A review of “Sex Before the Sexual Revolution: Intimate Life in England 1918–1963” by Simon Szreter and Kate Fisher.

Brief Excerpt:

As a young obstetrician in London in the 1960s, who had just moved into a house built in the 1920s, I began talking to my two neighbors, literally over the garden fence. They were both widows in their 80s and we soon wandered into conversations about the role of contraception in their married lives half a century earlier. Looking out on the sexual revolution of the 1960s, they were almost eager to talk about intimate details of their younger lives.

The fifth Millennium Development Goal has brought critical attention to the unacceptably high burden of maternal mortality and the need to improve antenatal health care. However, many of the approaches to reducing maternal mortality (e.g., increasing the number of deliveries at health facilities with skilled attendants or improving access to emergency obstetric care) are complex and will take time to implement. In the meantime, maternal mortality can be reduced relatively inexpensively by preventing unwanted pregnancy through family planning. The decision to practice family planning is personal and private, and it need not require professionals or health clinics. Although inexpensive at the program level, however, family planning may be difficult for individuals to afford. Thus, women face barriers, including cost, lack of transportation and the fear of side effects (real or rumored). In developing countries, making contraceptives available and accessible may be the most important, cost-effective and easily accomplished primary health care goal. Reducing barriers to family planning may lessen the burden of maternal death in low-resource settings.

Between February 2002 and January 2004 in the Adigrat Zonal Hospital, covering one-fifth of the large Tigray region of North West Ethiopia, there were 907 admissions with a diagnosis of abortion. Among these, 521 were induced by traditional, unsafe methods. Unsafe abortion was the leading cause of admission, accounting for 12.6% of all bed occupancy throughout this general hospital and 60.6% of the gynecological admissions. About 57% of patients admitted with unsafe abortions had serious complications, including tubo-ovarian abscess, vaginal laceration, uterine perforation, generalised peritonitis and renal failure. Three women died from complications of unsafe abortion. Five years later in the same hospital, between July 2009 and September 2010 unsafe abortion cases had declined, becoming the tenth cause of hospital admission. There were no deaths and no severe complications.

Niger—with the world’s fastest growing population, its highest total fertility rate (TFR), a small and diminishing amount of arable land, low annual rainfall, a high level of malnutrition, extremely low levels of education, gross gen- der inequities and an uncertain future in the face of climate change—is the most extreme example of a catastrophe that is likely to overtake the Sahel. 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 of the utmost importance. In this comment, we review the problems posed by Niger’s rapid population growth and the policy options proposed to confront it.

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.

Recent efforts to reduce maternal mortality in developing countries have focused primarily on two long-term aims: training and deploying skilled birth attendants and upgrading emergency obstetric care facilities. Given the future population-level benefits, strengthening of health systems makes excellent strategic sense but it does not address the immediate safe-delivery needs of the estimated 45 million women who are likely to deliver at home, without a skilled birth attendant. There are currently 28 countries from four major regions in which fewer than half of all births are attended by skilled birth attendants. Sixty-nine percent of maternal deaths in these four regions can be attributed to these 28 countries, despite the fact that these countries only constitute 34% of the total population in these regions. Trends documenting the change in the proportion of births accompanied by a skilled attendant in these 28 countries over the last 15-20 years offer no indication that adequate change is imminent. To rapidly reduce maternal mortality in regions where births in the home without skilled birth attendants are common, governments and community-based organizations could implement a cost-effective, complementary strategy involving health workers who are likely to be present when births in the home take place. Training community-based birth attendants in primary and secondary prevention technologies (e.g. misoprostol, family planning, measurement of blood loss, and postpartum care) will increase the chance that women in the lowest economic quintiles will also benefit from global safe motherhood efforts.