention and fixed follow-up times and including analyses of cost-effectiveness.

In 2020, a scholar uncovered an 1850 census form that enumerated a group of four enslaved men at the summer estate of Johns Hopkins, Maryland’s most famous philanthropist and founder of the renowned university and hospital that bear his name. This census record of enslaved people associated with Johns Hopkins, a birthright Quaker and reputed abolitionist, was a puzzling discovery. Who were the four men? Did Johns Hopkins own them or were they employed by him or others living at the estate? Are there other explanations that should be considered? This paper takes a closer look at this surprising document, at the history of the seventh United States population census, and at Johns Hopkins’ unique life as a merchant, banker, investor, and practicing Quaker. It introduces and scrutinizes four possible explanations for the presence of the men at Hopkins’ summer residence near Baltimore City during the summer of 1850.

Women naturally communicate using life narratives. Through systematic recall and sharing memories of their own childbearing and child rearing experiences, community health workers (CHWs) become engaged and empowered to change their own and other mothers’ health behaviors. Training CHW with sharing histories can improve capabilities as change agents for better child health., Key Findings Sharing Histories method for training community health workers (CHWs) was associated with reduced child stunting compared with a standard CHW training method.The training method’s impact on child stunting was not present when mothers were illiterate. Key Implications CHWs can learn better by using Sharing Histories as the basis for their training; then, they can use the same method to better help mothers change behaviors.Program managers can use this training methodology to strengthen capacities of CHW trainers to improve the cultural literacy of trainees.Primary health care personnel who train CHWs can identify local cultural and social norms when CHWs share their experiences of childbearing and childrearing.Primary health care personnel can easily apply this CHW training method to develop social bonds with CHWs, address CHW cultural competencies, and provide CHWs with a strategy to effectively discuss sensitive culturally determined behaviors with mothers., Background: Community health workers (CHWs) are increasingly deployed to support mothers’ adoption of healthy home practices in low- and middle-income countries. However, little is known regarding how best to train them for the capabilities and cultural competencies needed to support maternal health behavior change. We tested a CHW training method, Sharing Histories (SH), in which CHWs recount their own childbearing and childrearing experiences on which to build new learning. Methods: We conducted an embedded cluster-randomized trial in rural Peru in 18 matched clusters. Each cluster was a primary health facility catchment area. Government health staff trained female CHWs using SH (experimental clusters) or standard training methods (control clusters). All other training and system-strengthening interventions were equal between study arms. All CHWs conducted home visits with pregnant women and children aged 0–23 months to teach, monitor health practices and danger signs, and refer. The primary outcome was height-for-age (HAZ)

This paper presents the results of a 2011 wager between Stan Becker and David Lam about the trajectory of world food prices for the period 2011–2020 versus the period 2002–2010. The wager was a response to Lam’s 2011 presidential address to the Population Association of America, which showed that many health and socio-demographic indicators had improved over the previous fifty years, in spite of the addition of four billion people to the world’s population. Lam lost the wager, with the Food and Agriculture Organization’s price index for five food groups averaging about twenty per cent higher for 2011–2020 than for 2001–2010. Becker and Lam discuss the background of the wager, give their differing interpretations of the outcome and discuss future trends in population, food production and food prices. Lam gives a more optimistic perspective on future trends, while Becker raises concerns about rapid degradation of planetary ecosystems, species loss and global warming.

In some surveys, women and men are interviewed separately in selected households, allowing matching of partner information and analyses of couples. Although individual sampling weights exist for men and women, sampling weights specific for couples are rarely derived. We present a method of estimating appropriate weights for couples that extends methods currently used in the Demographic and Health Surveys (DHS) for individual weights. To see how results vary, we analyze 1912 estimates (means; proportions; linear regression; and simple and multinomial logistic regression coefficients, and their standard errors) with couple data in each of 11 DHS surveys in which the couple weight could be derived. We used two measures of bias: absolute percentage difference from the value estimated with the couple weight and ratio of the absolute difference to the standard error using the couple weight. The latter shows greater bias for means and proportions, whereas the former and a combination of both measures show greater bias for regression coefficients. Comparing results using couple weights with published results using women’s weights for a logistic regression of couple contraceptive use in Turkey, we found that 6 of 27 coefficients had a bias above 5 %. On the other hand, a simulation of varying response rates (27 simulations) showed that median percentage bias in a logistic regression was less than 3 % for 17 of 18 coefficients. Two proxy couple weights that can be calculated in all DHS surveys perform considerably better than either male or female weights. We recommend that a couple weight be calculated and made available with couple data from such surveys.

A proportion of women in couples use contraception without their partners' knowledge. There are two principal ways to measure this covert use in cross-sectional surveys like the Demographic and Health Surveys (DHS). First is a direct question, "Does your husband/partner know that you are using a method of family planning?" Second is an indirect method: the reports of both partners to the question on contraceptive use are matched, and if the woman reports a modern contraceptive method and the male partner reports nonuse, her use is considered covert. For 21 DHS surveys for which both estimates could be made, there are large discrepancies between the two. We found that a proxy variable-responses to the question, "Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision, or did you both decide together?"-has high sensitivity and specificity for classifying those in the open category for both methods and those in the covert category for both methods. Recommendations are that the direct question be reinstated in the DHS and that the indirect method not be used by itself but in conjunction with the decision-making variable.

A proportion of women in couples use contraception without their partners' knowledge. There are two principal ways to measure this covert use in cross-sectional surveys like the Demographic and Health Surveys (DHS). First is a direct question, "Does your husband/partner know that you are using a method of family planning?" Second is an indirect method: the reports of both partners to the question on contraceptive use are matched, and if the woman reports a modern contraceptive method and the male partner reports nonuse, her use is considered covert. For 21 DHS surveys for which both estimates could be made, there are large discrepancies between the two. We found that a proxy variable-responses to the question, "Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision, or did you both decide together?"-has high sensitivity and specificity for classifying those in the open category for both methods and those in the covert category for both methods. Recommendations are that the direct question be reinstated in the DHS and that the indirect method not be used by itself but in conjunction with the decision-making variable.

SummarySubstantial numbers of married women use contraceptives without their partner’s knowledge in sub-Saharan Africa, but studies of female covert use across time are rare. This study investigates the levels, trends and correlates of covert use in nine countries and determines which contraceptive methods are more frequently used covertly by women. Data from monogamous couples in Demographic and Health Surveys were used from nine sub-Saharan African countries that had experienced an increase of 10 percentage points in current modern contraceptive use between an earlier (1991–2004) and later (2007–2011) survey. Covert use was indirectly estimated as the percentage of women who reported a female modern method whose husband did not report a modern method. The percentage of women using covertly increased in eight of the countries studied (significantly in three of them), yet when comparing across countries cross-sectionally, covert use was lower where contraceptive prevalence was higher. In general, women with more years of schooling and those with larger spousal schooling gaps had lower odds of covert use. There was no significant difference between covert and open injectable use, though more than half of both groups used this method in the later surveys. Encouraging couple communication about contraception, where the woman feels it is safe to do so, could be an important strategy to minimize covert use. Further research is needed to better identify the contraceptive prevalence and social context in which covert use declines within a country.

Summary Background The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. Methods We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12–49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. Findings Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553–873 in Ragh vs 166, 63–270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3–2·1 in Ragh vs 0·2, 0·1–0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6–122·3 in Ragh vs 24·8, 20·5–29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US$66·20, IQR $61·30 in Kabul and $9·89, $11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. Interpretation Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings. Funding United States Agency for International Development (USAID).

Objectives The contraceptive prevalence rate (CPR) is generally reported among in-union women ages 15–49. Here, union status and age serve as proxies for exposure to the risk of pregnancy. As a result of changing dynamics, age and union status proxies may be insufficient for determining the rate of contraceptive use among women at risk of pregnancy. Our objectives are to define a measure of contraceptive use among women at risk, to measure contraceptive use among such women and to compare this rate with conventional CPR. Study design Using data from the United States 2011–2013 National Survey of Family Growth (NSFG), we explore self-reported data on contraceptive use, sexual recency, pregnancy status and fecundity to develop an alternative CPR (ACPR) measure, contraceptive prevalence among women at risk of pregnancy. After defining and measuring ACPR, we compare ACPR and conventional CPR estimates using NSFG and Demographic and Health Survey data from 48 surveys completed from 2000 to 2015 in low- and middle-income countries. Results For measuring ACPR, it is best to limit sexual activity recency component to “four weeks” to minimize underreport of coital-specific methods. It is best to limit the contraceptive use component to “current use” rather than “use at last sex” to minimize underreport of permanent methods. In the United States, 86% of women at risk of pregnancy are currently using contraception. Conclusion Women at risk of pregnancy report higher levels of contraceptive use than the conventional CPR indicates. Implications statement Development of ACPR exposed some potential family planning measurement weaknesses. Specifically, because CPR is based on report of “current use,” our analyses show that CPR may underreport coital-specific methods. As a result, CPR estimates may be somewhat deflated, and unmet need estimates may be somewhat inflated.

Unmet need for family planning is typically calculated for currently married women, but excluding husbands may result in misleading estimates of couples' unmet need. This study builds on previous work and proposes a method of calculating couples' unmet need for family planning based on spouses' independent fertility intentions. We analyze Demographic and Health Survey data from couples from three West African countries-Benin, Burkina Faso, and Mali. We find that fewer than half of couples having any unmet need had concordant unmet need (41-49 percent). A similar percentage of couples had wife-only unmet need (33-40 percent). A smaller percentage had husband-only unmet need (15-23 percent). Calculating unmet need based only on women's fertility intentions overestimates concordant unmet need. Additionally, that approximately 15-23 percent of couples have husband-only unmet need suggests that men could be an entry point for contraceptive use for more couples than at present. To calculate husbands' unmet need, population-based surveys should consider collecting the necessary data consistently.

CONTEXT: Unmet need for contraception has become a central concept in the family planning field and one of the most important indicators for program planning and evaluation. The measure has faced criticism however for not taking into account women’s stated intention to use contraceptives. METHODS: Using longitudinal data on more than 2500 rural Bangladeshi women in 128 villages this study links women’s contraceptive adoption and experience of unwanted pregnancy between 2006 and 2009 to their unmet need status and their stated intention to use contraceptives in 2006. RESULTS: Intention to use a method was predictive of subsequent use for both women with and without an unmet need. Three-quarters of the unintended pregnancies reported between 2006 and 2009 occurred among women without an unmet need in 2006. In addition nearly half of women without an unmet need who were pregnant or postpartum in 2006 had experienced an unwanted pregnancy compared with 30% of all women classified as having an unmet need. CONCLUSION: To adequately meet population family planning needs programs must look beyond unmet need and focus on the total demand for acceptable and effective methods.

In his PAA presidential address and corresponding article in Demography, David Lam (Demography 48:1231–1262, 2011) documented the extraordinary progress of humankind—vis-à-vis poverty alleviation, increased schooling, and reductions in mortality and fertility—since 1960 and noted that he expects further improvements by 2050. However, although Lam briefly covered the problems of global warming and pollution, he did not address several other major environmental problems that are closely related to the rapid human population growth in recent decades and to the progress he described. This commentary highlights some of these problems to provide a more balanced perspective on the situation of the world. Specifically, humans currently are using resources at an unsustainable level. Groundwater depletion and overuse of river water are major problems on multiple continents. Fossil fuel resources and several minerals are being depleted. Other major problems include deforestation, with the annual forest clearing globally estimated to be an area the size of New York State; and species extinction, with rates estimated to be 100 to 1,000 times higher than background rates. Principles of ecological economics are presented that allow an integration of ecology and economic development and better potential for preservation of the world for future generations.

Collecting contraceptive-use data by means of calendar methods has become standard practice in large-scale population surveys, yet the reliability of these methods for capturing accurate contraceptive histories over time remains largely unknown. Using data from overlapping contraceptive calendars included in a longitudinal study of 3,080 rural Bangladeshi women, we assessed the consistency of reports from the baseline interview month in 2006 with reports from the same month in a follow-up survey three years later, and examined predictors of reliable reporting. More than one-third of women were discordant in their reports for the reference month in the two surveys. Among women reporting use of any contraceptive method for the reference month in both surveys, 25 percent reported different methods at the two time points. Women using condoms or traditional methods and those with more complex reproductive histories, including more births and more episodes of contraceptive use, were least likely to report reliably. (STUDIES IN FAMILY PLANNING

Women’s empowerment is a dynamic process that has been quantified, measured and described in a variety of ways. We measure empowerment in a sample of 3500 rural women in 128 villages of Bangladesh with five indicators. A conceptual framework is presented, together with descriptive data on the indicators. Linear regressions to examine effects of covariates show that a woman’s exposure to television is a significant predictor of three of the five indicators. A woman’s years of schooling is significantly associated with one of two self-esteem indicators and with freedom of mobility. Household wealth has a significant and positive association with a woman’s resource control but a significant negative association with her total decision-making score.

Due to an urgent need for information on the coverage of health service for women and children after the fall of Taliban regime in Afghanistan, a multiple indicator cluster survey (MICS) was conducted in 2003 using the outdated 1979 census as the sampling frame. When 2004 pre-census data became available, population-sampling weights were generated based on the survey-sampling scheme. Using these weights, the population estimates for seven maternal and child healthcare-coverage indicators were generated and compared with the unweighted MICS 2003 estimates. The use of sample weights provided unbiased estimates of population parameters. Results of the comparison of weighted and unweighted estimates showed some wide differences for individual provincial estimates and confidence intervals. However, the mean, median and absolute mean of the differences between weighted and unweighted estimates and their confidence intervals were close to zero for all indicators at the national level. Ranking of the five highest and the five lowest provinces on weighted and unweighted estimates also yielded similar results. The general consistency of results suggests that outdated sampling frames can be appropriate for use in similar situations to obtain initial estimates from household surveys to guide policy and programming directions. However, the power to detect change from these estimates is lower than originally planned, requiring a greater tolerance for error when the data are used as a baseline for evaluation. The generalizability of using outdated sampling frames in similar settings is qualified by the specific characteristics of the MICS 2003—low replacement rate of clusters and zero probability of inclusion of clusters created after the 1979 census.

Background Nearly half of all pregnancies in the United States (US) are unintended. Nonuse, incorrect or inconsistent use of contraception may be related to limited support of male partners. Partners often accompany women seeking abortions to the clinic, representing an opportunity for health providers to engage them. This pilot study estimates the proportion of abortion patients accompanied by a male partner, the proportion agreeing to couples counseling and describes couples' experiences with the counseling. Study Design At a Baltimore clinic providing abortion, after preliminary qualitative research we recorded the number of patients who came with partners and accepted couples counseling in a 3-month period and sought feedback on the couples counseling in questionnaires from women, partners and the counselor. The counseling session consisted of giving information about the procedure and counseling regarding choices of a post-abortion contraceptive method and related topics that the woman and/or partner might raise. Results Overall, 27% of 774 patients came with their male partner, 28% with someone else and 45% alone. Fewer African-Americans (23%) came with a male partner, compared to 35% each among Whites and Hispanics (p n =88) accepted couple counseling. Many women (77%) and partners (59%) completing questionnaires ( n =66) had expected the partner to be involved in the clinic visit. The patients appreciated having the partner's support, having an informed partner with whom to communicate and being able to share decision making. Conclusion Over a quarter of patients to an abortion clinic came with a partner without any advance notice of the availability of couple counseling, and a sizable minority of these couples accepted couple counseling. Those who had the counseling evaluated it favorably.

This paper compares the performance of three methods applicable to national-level demographic data of estimating births averted as a consequence of contraceptive practice. Two are based on the relationship between the general fertility rate (GFR) or total fertility (TFR) and contraceptive prevalence, while the third uses Bongaarts' proximate determinants (PD) model. Estimates of the number of births averted and the percentage by which the number would have increased in the absence of contraception are consistent between the GFR-based and TFR-based methods, but in general lower than the estimates generated by the PD-based method, except for a few high-contraceptive-prevalence countries. For 156 countries and areas around the world the estimated number of births that would have occurred in a recent year in the absence of contraception--the average of the estimates of the three methods--is approximately 230 million, which is more than the estimated 129 million births that actually occurred.

Effective implementation of programmes with the community Integrated Management of Childhood Illness model has demonstrated improvements in care-seeking behaviours and utilisation of health services. The child survival programme implemented in Chokwe district of Gaza province, Mozambique, achieved high coverage for bed net use (80%), oral rehydration therapy for children with diarrhoea (94%) and prompt care-seeking from trained providers for children with danger signs. The project also instituted a community-based vital registration and health information system for routine surveillance of births, deaths and childhood illnesses using an extensive network of 2300 volunteers. Evidence from this system indicated a 66% reduction in infant mortality and a 62% reduction in under-five mortality. To check the reliability of the findings, an independent mortality assessment was carried out using a pregnancy history questionnaire with a sample population of 998 women using standard methodologies applied in the Demographic and Health Surveys. The mortality survey showed reductions of 49% and 42% in infant and under-five mortality, respectively. The leading causes of death identified by verbal autopsies were malaria (30%), neonatal causes (17%) and pneumonia (21.3%). These findings suggest that effective community-based partnerships that support the delivery of health services can contribute to mortality reductions.

The objective was to determine the non-specific effects of diphtheria tetanus and pertussis (DTP) vaccination and sex on mortality before 30 months of age among those who received Bacille Calmette Guerin (BCG) vaccine in a high mortality area. This analysis used a longitudinal study of child survival monitoring the use of primary care services morbidity and mortality in Metro Cebu The Philippines. Participants included 14 537 children under 30 months of age who received a BCG vaccination from July 1988 to January 1991. The main outcome measure was all-cause mortality. Mortality before 30 months of age was 57% lower among BCG-vaccinated children who received DTP vaccination than BCG-vaccinated children who did not receive DTP vaccination {hazard ratio (HR) for vaccinated vs unvaccinated 0.43 [95% confidence interval (CI) 0.21-0.88]}. Females had lower mortality rates [HR=0.19 (0.04-0.86) P=0.03] than males among DTP-unvaccinated children. The protective effect of DTP vaccination was more pronounced in males [HR 0.32 (0.14-0.73)] than in females [HR 0.86 (0.18-4.23)]. DTP vaccination increased (interaction term P=0.08) the female-to-male mortality ratio to 0.76 (0.52-1.12). Among BCG-vaccinated children under 30 months of age DTP vaccination is associated with improved survival. The increased female-male mortality ratio is associated with reduced mortality among males following DTP vaccination rather than increased mortality among female children. (authors)

Surveys have attempted to measure married women's decision-making power by asking women who has a say and/or final say in a number of household decisions. In several studies where the same questions were posed to husbands, considerable discrepancies in reports were found. This paper assesses husband and wife reports of decision-making on four matters (whether or not to buy household items; what to do if a child becomes ill; whether or not to buy medicine for a family member who is ill; what to do if a pregnant women becomes very ill) and the relationship of these reports to three recent health behaviors (having an emergency plan during pregnancy; delivering in a health facility; having a postpartum checkup within 4 weeks). A sample of 1000 women in 53 communities in three departments of western Guatemala was selected using a stratified random sampling approach. A standard household questionnaire was used to identify the respondents as well as to obtain data on household characteristics. Husbands of interviewed women were interviewed in every other household giving information on 546 couples for this analysis. Women and men's questionnaires were similar and were designed to obtain information on the respondent's knowledge, attitudes and behaviors regarding maternal health. Consistent with other research, results show that relative to their husbands' report, wives tend to under-report their household decision-making power. In couples with both partners educated and in couples in which women work for pay, both partners were significantly more likely to report that both of them participate in the final decisions than was the case in couples without education or in which the wife did not work for pay. Women's reports of their decision-making power was significantly related to the household having a plan for what to do in case of a maternal emergency, but was not associated with place of childbirth or with having a postpartum checkup, while husband's reports of the wife's decision-making power was negatively associated with the likelihood of having the last birth in a health facility.

In fertility surveys often women (and sometimes men) are asked their fertility desires, i.e. whether they want a/nother birth or not. Some respond that they are undecided. This study examines whether these persons are more like those who say they want more births or like those who say they want no more births. Data on married men and women in 29 Demographic and Health Surveys with sample sizes ranging from 300 to 3000 are used. A logistic regression equation is estimated within each country for those with known desires and then used to classify each person who was undecided. In all sub-Saharan African countries (n=20) and for both sexes, 50% or more of the undecided persons are classified as wanting more children (with one exception of wives in Kenya). By contrast in all five Latin American countries for both sexes less than 50% of the undecided were classified in the ‘want more’ group (with an exception of husbands in the Dominican Republic). Generally, the undecided tend to be classified the same as the majority among those in the survey with stated desires.

About half of the 1.2 million abortions each year in the United States are repeat abortions. While most abortion providers counsel women about contraception, one reason for the high repeat rate could be failure to take into account the social context of the women—in particular, the male partner. To assess whether there might be a window of opportunity for a contraceptive intervention that includes the male partner at the time of the abortion, we undertook a pilot study at an urban abortion clinic to examine the role of the male partner among women receiving abortions. Between May 2001 and August 2002, two questionnaires were administered to 109 women receiving abortions in a Baltimore City clinic. On the procedure day, women were more likely to be accompanied by a male partner upon arrival (30%) or when leaving (34%) than by any other individual. The majority of women receiving abortions reported that their partners played positive decision-making and support roles throughout the abortion process. A significant proportion of couples could be available for contraceptive counseling following an abortion, providing rationale for couples' post-abortion contraceptive counseling for women whose partners are already actively and positively involved in the abortion process. Such an intervention may help to reduce repeat abortions.

This article considers statistical means of evaluating profiling in searches of individuals by law enforcement agencies. It reviews examples of inappropriate methods that have been used to date. A relatively recent, more appropriate, and simple method is elaborated and its usefulness documented with data from Maryland State Police highway stops and searches. The method evaluates profiling for specified groups of interest by comparing the relative magnitudes of contraband find rates among those stopped and searched of each group. When find rates are approximately the same across groups, then profiling used in making the stops and searches is deemed effective and nondiscriminatory. With an increasing number of jurisdictions mandated to collect data on stops and searches, it is important that appropriate methods be used in their analyses so correct public policy conclusions can be drawn.

After contraceptive use, breast-feeding duration is the major determinant of the birth interval length. Three methods of estimating births averted by breast-feeding, and the increase in contraceptive use needed to substitute for breast-feeding, are presented. Method 1 simply utilizes Bongaarts’ Ci, and the other two are based on mean birth intervals with and without breast-feeding. Estimates for each method are derived for six countries with DHS surveys from the mid-1990s: Burkina Faso, Uganda, India, Indonesia, Brazil and Peru. The estimated percentage of additional births that would occur if there were no breast-feeding ranged from 1–4% in Brazil to about 50% in Burkina Faso and Uganda, reflecting very low breast-feeding in Brazil and very high levels in the sub-Saharan African nations. Strengths and limitations of the three methods are considered.

Background HIV counseling and testing for couples is an important component of HIV prevention strategies, particularly in Sub Saharan Africa. The purpose of this pilot study is to estimate the uptake of couple HIV counseling and testing (CHCT) and couple family planning (CFP) services in a single home visit in peri-urban Malawi and to assess related factors. Methods This study involved offering CHCT and CFP services to couples in their homes; 180 couples were sampled from households in a peri-urban area of Blantyre. Baseline data were collected from both partners and follow-up data were collected one week later. A pair of male and female counselors approached each partner separately about HIV testing and counseling and contraceptive services and then, if both consented, CHCT and CFP services (pills, condoms and referrals for other methods) were given. Bivariate and multivariate logistic regression analyses were done to examine the relationship between individual partner characteristics and acceptance of the services. Selected behaviors reported pre- and post-intervention, particularly couple reports on contraceptive use and condom use at last sex, were also tested for differences. Results 89% of couples accepted at least one of the services (58% CHCT-only, 29% CHCT + CFP, 2% CFP-only). Among women, prior testing experience (p

This paper examines the interaction between contraceptive use and breastfeeding in relation to resumption of intercourse and duration of amenorrhea post-partum. We used data from the month-by-month calendar of reproductive events from Demographic and Health Surveys (DHS) in Peru and Indonesia. The analyses show that breastfeeding women were less likely than non-breastfeeding women to have resumed sexual intercourse in the early months post-partum in both countries. In Peru, but not in Indonesia, breastfeeding women had a significantly lower odds than non-breastfeeding women of adopting contraception. Although the likelihood of contraceptive adoption was highest in the month women resumed menstruation in both countries, about ten per cent of subsequent pregnancies occurred to women before they resumed menses. These results emphasize the importance of integrating breastfeeding counselling and family planning services in programmes serving post-partum women, as a means of enabling those who wish to space the...

The objective of this study was to determine whether stopping smoking between the first prenatal care visit and the 32nd week of pregnancy affects the smoking-associated changes in five infant anthropometric indices. The study population consisted of 15,185 births in the Swedish Medical Birth Register from 1991 and 1992. The associations between birth weight, crown-heel length, head circumference, ponderal index, brain:body weight ratio, maternal smoking status at the first prenatal care visit and at 32 weeks' gestation, and other maternal and infant characteristics were assessed using multivariate linear regression. The infants of 946 women who stopped smoking before week 32 of pregnancy were statistically indistinguishable from the 9,802 infants of nondaily smokers in terms of birth weight, head circumference, and brain:body weight ratio, but they retained a significant deficit in crown-heel length of 0.23 cm (standard error, 0.08) and a significant elevation in ponderal index of 0.027 (standard error, 0.009). In this study, stopping smoking between the first prenatal care visit and week 32 of pregnancy prevented smoking-associated deficits in infant birth weight, head circumference, and brain:body weight ratio, but did not completely prevent deficits in crown-heel length in comparison with nonsmokers' infants of the same age, and did not prevent elevation of ponderal index in comparison with nonsmokers' infants of the same weight and age.

OBJECTIVES: This study examined the effect of maternal smoking during pregnancy on infant body proportion. METHODS: The ponderal index, defined as birthweight divided by crown-heel length cubed, was examined in 207,607 infants from the Swedish Medical Birth Register for 1991 and 1992. RESULTS: Infant ponderal index was used as the outcome variable in an ordinary least squares continuous regression, which included early pregnancy smoking status, gestational age, and birthweight among the predictors. Ponderal index increased by 0.030 (+/- 0.0014) among infants of moderate smokers and by 0.040 (+/- 0.0017) among infants of heavy smokers, showing a dose response. CONCLUSIONS: Smoking differentially alters the trajectory of weight vs length growth in the fetus.

In summary, progress in research on reproductive epidemiology will depend on the increased use of biologic measurement, a focus on multiple outcomes, and an increased use of the couple or sexual network as the unit of study, with appropriate statistical methods for analysis of correlated data. The combination of these approaches holds great promise for research in the 21st century.

Historically, the combination of women's rights to care, population concerns and the development of female-oriented contraceptive methods resulted in family planning programs focusing on women's contraceptive needs and little else. The 1994 United Nations Population Conference in Cairo called for an expansion of programs to cover reproductive health in its broadest interpretation. As this concept has developed and been put into practice it has become evident that a key element in reproductive health services should be the inclusion of the sexually active couple.

Objective: To re-examine data on sperm counts over time from 61 studies from around the world. Design: Parametric analyses and flexible nonlinear models of the relation between sperm counts and time. Main Outcome Measure(s): Mean sperm concentrations per milliliter and regression coefficients for possible trends of concentrations over time. Result(s): A significant decline was found only in U.S. studies. Conclusion(s): Studies from specific sites have found declines in sperm counts, but a worldwide decline has not been demonstrated. Rigorous assessment of statistical models should be done before conclusions are drawn. Flexible smoothing models are a useful addition to currently available analytic methods.

The effects of nutritional status on diarrheal and acute lower respiratory infection (ALRI) mortality in children < 2 y of age were examined by using data from a 1988-1991 longitudinal study of 9942 children in Metro Cebu, Philippines. Cox regression methods were used to study the strengths of the associations, possible interactions with birth weight and breast-feeding status, and the effect of additional confounding factors. Nutritional status as measured by weight-for-age was a significant risk factor for both ALRI and diarrheal mortality in the first 2 y of life. Poor nutritional status resulted in a 1.6-fold increased risk of diarrheal mortality for each one-unit decrease in weight-for-age Z score. For ALRI mortality, a one-unit decrease in weight-for-age Z score resulted in a 1.7-fold increase in risk, and for mortality associated with ALRI and diarrhea combined, the relative risk was 2.0. This study provides further evidence that malnutrition is a major determinant of mortality in very young children and it is one of the first longitudinal studies to estimate the magnitude of the effect on cause-specific mortality associated with nutritional status.

BackgroundPrevious estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011.Methods and findingsWe conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74-5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000-751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005-2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study.ConclusionsBeyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war. Please see later in the article for the Editors' Summary.

Risk factors for wasting and stunting were examined in a longitudinal study of 18 544 children younger than 30 mo in Metro Cebu, Philippines. Measures of household demographic and socioeconomic characteristics, maternal characteristics and behavior, and child biological variables were analyzed cross-sectionally in six child age-residence strata by using logistic regression. Our results support biological and epidemiologic evidence that wasting and stunting represent different processes of malnutrition. They also indicate that the principal risk factors for stunting and wasting in infants < 6 mo of age were either maternal behaviors or child biological characteristics under maternal control, eg, breast-feeding status and birth weight. After 6 mo of age, household socioeconomic characteristics emerged with behavioral and biological variables as important determinants of malnutrition, eg, father's education and presence of a television and/or radio. Household socioeconomic status influenced the risk of stunting earlier in rural than in urban barangays. Implications of the results for interventions are discussed.

This study uses couple-level data to measure couples' concordance of self-reported time since last coitus and of condom and other contraceptive use at last sexual intercourse among monogamous couples in Liberia (N = 1,673), Madagascar (N = 4,138), and Namibia (N = 588). The study also examines the characteristics associated with sexual behavior and contraceptive use occurring in the 28 days prior to the interviews among couples whose reports are concordant. Overall, our study finds less than 75 percent concordance in reporting of time since last coitus. Use of condoms and other contraceptives yielded fair (0.27) to substantial (0.67) agreement on the kappa index. Factors predicting a shorter time since last coitus among concordant couples in at least two of the countries included wealth, spousal age difference, education, and both partners wanting another child. The discordant reports of recent sexual behavior and contraceptive use suggest that caution should be exercised when inferring couples' behavior from the report of one spouse, that concordant reports should be examined when possible, that methodological changes to improve the validity of spousal reports should be pursued, and that family planning and HIV-prevention programs should target those groups found to be using condoms and other contraceptives less frequently, particularly poorer couples.

The accuracy of responses to a question on the frequency of sexual intercourse in the 4-week period prior to an interview is expected to be low. This paper examines the reliability of an alternative question: 'How many days since you last had sexual intercourse?'. This was a part of a larger longitudinal study of fertility dynamics in Matlab, Bangladesh. The response pairs of 61 women who were asked the same question by an interviewer and on the next day by a supervisor, were analysed. Refusals were more common among older women and among women who gave a response at the extremes of the distribution for the other interview. Of the pairs of two responses, 78% had a difference of 3 days or less. Further study and use of the question on days since last intercourse is recommended.Reported data reflect coital frequency accurately in a 24-hour period, but data are more questionable for reports over a four-week period. This study compared responses and reinterviews of 51 of about 2000 women in 1979 in the Matlab study area of Bangladesh. Exact correspondence on the last date of sexual intercourse (within one day) was determined. Out of an original 60 women selected, eight refused and one did not have any intercourse within the past month. Results indicate that 15 of cases (30%) coincided exactly. 26 cases (52%) were within one day, and 39 (78%) were within three days. Four cases involved extreme differences of more than 10 days, and these reports also included only one report for the period and were from women aged over 40 years. A comparison of reports of coital activity with those who refused a reinterview showed that women who refused reinterviews reported values at the extremes of the distribution. Either "last night" or "a month ago" were common responses. There was a significant difference in the number of cases reporting coitus the previous night to the supervisor reinterviewer. Care must be taken in wording sensitive questions having to do with the time of last sexual intercourse. Consideration must be given to the sex and social status of respondent, training of interviewers, and privacy for questionnaire administration. The suggestion is made to limit recall time to within the past week for those with frequent sexual intercourse; for those with low levels of sexual activity, a month might be more suitable. A less well-known supervisor might have affected responses in the reinterviews. In conservative settings in Bangladesh, there may be a need to establish a good rapport. Heaping responses for the reinterview did not fit the expected pattern of quadrupling a week's response. Heaping occurred for numbers ending in "0" and "5." The recommendation is made for continued use of the question, because data are reasonably reliable, and this type of information can be useful in estimating monthly coital frequency and fecundability.

SummaryExamining waiting time to birth among newlywed couples is likely to provide insights into the desire for spacing births among newlywed husbands and wives. Data from the Indian National Family Health Survey of 2005–06 are used to examine the desired waiting time (DWT) to birth among newlywed couples. The dependent variable is spousal concordance on desired waiting times. Overall 65% of couples have concordant desired waiting times. Among discordant couples, wives were more likely to want to wait longer than their husbands. Couples from richer wealth quintiles were more likely than couples from the poorest quintile to have concordant desired waiting times. Muslims were less likely than Hindus to have concordant desires. There is a need for spacing contraceptive methods among newlyweds in India. This may have implications for the Indian Family Planning Programme, which to date has largely focused on sterilization. Programmes need to include newlywed husbands to promote use of spacing methods.

Background Pakistan has high maternal mortality, particularly in the rural areas. The delay in decision making to seek medical care during obstetric emergencies remains a significant factor in maternal mortality. Methods We present results from an experimental study in rural Pakistan. Village clusters were randomly assigned to intervention and control arms (16 clusters each). In the intervention clusters, women were provided information on safe motherhood through pictorial booklets and audiocassettes; traditional birth attendants were trained in clean delivery and recognition of obstetric and newborn complications; and emergency transportation systems were set up. In eight of the 16 intervention clusters, husbands also received specially designed education materials on safe motherhood and family planning. Pre- and post-intervention surveys on selected maternal and neonatal health indicators were conducted in all 32 clusters. A district-wide survey was conducted two years after project completion to measure any residual impact of the interventions. Results Pregnant women in intervention clusters received prenatal care and prophylactic iron therapy more frequently than pregnant women in control clusters. Providing safe motherhood education to husbands resulted in further improvement of some indicators. There was a small but significant increase in percent of hospital deliveries but no impact on the use of skilled birth attendants. Perinatal mortality reduced significantly in clusters where only wives received information and education in safe motherhood. The survey to assess residual impact showed similar results. Conclusions We conclude that providing safe motherhood education increased the probability of pregnant women having prenatal care and utilization of health services for obstetric complications.

OBJECTIVE: To examine historical estimates of infant and under-five mortality in Afghanistan, provide estimates for rural areas from current population-based data, and discuss the methodological challenges that undermine data quality and hinder retrospective estimations of mortality. METHODS: Indirect methods of estimation were used to calculate infant and under-five mortality from a household survey conducted in 2006. Sex-specific differences in underreporting of births and deaths were examined and sensitivity analyses were conducted to assess the effect of underreporting on infant and under-five mortality. FINDINGS: For 2004, rural unadjusted infant and under-five mortality rates were estimated to be 129 and 191 deaths per 1000 live births, respectively, with some evidence indicating underreporting of female deaths. If adjustment for underreporting is made (i.e. by assuming 50% of the unreported girls are dead), mortality estimates go up to 140 and 209, respectively. CONCLUSION: Commonly used estimates of infant and under-five mortality in Afghanistan are outdated; they do not reflect changes that have occurred in the past 15 years or recent intensive investments in health services development, such as the implementation of the Basic Package of Health Services. The sociocultural aspects of mortality and their effect on the reporting of births and deaths in Afghanistan need to be investigated further.

Voluntary counseling and testing (VCT) for couples (CVCT) is an important HIV-prevention effort in sub-Saharan Africa where a substantial proportion of HIV transmission occurs within stable partnerships. This study aimed to determine the acceptance and effectiveness of CVCT as compared to individual VCT (IVCT). 1,521 women attending three antenatal clinics in Dar es Salaam were randomized to receive IVCT during that visit or CVCT with their husbands at a subsequent visit. The proportion of women receiving test results in the CVCT arm was significantly lower than in the IVCT arm (39 vs. 71%). HIV prevalence overall was 10%. In a subgroup analysis of HIV-positive women, those who received CVCT were more likely to use preventive measures against transmission (90 vs. 60%) and to receive nevirapine for themselves (55 vs. 24%) and their infants (55 vs. 22%) as compared to women randomized to IVCT. Uptake of CVCT is low in the antenatal clinic setting. Community mobilization and couple-friendly clinics are needed to promote CVCT.