Impact of HIV infection on mortality and accuracy of AIDS reporting on death certificates

POPLINE Article Titles
[Residents originating from one of the E.C. member states, January 1, 1990]
Results are presented and analyzed from a partial enumeration conducted by the Netherlands Central Bureau of Statistics from computerized population registers. The aim was to determine what percent of the resident population is from a member state of the European Community other than the Netherlands. Consideration is given to native residents, defined as nationals born in the Netherlands whose parents were also born there; non-natives; and labor migration. A historical overview of migration to the Netherlands, with a focus on country of origin, is also included. (SUMMARY IN ENG)
Impact of HIV infection on mortality and accuracy of AIDS reporting on death certificates.
"In this analysis, we obtained information on HIV infection, reported infection, reported AIDS diagnosis, and deaths among a San Francisco [California] cohort of homosexual and bisexual men. Our objectives were to describe the underlying causes of death; to assess underreporting of AIDS on death certificates; and to calculate cause-specific proportionate mortality ratios (PMRs), years of potential life lost (YPLL), and standardized mortality ratios (SMRs) for deceased cohort members." (EXCERPT)
[Population development in France, 1831-1989: no longer alone in Europe]
Changes in population size and structure in France from 1831 to 1989 are reviewed. The authors note that demographic trends in France have converged with those of other European countries in the period since World War II. Particular attention is given to postwar fertility, which after an initial surge is again below replacement level. Fears of the loss of cultural identity associated with large-scale immigration from Northern Africa are noted. The authors also describe recent changes in internal migration patterns. (SUMMARY IN ENG AND FRE) (ANNOTATION)
1990 population census of Japan. Preliminary counts of the population on the basis of summary sheets, as of October 1, 1990.
This is the first report providing results from the 1990 census of Japan. "This report presents the preliminary counts of population [by sex] and households of the whole country and by prefecture and municipality obtained from the prefectoral and municipal summary sheets prepared by the local governments." (EXCERPT)
1990 population census of Japan. Volume 2: results of the first basic complete tabulation. Part 2: 01 Hokkaido.
This is one in a series presenting results from the 1990 census of Japan by prefecture. "The first basic complete tabulation includes statistics on basic characteristics of population, households and dwellings and statistics on aged persons households, mother-child(ren) households and father-child(ren) households for the whole country, prefectures and municipalities." The population characteristics include sex and age distribution and marital status. This part presents data for Hokkaido. (EXCERPT)
1990 population census of Japan: final count, population and households, as of 1 October 1990.
"This report presents the final counts of population and households for the whole country, prefectures and municipalities (Shi, Ku, Machi, and Mura), obtained from the First Basic Complete Tabulation of the 1990 Population Census of Japan which was taken as of 1 October 1990." The population totals for each administrative area are provided separately by sex. (EXCERPT)
[The link between demographic events: a study of nuptiality patterns]
The author examines links between the timing of various major life events (including women's age at marriage and the spacing of children) and the economic and urban development of a society, using Mexico as an example. The focus is on marriage patterns. She finds that nuptiality influences rural-urban migration for women, as do age and socioeconomic factors and husband's employment status. Data are from the Mexican Fertility Survey for the period 1976-1977. (SUMMARY IN ENG) (ANNOTATION)
Transfer of population as a solution to international disputes: population exchanges between Greece and Turkey as a model for plans to solve the Jewish-Arab dispute in Palestine during the 1930s.
The author explores the reasons for the failure of a plan for population exchanges that took place between Jews and Arabs in Palestine in the 1930s. Special focus is given to the success of previous exchanges between Greece and Turkey that took place during the 1920s and why this model failed in Palestine. The author concludes that "the Zionist plans which assumed that one could encourage voluntary transfer by creating attractive economic conditions in the target areas, did not take into account the factors of nationalism, ties to place of residence, religion, etc. These factors carried no less weight than the economic factor and they could effectively prevent any voluntary transfer of the Arab population." (EXCERPT)
Experiments in the projection of mortality.
"How fast will mortality fall in the decades ahead? One way of phrasing the question is in terms of past periods: will it be as fast as Canada showed in 1976-81, or only as fast as the average 1921-81, or as slow as 1926-31?...I will argue that the whole matter of projecting mortality comes down to deciding what past period describes the future...." The author concludes that any of several methods could be used, including the Brass method, but that "no trend calculation, or regression on economic variables, seems able to forecast the future, that is to [accurately account for such events as] technical advance...and new fashions in behaviour." Life tables for Canada concerning the period 1920-1982 are used as illustrations. (SUMMARY IN FRE) (EXCERPT)
Consistency of ancestry reporting between parents and children in the 1986 census.
The author examines responses to a question on ancestry that was included in the 1986 census of Australia, with a focus on consistencies between the responses of parents and children. It is found that "the level of consistency was more than 90 per cent when both parents were of the same ancestry; when parents were of different or mixed ancestries, the level of consistency was lower. It was estimated that about 75 per cent of all dependent children had an ancestry response consistent with that of the parent or parents with whom they lived." (EXCERPT)
Problems of urbanization and the growth of Seoul, Korea.
"The present study discusses the nature and magnitude of problems faced by Seoul city [Republic of Korea] in recent years and the policy response of both the national government and city authorities....As the study demonstrates...the city authorities have been quite successful in decentralising population and economic activities away from the capital. A number of policy measures such as decentralisation of manufacturing industry through special incentives, infrastructure development in other regions, and reduction in urban bias in economic and social policies have contributed to this success....Notwithstanding the relative success of Seoul...the city still suffers from several problems such as environmental pollution, urban unemployment, rising land values and shortage of low cost housing....The authors suggest a number of policy measures on how to cope with these problems." (EXCERPT)
Demographic dimensions of population aging in developing countries.
"Several demographic aspects of population aging in developing countries are considered: the older old, the median age of a population, life expectancy and mortality, functional status and disability, sex differences, urbanization, and the labor force. While the demographic impact of population aging is becoming better appreciated, the descriptive epidemiology of age-related changes in health and physical functioning in developing countries is still at an early stage." (EXCERPT)
Immigrant suicide in Australia, Canada, England and Wales, and the United States.
"Factors influencing the suicide rates of numerous immigrants in groups in Australia, Canada, England and Wales, and the United States during the period 1959-73 were examined....For males, the foreign-born in England and Wales had the lowest suicide rates and the foreign-born in the United States the highest. For females the variation was smaller, with immigrants in the United States having the lowest rates, and those in Australia the highest....In each destination significant correlations existed between the suicide rates of the immigrants and those of the origin populations, indicating that the suicide rates for individual immigrant groups were to some extent predisposed by their experiences in the origin countries. Factors in the destination country also influenced immigrant suicide rates, as the rates of the majority of the immigrant groups converged towards the rates of the destination native-born....The analyses also suggested that migration is more deleterious for females than males." (EXCERPT)
[Population development in Czechoslovakia in 1990]
Population dynamics in Czechoslovakia during 1990 are outlined using data from official census sources. Increases in both nuptiality and divorce are noted. Abortion rates remained static, while the number of live births increased. Mortality levels remained unimproved, hence, so did the average life span. Both immigration from elsewhere in Eastern Europe and emigration to the West have increased. (SUMMARY IN ENG AND RUS) (ANNOTATION)
Are Americans still in love with marriage?
Recent trends in marriage patterns in the United States are reviewed using data from published studies. The author notes increases in marriage age, the number of consensual unions, divorces, and births outside of marriage. (ANNOTATION)
[Health, illness, and death among Latin American children]
This collection of 15 papers results from a conference entitled Perinatal and Infant Health and Mortality in Latin America, held November 25-29, 1985, in Buenos Aires, Argentina. Topics covered include research methodology, socioeconomic and cultural factors influencing infant mortality, diet and nutrition, availability of medical services, poverty, and recent trends in and causes of infant mortality in various countries. (ANNOTATION)
Trends and directions of population migration in Guangdong province.
The authors explore the effects of regional socioeconomic and geographic diversity and the flexible economic policies of Guangdong province in China on migration both into and within the province, particularly into the Pearl River delta. They suggest that management of the resulting population imbalances can be accomplished through development of the household economy and the transfer or export of surplus rural labor. (ANNOTATION)
A study on the trend of demographic aging in Zhejiang province.
Using data from the 1987 sampling survey of one percent of the population of China, the author examines trends in demographic aging in Zhejiang province. The proportion of adults and the elderly in the population has increased due to the one-child-per-family policy, and there has been an increase in the average life span and a migratory influx of 15-33-year-olds. The aging of the Zhejiang population is expected to accelerate. The author suggests approaches to meet the needs of the increased numbers of elderly residents. (ANNOTATION)
[Cities in conflict: a Latin American perspective]
This volume contains papers by various authors that were presented at a seminar entitled The Urban Crisis in the South Core: Patterns and Approaches, held in November 1988 in Montevideo, Uruguay. Aspects of the urbanization and growth of cities in Latin America, with a focus on Argentina, Brazil, Chile, and Uruguay, are described, as are related problems that have arisen during recent decades. Some possible solutions are proposed. (ANNOTATION)
[General census of population and housing: final results. Volume 0: the whole country. Part 4: census divisions]
This is one of the four parts into which Volume 0 of the Mali census of 1987 is divided. This volume provides data for the country as a whole. Part 4, cited here, presents data by minor civil division on total population and households. (ANNOTATION)
[The challenge of immigration: general issues and the specific problems posed by the case of Italy]
Some general problems posed by immigration in developed Western countries are reviewed, with a focus on immigration to Italy. The author notes that immigration in Italy is distinguished by the concentration of migrants in the tertiary sector of the work force, with only minor migrant participation in the industrial labor force. (ANNOTATION)
[Mortality by cause among children younger than age one in Mexico]
"This article presents the levels and trends of deaths among children [in Mexico] under the age of one, by groups of causes, for some states, for the years 1979-1985. Identifying the causes of death according to the international classification of diseases, both for deaths among children under the age of one and for total deaths, the goal is to establish a comparison of the levels of general and infant mortality by groups of causes. The data are taken from the statistical yearbooks of the Head Office for Statistics, for the years 1979 to 1985." (SUMMARY IN ENG) (EXCERPT)
Population, labour force and household projections, 1991-2031.
"This publication presents the latest official projections of the New Zealand population, labour force and household numbers produced by the Department of Statistics. They have as their base the total New Zealand population at 31 March 1988, and cover the period 1991-2031." (EXCERPT)
[Population and housing census, 1990: preliminary results]
Preliminary results from the 1990 Norwegian census are presented in this report. They include data on population by sex, marital status, and age; employment; and households. (ANNOTATION)
The lowest birth-weight infants and the U.S. infant mortality rate: NCHS 1983 linked birth/infant death data.
This analysis links birth and infant death data for the 1983 U.S. birth cohort to show that infants weighing less than 750 grams, comprising 0.3 percent of all births, account for 25 percent of all deaths in the first year of life and 43 percent of deaths in the first week. The implications for reducing infant mortality rates, black-white mortality differentials, and mortality among low birth-weight infants are discussed. (ANNOTATION)
[National censuses of population and housing, May 13, 1990. Final basic results: the whole country]
Final results are presented from the 1990 census of Panama. They concern population by province, 1911-1990; age and sex distribution; population density by province and district; and labor force activity. (ANNOTATION)
Papua New Guinea 1990 national population census: preliminary figures. Census division populations.
Preliminary results are presented from the 1990 census of Papua New Guinea. They include population by major town and province. (ANNOTATION)
[A method for projecting the population according to size of locality. (Application to the case of Mexico's urban population in 1990)]
"In this article, a restricted components method is presented (because sex and age are not taken into account) to project the population classified according to the size of the locality....The application is presented for urban centers (15,000 or more inhabitants) of Mexico in 1990, utilizing the trend in demographic growth for the 1960-1980 period." Data are from Mexican censuses conducted in 1960, 1970, and 1980. (SUMMARY IN ENG) (EXCERPT)
[Mexico: population in localities with 10,000 or more residents according to the censuses of 1960, 1970, and 1980]
Data on localities in Mexico with populations of 10,000 or more according to the censuses of 1960, 1970, and 1980 are presented in tabular format. A brief description of the methodology used in each census is included. (ANNOTATION)
[Is the marriage market unbalanced? The case of Mexico in 1980]
"The objective of this article is to present the results obtained when estimating how balanced, in numerical terms, the Mexican population of marriageable age [12 to 50 years old] was in 1980, in relation to its structure by age and sex, as well as the timing of its nuptiality. This estimate was made for both the state and national levels, using as a source of information the 1980 Census...." (SUMMARY IN ENG) (EXCERPT)
[Demography, 1990]
This is the latest in a series of annual publications presenting demographic data for Poland. It contains data on population size and structure, vital statistics, and migration. Tables of contents and lists of tables are provided in Russian and English. The most recent data are for 1989, with extensive retrospective data also included. Until 1989, the title of this series was Rocznik Demograficzny (Demographic Yearbook). (ANNOTATION)
Fun with Gompertz.
The author examines Gompertz's law of mortality and describes approximations and shortcuts in calculations made using the law. The usefulness of these formulas for the demographer is noted. The formulas are illustrated using data for the Federal Republic of Germany and Yugoslavia. (SUMMARY IN FRE AND ITA) (ANNOTATION)
[Migration in the Mediterranean region]
The implications for Europe of growing migration pressures in the Mediterranean region are examined. The authors note that it will be necessary to create about 25 million new jobs in the region by the year 2000 to satisfy the projected demand. This will involve controlling the flows of migrants to the north and the movement of capital to the south. The need for the countries of the European Community to act together is stressed. (SUMMARY IN ENG) (ANNOTATION)
[Features of nuptiality in the border zone]
"This article is limited to an analysis of some characteristics of nuptiality in the municipalities in the northern border zone of Mexico, based on the classification of the population by age and sex [and] by marital status...contained in the 1980 Census....Nuptiality in the border zone is not only distinguished from that of the country as a whole, but also in relation to the states in which the municipalities comprising it are located." (SUMMARY IN ENG) (EXCERPT)
Polyandry in India: retrospect and prospect.
This is a review of the literature concerning polyandry in India from ancient times to the present. Consideration is given to socioeconomic aspects of polyandrous societies, fraternal polyandry, and the allocation of paternity. (ANNOTATION)
Transition probability change and the growth of female family headship in the United States, 1968-88.
"The growth in female family headship (single motherhood) in the United States over the 1968-88 period, both as a proportion of all 18 to 59 year old women and as a proportion of all those who are raising families, is studied. Family structure transition probabilities are estimated from Panel Study of Income Dynamics data. The implications of these transition probabilities for population headship proportion growth are modeled by two- and three-state Markov processes....Headship growth was stronger in the 1970s than in the 1980s, and was produced entirely by headship entry probability increases: mostly by increases in union dissolutions among women with families in the 1970s, although increases in family initiations by unpartnered women became the major source of headship growth into the 1980s." (EXCERPT)
Beyond the family: the social organization of human reproduction.
This study is concerned with the social organization of reproduction in modern Western societies. The main theme is that reproduction is not simply a family affair, but one that has helped shape many aspects of modern societies, including such things as salaries, mortgages, suburbs, and social classes. "In the first part of the book I begin by clarifying the relationship between the physical processes of reproduction and such basic social groupings as 'family' and 'household'....Chapters 4 and 5 examine more closely the interdependence of political-economic and reproductive processes. First, I discuss how people come to grips economically and politically with mating, child-rearing and death; and then, turning the coin, I explain how economic processes respond to the need to organize reproduction. In the sixth chapter I shall show how these considerations help us to understand the social and historical significance of broader relations of class, gender and generation. In the second part of the book I treat reproduction as an active force in the making of the modern world, tracing the expansion of reproductive organization from households and local communities out into the institutions of modern industrial states. Chapter 8 shows how this analysis can help us to understand the ways in which labour is rewarded in industrial economies, by explaining important differences between wages and salaries. The concluding chapters focus on our ideas about the organization of reproduction....I finally return to the perplexing issues of how we, as social scientists, should interpret reproduction as a social and historical force." (EXCERPT)
Egyptian emigrant labor: domestic consequences.
The economic and social consequences for Egypt of its dependence on large-scale labor emigration are assessed. These include the vulnerability of the economy to excessive dependency on remittances as a source of foreign exchange earnings, the scale of which can fluctuate dramatically; the shortage of skilled labor at home; and potential political pressure from migrants. (ANNOTATION)
Patterns of delayed marriage: how special are the Irish?
"This paper deals with delayed marriage and singlehood among the Irish as a focus for the study of the persistence of ethnic characteristics. Patterns of delayed marriage in Ireland in the nineteenth and twentieth centuries are reviewed, and evidence is also presented that Irish persons in other countries (especially in the United States) continue to show significantly higher rates of singlehood and postponed marriage than persons of other nationality groups. Discussion includes how delayed marriage became common in Ireland during the past 150 years and what may be involved in the apparent persistence of this pattern today in Ireland and among the Irish in other countries." (EXCERPT)
Recent trends and future prospects for urban-rural migration in Europe.
Patterns in population movement in Europe are described. "This paper will review the findings of relevant studies...to determine the state of our knowledge regarding the magnitude of, and differences in the urban-rural or metropolitan-non-metropolitan mobility of the population. In doing so, the paper will touch upon the influences of demographic, social, economic and environmental variables." (EXCERPT)
1990 Singapore census.
Selected results from the 1990 census of Singapore are presented and analyzed. Data are included on ethnic groups; the elderly; age dependency ratios; proportion of females in the population, including parity and number of women who are childless; religion; economic characteristics, including employment by ethnic group; and households and housing. Some projections to the year 2050 are provided. (ANNOTATION)
[Explaining migration: theory at the crossroads]
The author presents the case that the study of migration over the past century has become too diverse. He reviews works by writers from the several disciplines covering the topic, then cites the need to develop a consistent classification of the types of migration and their origins using standardized terminology. (SUMMARY IN ENG) (ANNOTATION)
Population decline: is Europe vanishing?
Demographic trends in Europe are reviewed. The future implications of current low levels of fertility are considered, as are prospects for raising them. (ANNOTATION)
1991 population census: preliminary results.
Preliminary results are presented from the 1991 census of South Africa. The data concern population by race and sex for provinces, self-governing territories, development regions, and districts, as well as levels of urbanization. (ANNOTATION)
[Causes of death, 1987. Volume 1. Basic results: statistics on natural increase]
This is the first issue of a revised format for presenting vital statistics for Spain. Data on causes of death will be provided in two volumes. Volume 1, the publication cited here, contains basic data for the country as a whole. Volume 2 will have data for the autonomous communities. The data in Volume 1 concern deaths by cause, age, and sex; provincial data; late fetal deaths; standardized death rates; and potential years of life lost. Appendixes include data on population estimates by age and sex. (ANNOTATION)
[Natural increase of the population of Spain, 1987. Volume 1. Results at the national level and distribution by province and capital]
Vital statistics are presented for Spain for 1987. Volume 1, the publication cited here, provides data for the country as a whole and for provinces and provincial capitals. Volume 2, which will be in 18 separate publications, will cover each autonomous community and Ceuta and Melilla. The present volume has sections on births, late fetal deaths, live births, marriages, and deaths. Appendixes contain population estimates by age and sex and a selection of retrospective data. (ANNOTATION)
[Population census, 1991: preliminary results]
Some preliminary results are presented from the 1991 census of Spain. The data are provided by autonomous community, province, provincial capital, and municipality. (ANNOTATION)
[Migration and the population aging process in Poland]
The impact of internal migration on demographic aging in Poland is analyzed. The authors note that migration accelerates this process in rural areas but acts to slow it down in urban ones. The rural regions of the country most affected are identified. (SUMMARY IN ENG AND RUS) (ANNOTATION)
International labour migration in Nigeria 1976-1986: employment, nationality and ethnicity.
International migration trends associated with the oil boom and bust that occurred in Nigeria between 1976 and 1986 are analyzed. "Large numbers came from Ghana..., [and] Niger, Chad and Togo, whose countries were suffering from a mixture of drought, political instability and stagnant economies. The resultant labour market became segmented according to job skills, nationality and ethnicity...." The decline in the oil industry led to the expulsion of some two million aliens between 1983 and 1986, causing considerable friction between Nigeria and its neighbors. The author concludes that "the rise and fall of migrant labour in Nigeria and the political situation within the country were embedded in the changing regional political economy of West Africa and its linkages to the larger world capitalist economy." (SUMMARY IN GER) (EXCERPT)
Botswana's population trends: past and future.
This essay "described the past, present and future demographic characteristics of Botswana, explained the dynamics of population change and illustrated some of the implications of rapid population growth." Data are from official sources. (EXCERPT)
Census 1981: general report. England and Wales.
"The scope of this report covers the administration, fieldwork, processing and statistical assessment of the 1981 Census of Population in England and Wales." (EXCERPT)
International migration: migrants entering or leaving the United Kingdom and England and Wales, 1990.
"This volume presents statistics on the flows of international migrants to and from the United Kingdom (UK) [and England and Wales] during the last ten years, but concentrates on detailed figures for the calendar year 1990....The primary source of the data tabulated in this volume is the International Passenger Survey...." Data are included by country on population dynamics, estimates of migratory flows from 1980 to 1990, migrants' origin and destination, citizenship, marital status, and occupation. Numbers of persons accepted for British citizenship are also included by previous nationality for the years 1987-1990. (EXCERPT)
1991 census: preliminary report for England and Wales.
Preliminary results are presented for England and Wales from the 1991 U.K. census, as is a commentary which describes some general patterns and salient features. Comparisons are made with estimates based on 1981 census data. Attention is given to the extent of the undercount and reasons for it. The report also includes a description of census methodology and of planned future publications of census results. (ANNOTATION)
Census of population and housing, 1990: Public Law (P.L.) 94-171 data on CD-ROM [MRDF].
These files contain U.S. population and housing data for each state that were submitted to the President and Congress of the United States in fulfillment of Public Law 94-171. The files provide "a race count (five race categories) and a count of all persons of Hispanic origin and persons 18 years old and over of Hispanic origin....The file also includes area characteristics information such as land area, water area, latitude, and longitude....The data files on the CD-ROM are in dBASE III+ format....CD-ROM's are released for groups of States as the files become available....These CD-ROM files are not cumulative. Cost of each CD-ROM is $150." (EXCERPT)
Census of population and housing, 1990: Puerto Rico redistricting data [MRDF].
"The file contains a count of all persons and all housing units in Puerto Rico. It also provides a count of persons under 18 and 18 years old and over. Counts also are supplied for occupied and vacant housing units....The data for Puerto Rico and its subareas are presented in hierarchical sequence down to the block level....In addition to geographic codes, the file includes area characteristics information such as land area, water area, latitude, and longitude....The record size is 516 characters consisting of 300 characters of identification followed by 54 characters of data and 162 characters of filler." The file is available on IBM 3480-compatible tape cartridge or on magnetic tape at 6250 or 1600 bpi, in ASCII or EBCDIC, labeled or unlabeled. The cost of the file is $175. The file is also available on CD-ROM at a cost of $150. (EXCERPT)
Census of population and housing, 1990: Summary Tape File 1 (Virgin Islands of the United States) [MRDF].
"Summary Tape File 1 (STF 1) for the [U.S.] Virgin Islands contains Stateside 100-percent equivalent data. Population items include data on age, sex, race and Hispanic origin, marital status, group quarters, household type, and household relationship....Summary Tape File 1 (Virgin Islands) is released as file 1A and file 1B. The record layout is identical for both files but the geographic coverage differs....STF 1A provides data for the Virgin Islands and its component areas in a hierarchical sequence down to the block group level....STF 1B provides data down to the lowest level of census geography, census blocks....STF 1 data files for the Virgin Islands have a record size of 7,554 characters in one segment. The first 300 characters of the segment contain geographic information." The files are available on IBM 3480-compatible tape cartridge or on 9-track tape reel at 6250 or 1600 bpi, in ASCII or EBCDIC, labeled or unlabeled. The cost for either tape option is $1.25 per megabyte, with a minimum charge of $175 per order. (EXCERPT)
Current Population Survey, March 1988-1991 on CD-ROM [MRDF].
"This file, also known as the Annual Demographic File, provides the usual monthly labor force data, but in addition, provides supplemental data on work experience, income, noncash benefits, and migration. Comprehensive information is given on the employment status, occupation, and industry of persons 15 years old and over....Data on employment and income refer to the preceding year, although demographic data refer to the time of the survey....Characteristics such as age, sex, race, household relationship, and Hispanic origin are shown for each person in the household enumerated." The file structure is hierarchical and the sort sequence is by census state code and metropolitan statistical area codes. File size for 1988 is 295,459 logical records; for 1989, 275,770 logical records; for 1990, 299,576 logical records; and for 1991, 300,012 logical records. Each record contains 656 characters. The cost of the CD-ROM is U.S. $150. (EXCERPT)
[Population of towns in Croatia at the turn of the century (socioeconomic structure and social groups, 1890-1914)]
This is an analysis of the urban population of Croatia at the turn of the century, based on data from official sources in Zagreb and Vienna. It includes information on the demographic and economic characteristics of the population. (ANNOTATION)
Analysis of the income of the elderly in China.
Income levels among the elderly in China are analyzed. The sources of their income are described and the reasons for their generally low level of income are discussed. Ways to resolve the resulting problems are considered, including utilization of the healthy elderly in the labor force. (ANNOTATION)
Are immigrants overrepresented in the Australian social security system?
"This article discusses the statistics commonly used for judging whether immigrants are more or less likely than those born in Australia to receive social security payments...[taking] into account the eligibility conditions applying to different payments, and the effect of differences between the age distributions of different birthplace groups....The article presents estimates of social security receipt in 1989....The statistics discussed here do not prove that immigrants are either overrepresented or underrepresented in the social security system....This article has, however, supported the view that Australians born in Vietnam and in Lebanon do have higher levels of social-security receipt than other immigrant groups....This result implies that after Aborigines, these groups are likely to have the lowest economic status in Australian society." (EXCERPT)
Birth weight and perinatal mortality: the effect of gestational age.
The authors examine the effects of gestational age and other factors on perinatal mortality using data from the Norwegian Medical Birth Registry for 400,000 singleton births that occurred over the period 1967-1984. The results suggest that "gestational age is a powerful predictor of birth weight and perinatal survival. After these effects of gestational age are controlled for, relative birth weight retains a strong association with survival." (EXCERPT)
[European community 1992 and labor force migration]
The projected impact of a more closely unified European Community on international labor force migration is discussed. Consideration is given to the "globalization" of economic processes and to policy implications. (ANNOTATION)
[Effects of asylum seekers on external migration]
Data concerning requests for asylum from migrants to the Netherlands are discussed. The author finds an increase from around 1,000 such requests per year in the early 1980s to over 20,000 for 1990 and 1991. It is also noted that, although women and children have a good chance of being granted asylum, most requests are rejected. The effect of this on the number of illegal aliens in the country is examined. (SUMMARY IN ENG) (ANNOTATION)
Annual report 1988-89.
The Family Planning Association of Hong Kong moved into new headquarters comprising 2250 square meters. It also plans to renovate its old headquarters which it has occupied since 1964. The working report on the Adolescent Sexuality Study of 1986 indicated that the youth of Hong Kong are in need of sex education and contraception. Another study is planned for 1991. The study Knowledge, Attitude and Practice of Family Planning 1987 showed that the ideal family size is 2.1 and that the current contraceptive usage rate is 80.8%. It also showed that 40.2% of women have not heard of the annual check-up service, and that parents do not provide adequate knowledge pertaining to matters of sexuality. Sex education must be strengthened according to 2 other studies besides the one mentioned above. The Family Planning for Vietnamese Project involved a great strain on the clinical resources allocated to the flood of boat people. Other volunteer organizations were needed to make up the difference between what was needed and what was available. Currently an education program for Vietnamese health instructors is underway so that they can teach their own people.
The interface between population and development models, plans and policies.
Scant attention has been given to integrating policy issues in population economics and development economics into more general frameworks. Reviewing the state of the art, this paper examines problems in incorporating population economics variables in development planning. Specifically, conceptual issues in defining population economics variables, modelling relationships between them, and operationalizing frameworks for decision making are explored with hopes of yielding tentative solutions. Several controversial policy issues affecting the development process are also examined in the closing section. 2 of these issues would be the social efficiency of interventions with fertility, and of resource allocations to human development. The effective combination between agriculture and industry in promoting and equitably distributing income growth among earning population groups is a 3rd issue of consideration. Finally, the paper looks at the optimal combination between transfer payments and provisions in kind in guaranteeing minimum consumption needs for poverty groups. Overall, the paper finds significant obstacles to refining the integration of population economics and development policy. Namely, integrating time and place dimensions in classifying people by activity, operationalizing population economics variable models to meet the practical situations of planning and programs, and assessing conflicts and complementarities between alternative policies pose problems. 2 scholarly comments follow the main body of the paper.
[Demography: an irreplaceable and misunderstood discipline]
Population structure and dynamics are defined and discussed and their implications for health care are assessed in this document intended to draw attention to the demographic aspects of health care planning. Population pyramids are a useful device for demonstrating features of the age and sex distribution and for comparing populations or subpopulations. Population pyramids make serious historical occurrences affecting the population immediately obvious. The structure of a population is the results over time of the demographic factors of fertility, mortality, and migration. Countries with a total fertility rate under 2.1 for many years will have below-replacement level fertility. A population's crude death rate is very sensitive to its age structure; age specific mortality rates are more useful for comparisons. Calculations of life expectancy of risk of death should be done separately for the 2 sexes. Until recently, most gains in life expectancy were due to declining infant mortality rates rather than to prolongation of life after age 60. Migration, defined as a permanent change of residence, can be either internal or international. Most migration except in times of political trouble is due to economic factors. Young adults are usually the most likely to migrate. The population structure influences the demographic factors as well as being determined by them. The proportion of young persons is determined by the birth rate, which depends on the proportion of young couples and on their behavior. Mortality decline contributes to an increase in the number of aged persons. In developing countries, the mortality decline caused the "population explosion" by increasing the number who arrived at reproductive age. Migration affects the age structure by increasing or decreasing the number of inhabitants and by affecting reproductive potential. Demographic aging in Europe is due almost exclusively to fertility decline rather than to mortality decline. The population structure influences fertility; a young population has more births, and efforts to limit birth require years to significantly influence fertility. In an aging population, mortality is concentrated among the elderly. And migration is likely to be prevalent in areas with young populations and limited local sources of employment. Economic and social consequences of France's population structure and dynamics include demographic aging which will intensify in coming decades. The marked decline of children under 15 does not compensate for the increase in the elderly in the overall dependency burden. Changes in the family, increased employment of women, and the problem of solitary elderly persons living alone are other challenges. Financing of pensions and providing health care for the elderly will be increasingly acute problems as the population continues to age.
Endocrine factors in common epithelial ovarian cancer.
Ovarian cancer is responsible for 4% of all cancers in females and 6% of all their cancer deaths. Its mortality rate is greater than that of cervical and endometrial cancer together. The concentration of estrogen receptors (ER) rises and progesterone receptors (PR) falls in malignant ovarian tumors. In fact, ER and PR at present in 61% and 49% of malignant ovarian tumors respectively. 36% of these tumors contain both ER and PR. Further 69-90% of such tumors contain androgen receptors (AR). After (anti)hormonal agent therapy fails, physicians use progestins in combination with the synthetic antiestrogen tamoxifen in progressive or recurrent advanced ovarian cancer. The response rate for this treatment of ovarian cancer is only around 15%. Patients with malignant ovarian tumors with PR levels =or+ 50 fmol/mg tend to have a better prognosis than those with PR levels <50 fmol/mg. Neither age, stage of disease, nor tumor histology affect the prognostic value of PR. In vitro studies demonstrate that pure antiandrogens significantly inhibit about 60% of ovarian tumors. Another study also demonstrates that antiandrogen therapy alone may an effective endocrine therapy. As a result, the Gynecologic Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer if conducting a clinical trial on the effect of the antiandrogen flutamide on advanced or recurrent ovarian cancer. Researchers plan to investigate the effect of combining endocrine therapy with current standard chemotherapy. In fact, they intend to learn if combined chemo-endocrine therapy should be used as 1st line treatment for ovarian cancer.
Gonococcal peritonitis after tubal ligation. A case report.
Presented is the first case report of intraperitoneal Neisseria gonorrhoea infection after tubal ligation. The patient, a 34-year-old women who underwent bilateral tubal ligation 10 years prior to presentation, complained of right lower quadrant pain, fever, chills, anorexia, and constipation. Prior to sterilization, she had been treated at least 3 times for pelvic inflammatory disease (PID). Laparotomy revealed 200 mL of free pus in the abdominal cavity, induration of the proximal stump of the right fallopian tube, and a tuboperitoneal fistula. the intraperitoneal culture was positive for N gonorrhoea and pathology demonstrated acute salpingitis. Treatment with ampicillin, gentamicin, and clindamycin eliminated the infection, although uterine and adnexal tenderness persisted at the 6-week follow-up. Falk's postulate that cornual resection prevents reinfection with PID of the upper genital tract apparently cannot be extended to isthmic interruption of the lower and upper tracts. Since this case demonstrates that there can be ascending gonococcal infection in women with prior tubal sterilization, PID should be part of the differential diagnosis of all sterilized women who present with acute pelvic pain.
[Retinoids: drug interactions (editorial)]
There is little available literature on possible drug interactions involving retinoids despite their widespread use. Unlike some other molecules, the retinoids regardless of their generation do not entail a high risk of interference with other medications. A current study found that concomitant administration of etretinate did not significantly modify the timing or value of the peak serum level of 8 methoxy sporalene. Isotretinoin seems to have an inhibiting effect on certain microsomal hepatic and cutaneous oxydases. An isolated observation has been reported of reduced serum concentration of the antiepileptic Carbamazepine in a patient treated with isotretinoin for severe acne. The report, through unconfirmed, should prompt intensified monitoring of patients receiving antiepileptics and retinoids. Among potential pharmacodynamic interactions, studies with the most evident practical importance have assessed possible interference of orally administered retinoids with the efficacy of oral contraceptives (OCs). 1 study of isotretinoin and OCs concluded on the basis of serum levels of progesterone on the 21st or 22nd cycle day that there was no interference. Another study using the same evaluation criteria concluded that there is no interaction between the aromatic retinoids etretinate or acitretin and OCs. The use of low-dose progestins is however not recommended. A recent study on healthy volunteers demonstrated the absence of influence of acitretin on the efficacy of the antivitamin K agent phenprocoumon. The combination of cyclines with isotretinoin can cause intracranial hypertension and is formally contraindicated. Intracranial hypertension has also been reported with aromatic retinoids, which are not recommended. The combination of lithium and retinoids should also be avoided. Because of the additive effect of undesirable side effects, the combination of retinoids and potentially hepatotoxic molecules especially methotrexate and of isotretinoin and potentially photosensitizing molecules should be avoided.
Midwifery: an international career.
a nurse-midwife born and trained Belgium recounts her decision to be a nurse-wife and her experience in the Third World. Her 1st international position was at a obstetric/gynecologic (OB/GYN) ward in a hospital in Mogadishu, Somalia operated by Europeans. The foreigners here were still behaving as colonialists. All OB/GYN clients had undergone circumcision before reaching puberty. These genital mutilations caused them problems, such as infections and multiple episiotomies. Many pregnant women never received prenatal care. She learned prevention would have eased the suffering of many OB/GYN clients. This led her to a maternal-child health care project in Baltimore, Maryland, USA. This experience reinforced what she had learned in Somalia: women were not in charge and were victims of events beyond their control. Indeed this was especially true in Baltimore's slums than in Somalia. Then she earned her masters degree in public health at Johns Hopkins University. She later tool an assignment with a WHO community health development project in Haiti, the poorest country in the western hemisphere. By the end of the 1st year, health personnel had switched focus from curative care to preventive care, such as mass immunization campaigns. Since the early 1970s, Haiti did not train professional midwives. Yet schools for nurse midwives existed in virtually every other country. Under the auspices of WHO, she later went to Algeria to train nurse midwives at the Institute of Public Health. She has worked in a total of 32 countries. Later she worked at family planning clinic in Brooklyn and taught foreign midwives in New York City. Since 1979, she has worked on short term technical assistance projects, especially family planning projects, in developing countries. She pointed out the advantages and disadvantages of short term consultancies.
[Iron nutrition in breastfed Mapuche infants (2nd phase)]
To assess iron nutrition in rural Mapuche children of southern Chile, 140 healthy infants 8-15 months of age of both sexes were studied for blood hemoglobin, serum iron, total iron binding capacity, and serum ferritin. 90 infants evaluated in an earlier phase of the study published in 1987 were exclusively breast fed. 50 infants totally weaned by 4 months who served as a control group were studied later. Introduction of supplemental foods began at 5-6 months in both groups and was of similar composition, mainly cereals and flours. The 90 exclusively breast fed infants were selected from 3 rural clinics in the province of Cautin, region of La Araucania. The 50 control infants were studied in 8 rural health posts. Both groups belonged to extremely impoverished families. Average values of the breast fed infants were normal except for serum ferritin, which was below normal. Statistically significant differences were found in the group fed cow's milk in the levels of hemoglobin, total iron binding capacity, serum iron, transferrin saturation, and serum transferrin. 70% of the breast fed infants had concentrations of hemoglobin of over 12 g/dl, while 75% of those fed cow's milk had levels below 12 g/dl. Iron deficiency anemia was observed in 4.5% of breast fed infants but in 38.8% of those fed cow's milk. Erythropoiesis deficient in iron was observed in 5% of breast fed children and in 815% of those fed cow's milk. Iron deposits were depleted in a similar proportion in both groups, 76.4 and 81% respectively. Human milk protects Mapuche children from iron deficiency anemia during the entire 1st year of life, a longer period than in non-Mapuche children in Chile. The reasons for the difference are not well understood. The explanation may lie in different hemoglobin levels ethnic groups or in the later introduction of solid foods, which may avoid contact with elements that inhibit iron absorption from mother's milk before 6 months. A 3rd phase of the study is planned to analyze the possible role of iron cooking utensils.
Women's health: potential for better coordination of services.
This study sought to determine the proportion of women attending a genitourinary medicine clinic (GUMC) who are in need of contraception and the proportion of women attending family planning clinics (FPC) who may require screening or treatment for sexually transmitted diseases (STDs). This cross-sectional survey conducted in an inner London health district focused on a large FPC (17,600 attendances by women/year) and a large GUMC (20,000 attendances by women/year). All clients investigated attended the 2 clinics in consecutive weeks (356 GUMC and 335 FPC). In addition, a nonrandom cluster of other women attending the same clinics later in the year were interviewed in depth (21 GUMC and 20 FPC). Of the women at the GUMC, 10.4% (95% CI 7.2-13.6) were at risk of unwanted pregnancy and were not using contraception. Women under age 20 and those not registered with a general practitioner (GP) were more likely to be in this group. A further 13.8% may have been using contraception unreliably since they had not obtained it from a GP or from the FPC. Of women at the FPC, 1.8% (95% CI 0.3-3.2) complained of symptoms of genitourinary infection. In-depth interviews showed that some women assumed the staff at both clinics would counsel them in all aspects of sexual health. The opportunities presented at GUMCs to reduce the incidence of unwanted pregnancy and the opportunities presented at FPCs to reduce the incidence and prevalence of STDs should not be missed. (author's modified)
Patterns of research: oral contraceptives and cervical cancer.
Original paper on the oral contraceptive (OC) use-cervical cancer relationship are analyzed. The purpose of this study was to ascertain the biases of the original articles collected in relation to various characteristics of any investigation. Papers were located by using MEDLINE, by reviewing the references of each article identified by MEDLINE, and then by reviewing the contents of those journals in which an original article could be published. 55 publications (from 49 original studies) were graded for quality and classified as biased or unbiased. 10 studies were considered unbiased. The most common biases identified were confounding, detection bias, and misclassification bias. The pattern of research/publication has changed since the association was first analyzed: articles shift from gynecological to cancer and epidemiological journals and the number of studies performed by gynecologists alone and pathologists alone decreases, while studies performed by epidemiologists alone or in collaboration with gynecologists increase. This collaboration produced studies with fewer biases. it is thus suggested that the above mentioned collaboration should be increased to improve access to and application of the results obtained in the original studies on OCs and cervical cancer. (author's)
The "anatomy" of Thailand's successful family planning program.
Begun in the early 1970s, Thailand's Population Program has been and unqualified success. The program has been able to reduce population growth from 3.2% in 1970s to 1.2% as of 1989. From the early 1970s to 1987, contraceptive prevalence increased from 14.8 to 70.6%. Several factors account for the success. In contrast to the Philippines, whose population program has not been as successful, Thailand has not experienced religious opposition to family planning, since BUddhists favor limiting children. The Thai program has also stated a clear delineation of roles for nongovernment organizations. In order to avoid duplication of programs and competition among field workers, the Ministry of Health coordinates all programs. Success is also due to the program's demographic-economic approach, which stresses the economic implications of population growth. Finally, the availability and accessibility of to family planning services has greatly contributed to the success of the program. All government hospitals have a family planning clinic, and midwives, nurses, and doctors all receive family planning training. Unless clients can demonstrate that they are unable to pay, all family planning services carry a standard fee. The Thai Population Program has evolved from a purely family planning contraceptive service to a community development program designed to improve the productivity of individuals. The government has implemented the Thailand Business Initiative in Rural Development, which involves the participation of civic-minded business groups in assisting community development.
Cameroon Child Spacing Project. Report of the pretesting of materials and baseline studies.
A research/evaluation officer from Johns Hopkins University's Population Communication Services was in Cameroon from January 1-June 6, 1991 to help staff of the Cameroon Child Spacing Project conduct 4 baseline studies in 5 provinces. Moreover, the officer assisted with the pretesting of booklets, posters, a flip chart, and a family planning (FP) television (TV) drama. A researcher interviewed 432 participants to determine the acceptability of FP printed materials. Most of the 48 respondents of the pretest of the flip chart felt it influenced them to space births and to avoid poverty and poor health. Further, most of the 384 participants of the pretest of the booklets (88.54%) and posters (70.83%) believed these printed materials encouraged contraceptive use, child spacing, limiting family size, and avoiding sexually transmitted diseases. Most respondents found the Happy Family (97.92%) and youth (91.67%) posters acceptable, but not the On My Farm (64.5%) and Method for You (37.5%) posters. 34 participants viewed the TV drama and, after the viewing, completed a questionnaire. Most considered the TV drama successful, very interesting, entertaining, and educational. Indeed 100% believed that it encouraged them to use FP or child spacing methods to benefit both mother and child. All knew where they could get FP information and services. Even though most everyone felt the drama imparted correct information, they did make some suggestions to improve it.
Public awareness of AIDS in Singapore.
With only 52 cases of human immunodeficiency virus (HIV) diagnosed as of June 1990, Singapore falls into the low infection load group of countries. A national acquired immunodeficiency syndrome (AIDS) prevention campaign was launched in Singapore in 1985, the year the first case of HIV infection was reported. Components of this campaign have included the distribution of 2 million copies of printed material and mass media campaigns conducted in 4 languages. To evaluate the impact of this health education effort, the Ministry of Health's Research and Evaluation Department conducted a survey in 1987 of a representative sample of 3301 Singaporeans. Although 98% of respondents were aware of AIDS, 52% indicated that their knowledge of the disease was minimal. Over 90% were aware of the major risk factors for HIV infection (i.e., sexual relations with an infected partner, sharing unsterilized needles, and maternal-fetal transmission), yet 50% incorrectly believed that the virus could be spread by eating food prepared by HIV-positive individuals or sharing dishes. 19% believed that an AIDS vaccine is available. The most common sources of information about AIDS were newspapers (93%), television (83%), other individuals (51%), magazines (50%), Ministry of Health brochures (38%), and radio (36%). Of concern was the finding that only 27% of parents had discussed AIDS with teenaged children. While only 55% of respondents believed AIDS poses a serious health threat in Singapore at present, 72% believe the problem will become urgent within another 5 years. There was almost 100% support for continued health education in this area. Responses about contact with AIDS patients--59% would refuse to work with an AIDS patient, 55% believed the identifies of HIV-positive persons should be publicized, and 56% blame AIDS patients for their disease--indicate a need for education on the human rights of infected individuals.
The Czechoslovak legal regulation of family relations affected by development in medicine.
In Czechoslovakia, as in other countries, modern medical treatments have created unprecedented legal dilemmas. When Act 20 of 1966-the codification of basic rules governing Czechoslovakia's health service--was adopted, artificial insemination, prenatal genetic diagnosis, and neonatal intensive care were not available or regarded as essential subjects for regulation. The 1968 consolidation of Czechoslovakia as a federal state comprised of the Czech Socialist Republic and the Slovak Socialist Republic created additional dilemmas in terms of legal tensions between medicine and the family. The new regime has been forced to find a balance between the breach of traditional pronatalist values and the consequences of keeping traditional practices (e.g., restrictive abortion rights) unchanged. At present, Czech legislation in the field of public health prioritizes the interests of the community as a whole and sets forth statutory conditions under which the state and society agree on specific medical activities. Legislation regarding abortion, sterilization, and contraception has been significantly liberalized, however, an attempt is made to consider the impact of such activities on the spouse and other affected relatives. If agreement cannot be reached, the legally binding decision rests with the individual whose body is involved and the opposing partner can seek to terminate the marriage. Of concern is the lack of regulation of various family relations created by medical progress. For example, Czech law now permits abortion up to 12 weeks' gestation, but no uniform regulations have been developed to cover special situations such as a genetic indication for abortion that is not diagnosed until later or abortions involving mentally disabled women.
[Some determinants of infant mortality in Spain]
Rates of infant mortality were calculated for the 50 provinces of Spain and for the nation as a whole for 1975-79. 11 social, economic, and health indicators were also prepared for each province in an effort to determine which factors had exercised the greatest influence on infant mortality in the 5 years. The coefficient of interprovincial variation was used as a measure of relative inequality in the geographic distribution of infant mortality. Then 4 function were defined for a multiple regression analysis. The hypothesis behind the 1st 2 functions was that infant mortality is a function of socioeconomic variables and health resources, while the 3rd and especially the 4th added variables of utilization of health resources as predictors. The analysis was done for each function for each of the 5 years of the study period. The total infant mortality rate declined progressively over the 5 years from 18.88 in 1975 to 14.27 in 1979. The coefficient of interprovincial variation demonstrated that geographic differences also declined. Socioeconomic factors such as family income and per capita income had greater explanatory power than did health factors. Variables measuring utilization of health resources such as outpatient medical consultations per inhabitant and surgical interventions per 1000 inhabitants had the most weight among the health factors. It was concluded that infant mortality differentials in Spain in 1975-79 reflected the situation of a society still in transition. Socioeconomic factors still played an important role, as in developing countries. Health resources also played an important though at times contradictory role, as in industrialized countries. It appears that utilization rather than distribution of health resources was more important in explaining infant mortality in Spain in these years.
Meeting the future. Where will the resources for the USSR's family planning programs come from?
Providing resources for family planning programs in the USSR, where an extremely high rate of abortions threatens the lives of women, will require a multi-sectoral approach involving the government, international agencies, and the private sector. Every year, some 10-13 million of the USSR's 70 million women of fertile age undergo an abortion (only 7 million of the abortions every year are considered legal). A recent report indicates that only 15-18% of Soviet women have not had at least one abortion in their lifetimes. A result of the high rate of illegal abortions, morbidity and mortality affects many Soviet mothers. Additionally, infant mortality rates is as high as 58.5% in some areas of the USSR, a figure similar to that found in developing countries. Knowledge of modern contraception is high, but use remains low. This is due primarily to the lack of contraceptive availability. IUD's injectables, implants, and oral contraceptives are scarce. And even when oral contraceptives are available, few women opt for this method, due to the rampant misinformation and exaggeration concerning its side-effects. While the USSR does produce condoms, their quality is poor. Part of the solution to the lack of available contraception rests in the transition to a market economy. As the demand for these services increases, the market will begin meeting this demand. The government also has a important role to play, which includes the provision of information, medical and paramedical education, sex education, and service delivery. And international agencies will need to provide the necessary technical assistance.
Wholesome parenthood.
A study of 400 newly married Russian couples conducted in 1986 by the Soviet Family Health Association and the Iwanovo Institute for Maternal and Child Health revealed an early onset of sexual activity, little information about contraception, low contraceptive use rates, and unhealthy life-styles. The 400 couples, all from the town of Iwanovo, were under 25 years of age and in their first marriage. The average age at marriage in this group was 22.1 years for men and 21.6 years for women. 77% of males and 65% of females had been sexually active before marriage; 41% of the men and 33% of the women had experienced coitus before their 18th birthday. However, only 13% of respondents could be considered minimally knowledgeable about contraception, and contraceptive use in the respondents who were sexually active before marriage was 20%. 10% of sexually active female respondents were pregnant at the time of marriage. Characteristics of the life-styles of these respondents were poor nutrition habits, avoidance of exercise and sports, smoking, alcohol consumption, and failure to consult a physician in the case of an acute illness. 1/3 of the men and 1/5 of the men surveyed were suffering from a chronic disease. Moreover, 21% of males and 23% of females had medical and social risk factor scores that could jeopardize the health of potential offspring. Recommendations to improve the likelihood of healthy marriage and parenthood in the USSR include the teaching of healthy habits to schoolchildren, mass medical screenings for the early detection of disease, the provision of printed materials about contraception to engaged couples, counseling of couples on ways to increase the odds of having a healthy infant, and the opening of special reception centers for young people where they can obtain guidance on these issues.
[Cost-benefit model of the Rwanda family planning program]
Significant conclusions are presented of the application of a cost-benefit model of family planning in Rwanda. The model and computer programs used were developed by the Research Triangle Institute and financed by the US Agency for International Development. The UN Population Fund participated in the project, which represented the 1st application of the model in Africa. Rwanda's population growth is among the most rapid in the world. The population has increased from about 2 million in 1950 to over 7 million in 1989. The model is composed of 2 parts, the 1st of which discloses the scope of the family planning program and its impact on population growth. The resulting projections are the basis for the 2nd module, the actual cost-benefit analysis which measures the impact of family planning on sectorial expenditures and analyzes the costs and benefits of the program in different sectors. The sectors of health, education, and agriculture are included in this presentation. 2 hypotheses about population growth are included; the 1st assumes the current family planning program and the 2nd assumes no family planning program. The model commences with population and family planning data for 1981. Data through 1989 represent observed rates and those for 1990-2011 are target rates. Only modern family planning methods are included in the model. The prevalence rate for modern methods increased from nearly null in 1981 to 5.3% in 1989 and following current trends is projected at 34.8% in 2000 and 46.8% in 2011. The total fertility rate was 8.6 in 1981 and is projected at 5.5 in 2000 and 4.7 in 2011. The total population is projected at 13.2 million in 2011 with a family planning program or 17.7 million without one. Health expenditures in the final year of the projection would be 41% greater without a family planning program. The family planning program would permit a reduction in the number of children to be educated of over 1 million students, a 54% decrease, assuming that the rate of attendance would be the same with or without a family planning program. The amount of money saved in 2010 with a family planning program would exceed the entire 1988 government budget for education. Although the total food supply would be greater without family planning because of the larger number of workers, per capita food consumption would be less because of the much greater number of consumers. Per capita food consumption in the final year of the projection would be 23% greater with a family planning program than without it. Considering the costs and expenses in the 3 sectors, the country would realize a net savings of 221.8 billion Rwandan francs over a period of 30 years. The ratio of benefits and costs in 2010 in the 3 sectors was estimated at 15.8. For each Rwandan franc invested in the family planning program, Rwanda will save 15.8 francs in the time period considered.
Trip report: Kenya CBD training manual design and project monitoring.
In August 1991, a program officer from Johns Hopkins University's Population Communication Services was in Kenya to help the Family Planning Association of Kenya with activities related to the provider and client information, education, and communication (IEC) project. Specifically, she assisted FPAK and the IEC working group with the Community Based Distribution (CBD) Training Manual Design Workshop in Nakuru from August 26-30. Participants designed a 2 week training manual for CBD trainers based on the national CBD curriculum. Participants contributed to CBD agent training within their own organizations. FPAK also subcontracted formative research studies, e.g., situation analysis and indepth interviews. She also met with representatives of the Centre of African Family Studies to discuss planning communication courses. The program officer reviewed activities of the Union of Radio and Television Organizations of the Nations of Africa: the broadcasters' guidelines for the video It's Not Easy, articles for the next issue of the Family Health Broadcast Bulletin, and a video about AIDS in Kenya. She also discussed the possibility of assisting 2 nongovernmental organizations on the IEC component of a vasectomy promotion project.
Seasonal effects on the reported incidence of acute diarrhoeal disease in northeast Thailand.
Researchers compared data on acute diarrhea incidence with data on rainfall and temperature of 10 provinces and 15 districts of Khon Kaen province in northeast Thailand to determine the link between seasonal weather patterns and reported incidence of acute diarrhea. The relative incidence of diarrhea decreased with age in the winter while it increased with age in the hot season and early in the rainy season. Indeed reported incidence of diarrhea peaked in January for children <2 years old. The researchers suggested that rotavirus was the leading causative agent in this age group since it is common in cooler months and in children <2 years old. Another peak occurred in April-June when temperatures are high and early in the rainy season. This peak involved mainly adults. The researchers believed enterotoxigenic Escherichia coli, Campylobacter jejuni, and Shigella were the leading causative agents. The researchers posed a possible explanation for this April-June peak. In the beginning of the wet season, households changed their water source from groundwater to rainwater and began to use it differently. Further, they often stored water separately from rainjars. It was more likely that this water was more contaminated than stored rainwater or groundwater. In addition, fecal bacteria transmitted by food preparation and utensil handling and the rising humidity fostered its growth. These events may have accounted for the increased incidence of diarrhea in the early rainy season. A steep reduction in diarrhea incidence occurred around the middle of the wet season (July and August). Research has shown that increased water quantity may be better in reducing diarrhea incidence than only improving water quality. Furthermore, it also demonstrated that bacteriological quality of water stored in rainjars was better than water from shallow wells.
Response to hepatitis B vaccine in relation to the hepatitis B status of family members.
As part of The Gambia Hepatitis Intervention Study (designed to protect children from hepatitis and therefore liver cancer when adults), researchers took blood samples from at least 291 families of 293 index children from Brikama in the western region and 2 neighboring health centers in the Upper River Division (URD) in the eastern area of The Gambia who had received the hepatitis B virus (HBV) vaccine to examine vaccine response in infants in relation to the pattern of HBV infection in their families. 1 family member tested positive for hepatitis B surface antigen (HBsAg) in at least 30% of the children. The researchers did not find a correlation between the level of antibody in the index children and the HBsAg status of the family. 23% of families in Brikama had at least 1 HBsAg positive member compared to 37% in URD (p=.01). Even though no association existed between child's response to the vaccine and type of dwelling, an association did exist between HBsAg positive family members and type of dwelling. 35% of families who lived in a house constructed of mud or grass had at least 1 HbsAG positive family member whereas only 19.7% who lived in a concrete house had at least 1 HBsAg positive family member (p<.02). Further, 40.8% of families who lived under a thatched roof had at least 1 HbsAg positive family member compared to 24.8% who had a corrugated roof (p<.02). The researchers suggested that houses constructed of mud or grass or with a thatched roof may harbor more insects which transmit HBV. The socioeconomic factors of sanitation and water supply did not contribute to HBV infection. They concluded that the HBV status of a child's family did not affect his/her response to the vaccine. Therefore the vaccine protects children at high risk of becoming HBV carriers.
Ruptured uterus.
Uterine rupture, an important cause of maternal and fetal mortality, is still occasionally seen in the region. In this study, the authors reviewed 41 cases of uterine rupture encountered between 1983-88, in a total of 3962 hospital deliveries with a frequency of 1 in 96.6 deliveries. 16 cases (39.0%) were older than 35. 25 patients (60.9%) were grand multiparas (more than 5 pregnancies). There was no uterine ruptures in primigravid women. Ruptures were due mostly (75.6%) to cephalopelvic disproportion. Subtotal hysterectomy was the 1st choice in managing 35 of the cases; maternal mortality was 7.3% while fetal mortality was 82.9%. Midwife education, regular antenatal care, and hospital deliveries are important factors in preventing this obstetric hazard. (author's modified)
Contraception and sexuality in an area-specific group of Swedish women 15-34 years of age.
In a community-based study in a Swedish suburban/rural area, all women ages 15-34 (n=671) were invited to the local health center to be examined for chlamydia infection and to participate in an interview. The attenders were questioned about contraceptive history, age at 1st intercourse, number of lifetime sexual partners, and socioeconomic background. The net attendance was 69% and contraceptive information on an additional 20% could be gathered through medical records. The average age at 1st intercourse was about 16 years, and the average number of sexual partners in the groups 20-24, 3=25-30, and 31-34 years was 4.0, 5.6, and 6.1, respectively. Of all women, around 75% had used contraception at 1st intercourse, and there was no tendency to a changing pattern over the 20 years studied through the interviews. Combined estrogen-progestogen pills were by far the most used contraceptive method, presently being used by 42% of the women who were contracepting. This was followed by the condom (23%), the IUD (19%), and other hormonal methods (10%). It is concluded that sexual life in Sweden begins earlier than it did 30 years, that the number of sexual partners is higher, that most women in the studied group were efficient users of contraception, and that hormonal contraception was by far the most common method. (author's modified)
Use of hCG stimulation test in women immunized with Beta-hCG vaccine.
11 normally menstruating women who had earlier been immunized with NII beta-hCG vaccine but had no detectable anti-hCG antibody titers were selected as controls for the hCG challenge test using 1000/2000 I.U. The test was repeated in 5 of them after a booster immunization, which raised antibody titers to 18-450 ng/ml. Stimulation of serum progesterone secretion was used as an index of corpus luteum response to the intravenous hCG. In the control group, the progesterone secretory response following hCG stimulus showed peak levels which were significantly higher than basal levels in all but 2 subjects. The nonresponsiveness in 2 subjects cannot be easily explained but may be dose-related. No significant difference was noted between the 2 dose levels. Length of luteal phase was increased by 4-5 days in 6 of 20 cycles studied. The results of this study in 5 women before and after the vaccine boosters were encouraging as peak progesterone levels appeared higher than basal levels in controls, but not so in the immunized group. However, these results could not be confirmed statistically. Nonetheless, this study is suggestive that the antibodies which were generated by this vaccine were capable of intercepting the effect of exogenous hCG in the human female. Further studies with more subjects and higher dosages of hCG are necessary. (author's)
Child mortality after high-titre measles vaccines: prospective study in Senegal.
The use of Edmonston-Zagreb high titer (EZ-HT) vaccine at age 6 months has been recommended for countries in which measles before the age of 9 months is a substantial cause of death, but little is known about the longterm effects of high titer live measles vaccines given early in life. In a randomized vaccine trial in a rural area of Senegal, children were randomly assigned at birth to 3 vaccine groups--EZ-HT at 5 months (n=336); Schwarz high titer (SW-HT) at 5 months (n=321); and placebo at 5 months followed by standard low tier Schwarz vaccine at 10 months (standardw; n=358). All children were followed prospectively for 24-39 months in a well-established demographic surveillance system. Child mortality after immunization was significantly higher in the 2 groups which received high titer vaccines than in the group given the standard vaccine. The relative risk of death was 1.80 (95% confidence interval [CI] 1.18-2.74; p=0.007) in the EX-HT group in 1.51 (0.97-2.34; p=0.07) in the Sw-HT group compared with the standard group. The 3 vaccine groups were comparable with regard to various social, family, and health characteristics, and there was no difference in mortality between children who received the standard vaccine and those who were eligible for the trial but did not take part for various reasons. The higher risk of death in the 2 high titer vaccine groups remained significant in multivariate analyses. These findings suggest there is a need to reconsider the use of high titer measles vaccines early in life in less developed countries. (author's)
Intestinal permeability, mucosal injury, and growth faltering in Gambian infants.
There is controversy over whether children in developing countries can catch up on their growth rates after bouts of diarrhea. A factor which influences catchup growth is the extent and duration of mucosal injury. To explore the relationship between intestinal disease and growth performance, a noninvasive test of intestinal integrity, the lactulose-mannitol permeability test, was done regularly on children ages 2-15 months, whose growth was monitored over a mean of 7.5 months. The study revealed persistent abnormalities in the small bowel mucosa of 2-15 month old Gambian infants and a negative correlation between those abnormalities and growth. Up to 45% of observed growth faltering can be explained on the basis of these longterm intestinal lesions. (author's)
Observation of the activity of Factor VIII in the endometrium of women pre- and post-insertion of three types of IUDS.
Endometrial Factor VIII activity was measured at different phases of the menstrual cycle in 90 women who were randomly assigned to 1 of 3 IUD types: Stainless Steel ring, Copper T 220, and a levonorgestrel-releasing device. Since Factor VIII is hypothesized to be one of the variables responsible for the irregular bleeding in IUD users, research in this area has the potential to increase IUD acceptability. An endometrial biopsy was taken from study subjects before IUD insertion and after 24 months of use (3-10 months in users of the levonorgestrel-releasing device), and immunoperoxidase was performed to demonstrate the presence of Factor VIII. After IUD use, subjects were further categorized into bleeders (women experiencing over 8 days of bleeding/spotting per month) and nonbleeders (women having less than this amount of bleeding). There was no significant differences between study subjects in Factor VIII activity before IUD insertion. Factor VIII activity was found to decrease significantly over time in acceptors of the Stainless Steel IUD (from 2-17 + or - 0.54 at baseline to 0.98 + or - 0.80) and the Copper T 220 (from 2.16 + or - 0.46 to 0.37 + or - 0.43), but there was no significant change after 3-10 months of use of the levonorgestrel-releasing IUD (from 2.17 + or - 0.62 to 2.15 + or - 0.57). The Factor VIII activity of bleeders was significantly different (lower) than that of bleeders only in the case of the Stainless Steel IUD. The decrease of Factor VIII activity was most pronounced in the late proliferative phase of the menstrual cycle and there was a decline in the secretory phase. a new type of IUD containing agents that increase Factor VIII and inhibit fibrinolysin should be investigated in order to reduce IUD-induced endometrial bleeding.
[Policy implications of the DHS findings for Peru]
Data from the 1986 Demographic and Health Survey (DHS) were used to update population projections and apply a model of family planning use to aid in implementation of Peru's family planning program through the year 2000. Peru's population has increased from 6.2 million in 1940 to 21.6 million in 1990. 1 of the most salient factors in Peru's current demographic situation is the tremendous diversity in fertility and mortality rates in different departments and provinces. At the national level the total fertility rate has declined from about 6 in the early 1970s to around 4.3 in 1986. The Andean departments of Huancavelica and Apurimac have total fertility rates of nearly 6 while that of Lima was 2.5 in 1990. The tendency of some departments to expel population and others to attract migrants contributes greatly to Peru's demographic diversity. Data from the DHS and 2 other national level demographic surveys were used to revise population projections. The new projections, which were adopted officially in late 1990, indicate a growth rate of 2.1% from 1990-95 and 2.0% from 1995-2000. The total fertility rates for 1990-95 and 1995-2000 were projected at 3.6 and 3.2. Although Peru's family planning program has a short history, the proportion of women of reproductive age using contraception has increased from 12% and 1970 to 28% in 1986. 23% of women currently in union used a modern method and 23% used traditional methods, especially rhythm. Goals of the family planning program are to achieve a prevalence of safe and effective methods amounting to 36% of fertile aged women in 1991, 42% in 1995, and 45% in 2000. Other goals are to increase the proportion of contraceptive users who select the most effective methods, increase coverage of reproductive health services at the national level, and achieve total fertility rates of 3.35 for 1995 and 3.00 for 2000. The family planning model designed by the Andean Institute for Studies in Population and Development in collaboration with the research Triangle Institute is based on results of population projections and was intended to indicate the level of contraceptive prevalence needed to meet the family planning goals and objectives through the year 2000. Objectives of the model are to estimate the number of new and continuing users by method type and source of supply, calculate the volume of contraceptive inputs necessary, calculate the direct and indirect costs associated with the required supplies by method type and source of supply, and disaggregate the estimates at the departmental level and for calendar years. An important aspect of the model is its taking into account the heterogeneous family planning and fertility behavior of the different departments and regions. The disaggregation at the level of sources of supply is also important because the national family planning program includes distinct public and private sector institutions.
[Fertility changes in Bolivia]
Regional fertility differentials in Bolivia are analyzed using data from the 1989 Demographic and Health Survey (DHS). Bolivia is divided geographically into 3 zones of unequal size and population and with distinct social and ethnic characteristics. The DHS demonstrated that overall fertility differentials were minimal between the 3 regions, but that in terms of the proximate fertility differentials of nuptiality, contraceptive usage, and lactation, the 3 regions were very distinct. Better understanding of the different fertility behaviors of the 3 regions should contribute to adapting national population policies to the specific needs of each region. The highlands contain 50% of Bolivia's population and 48% of its urban population. The valleys, at altitudes of 1800-2500 meters above sea level, contain 28% of the national population, 44% of which is urban. The population of the highlands and valleys contains a strong indigenous component predominantly of Aymara and Quechua origin. The tropical lowlands cover 68% of the national territory and contain 22% of the population, 63% of which is urban. The lowlands have a much more hispanicized population than the other 2 regions. Estimated regional total fertility rates for 1965-90 derived from the 1976 census, the 1988 National Survey of Population and Housing, and the 1989 DHS show that overall total fertility rate remained at around 6.5 until 1975, when it began its decline to about 5 in 1985-90. Between 1965-90, the total fertility rate fell from 5.50 to 3.80 in urban areas, from 7.00 to 6.10 in rural areas, from 6.00 to 4.70 in the highlands, from 6.60 to 5.10 in the valleys, and from 7.00 to 4.90 in the lowlands. Fertility thus remains high in rural areas and the rural-urban differential is much more significant than the regional differentials. Estimated 1985 total fertility rates were 3.8 for the urban highland and valleys, 4.4 for the urban lowlands, 6.2 for the rural highlands and valleys, and 6.9 for the rural lowlands. Data from the 1988 regions. According to the DHS, the median age at 1st union is 18.8 years in the lowlands, 21 in the valleys, and 20.5 in the highlands. The data imply nuptiality patterns that maximize reproductive potential in the lowlands. Although breastfeeding remains a strong cultural trait, there are regional differentials. The period of postpartum nonsusceptibility to pregnancy is estimated at 14 to 15 months in the highlands and valleys but only 10 months in the lowlands. Among women in union, 43% in the lowlands, 31% in the valleys, and 25% in the highlands used a contraceptive method. 50-60% in the highlands and valleys used periodic abstinence, while female sterilization was most used in the lowlands. Application of a Bongaarts model confirmed the unequal weight of the proximate fertility differentials studied in the relatively similar fertility levels of the 3 regions.
[Study on the use of educational material by health care personnel in Mauritania]
A survey was conducted among 43 health agents at all levels and 7 mothers of small children in Trarza and Nouakchott, Mauritania, to assess why health education materials are not more widely utilized. The health workers interviewed included 4 physicians, 6 senior health technicians, 4 graduate nurses, 9 midwives, 9 nongraduate nurses, 4 promoters, 2 nutrition aides, 1 nurses' aid, 1 health communication agent, and 3 religious working in the centers visited. The 7 mothers were selected at random from the waiting rooms of the health facilities visited. 9 health facilities were visited in Nouakchott in June 1990 and 10 were visited in the Trarza in July 1990. Only 4 of the 19 health facilities displayed health education materials in prominent places. Health education materials were never observed in use in the course of consultations during the study. On the other hand drug advertisements were prominently displayed. Both health personnel and patients accorded higher priority to curative services than to health education and other preventive activities. Organized health education activities were most often presented by auxiliaries and lower level personnel. 32% of the health workers reported having received some training in health education. 2 facilities containing workers trained in health education techniques were the only ones that had made an effort to adapt their health education programs and techniques to local realities. Most of the personnel who received training in health education were middle level, but no effort was made to share the results of training with personnel further up or down the hierarchy. The use of educational materials was somewhat better in facilities directed by private organizations rather than by persons paid by the government. Only 2 of the 7 mothers interviewed were able to interpret correctly a large poster on oral rehydration therapy. It is recommended that supervision be intensified in order to increase awareness of the importance and techniques of health education and that continuing education be organized in communication and in use of educational materials. Personnel at each level should be reminded of their role in health education, and techniques of health education should be included in the curriculum of individuals training to be health workers.
[The political and demographic intersection in central and eastern Europe]
Political changes in Eastern Europe and the Soviet Union have revised the postwar division of the area into the 3 great geopolitical units of the Soviet Union, Eastern Europe, and Western Europe. The division of Europe into East and West became modified in late 1989. Nationalist conflicts and the disintegration of states along the old borders of the Austro-Hungarian and Ottoman empires are drastically altering the map. The division of Europe reflected more the military position of the victorious powers in 1945 than any geographic, cultural, or historical reality. Fertility was higher in most of the Eastern European countries prior to World War II than in France, the United Kingdom, Scandinavia, or Switzerland, but it was lower in what became East Germany and in the Czechoslovakian countries than it was in the remaining area. All the countries were engaged in the demographic transition, but from variable dates ranging from 1870 in the Czechoslovakian countries and East Germany to 1920 in Bulgaria and Rumania. These different dates explained fertility differentials in the 1930s in Eastern Europe. There were also large mortality differentials. Life expectancy was 53.5 years in Czechoslovakia but only 42 in Rumania. Fertility and mortality differentials were reduced in the 20 years after World War II in both Eastern and Western Europe. After 1965, however, fertility and mortality followed different courses in Eastern and Western Europe. Chaotic fertility variations caused by government intervention in abortion in Eastern Europe occurred while in Western Europe fertility rates declined profoundly before stabilizing at a low level. By the late 1980s, fertility and mortality were both significantly higher in the East. Life expectancy is less than 70 in only 1 Western European country, Portugal, but is under 70 in all Eastern European countries. Significant progress occurred after 1970 in control of degenerative diseases in western Europe but not in the East. Changes in nuptiality and family formation have been less significant in Eastern Europe, where extramarital cohabitation and childbearing remain marginal except in East Germany. Eastern Europe is different from Western Europe, but very diverse. Muslims in the Balkan countries have higher levels of fertility than non-Muslims. Demographic differentials within Eastern Europe are largely to be explained by contrasts in general development policies: implementation of pronatalist policies, deficiencies in the health care system, or extensive industrialization. Structural and political changes that may create new conditions and influence future demographic behavior in Eastern Europe include migration, especially if some new destination willing to absorb large amounts of labor can be found; institutional changes affecting family policy, abortion legislation, or contraceptive availability; changes in family structure; and mortality decline to the levels of the rest of Europe.
[Policy implications of the National Demographic and Health Survey of Bolivia, 1989]
The implications of data from the 1989 National Demographic and Health Survey (DHS) for implementation of Bolivia's National Plan for Infant Survival and Development and Maternal Health (PNSDISM) are assessed. The PNSDISM was prepared in 1989 as the basis for the Bolivian government's maternal-child health policy, but implementation has been slow, partly because of a lack of understanding of the use of data in developing policies and administering programs. Definition or redefinition of the M-CH policy requires data on maternal and early childhood mortality so that plan objectives can be specified and the magnitude of problems assessed. Most of the data required for the PNSDISM plan as well as data on biological, socioeconomic, geographic, cultural, and environmental factors related to maternal and infant mortality are needed for the design of strategies to combat mortality that are available from the DHS. DHS data indicate that just 4 causes accounted for 77% of deaths in children under 5: diarrhea (36%), acute respiratory infections (21%), problems related to labor and delivery (13%), and accidents (7%). The highest mortality indices are found in multiple births, in children born less than 2 years after an older sibling, in children of mothers with 5 or more children, and in children of mothers over 35. Mortality and morbidity levels are higher in children of mothers who are illiterate, non-Spanish speaking, with no daily access to radio or television, and married to agricultural workers or rural. The components and stages of development of programs are the same as those for development of policy. Some of the same data are needed to define objectives, strategies, implementation plans, and target populations. The DHS gathered specific data for each area of the PNSDISM that would allow definition of target populations and their needs, where they are located, the obstacles involved, and the resources needed and available to meet their needs. Data on diarrhea, reproductive health including prenatal care and family planning, acute respiratory infections, nutrition, and immunization are all available in the DHS. DHS data demonstrate the need for a policy to reduce maternal and infant mortality rates, which are the highest in Latin America. DHS findings of relevance for design of general strategies to reduce maternal and infant mortality are identified; they suggest a need to emphasize reducing neonatal mortality, improving activities in reproductive health and diarrhea control, combatting chronic malnutrition, and making greater efforts to reach women isolated from the health system. Some implications of DHS data for the proposed PNSDISM program components are also outlined. Finally, some data needs that should be addressed in future research are identified.
[National Seminar on Integration of Demographic Variables in Economic and Social Development Planning. Summary of discussions. Rabat, December 2-4, 1986]
This work summarizes the contents of 10 communications presented at Morocco's National Seminar on the Integration of Demographic Variables into Economic and Social Planning, which was held in Rabat in December 1986. The opening address by the Minister of Planning, presented in Arabic with a French translation, briefly outlined the history and major emphases of Morocco's efforts at development planning since independence and the growing realization among many developing nations and Morocco of the need to incorporate demographic variables into development planning. The address also assessed the progress of Morocco's demographic data gathering. the synthesis and recommendations each contain 5 sections. The discussion of population and migration was based on 2 communications which reevaluated the principal parameters of Morocco's recent population changes, while the 2nd assessed recent trends in internal and international migration. The 2nd section, on women in the development process, summarized the contents of 2 communications, the 1st a methodological discussion concerning the imprecision of concepts inherent in measurement of female labor force participation, and the 2nd a consideration of existing data on the subject and an attempt to measure recent trends in female economic activity. The 2 communications in the section on professional training and employment were a qualitative analysis of professional training and absorption of young people into the labor force, and a detailed analysis of demographic data to preview the supply and demand for labor and equilibrium in the labor market over the coming 2 decades. 3 communications on education and literacy analyzed government efforts to eliminate illiteracy, highlighted the accomplishments of the educational system, and discussed the relationship of the demographic variables with education in an attempt to demonstrate that education should be considered an investment. The final communication, on housing, represented an attempt to quantify the magnitude of Morocco's current and future housing deficit. 2 general recommendations of the seminar were that in-depth discussions of the integration of demographic variables into development should continue, and that efforts be increased to include institutions and especially universities outside the capital. Recommendations were also made for each of the 5 areas.
Substrate and hormonal responses to exercise in women using oral contraceptives.
Hormone and substrate responses to mild and heavy treadmill exercise were compared in women who had used oral contraceptives (OCs, n=7) and in normally menstruating women (controls, n=8). Venous blood samples were drawn prior to exercise (-5 minutes), during exercise (15, 30, 45, and 60 minutes), and 30 minutes after exercise. All samples were analyzed for glucose, lactate, free fatty acids (FFA), glycerol, follicle stimulating hormone (FSH), luteinizing hormone (LH), human growth hormone (hGH), cortisol, insulin, estradiol (E2), and progesterone (P). Substrate patterns during exercise were not altered by the phase of the menstrual cycle or OC use. However, among the OC group, the FFA concentrations were consistently higher during mild exercise and the glucose concentrations were lower at rest and during exercise than among the controls(p>0.05). No differences in the lactate or glycerol responses were seen between groups (p>0.05). The responses of insulin and hGH to exercise were not related to OC use per se but rather to the steroid status, either endogenous or exogenous. Specifically, during the steroid phases (OC use phase and luteal phase), insulin concentrations were not as markedly reduced (12% higher when luteal phase and OC use phase data were combined; p<0.05),>0.05) but there was a slight decrease seen in FSH (p<0.05).>0.05). Therefore, the new observations in this study are that: 1) insulin and hGH respond in a complex manner during exercise with either the phase of the menstrual cycle of the phase of OC use and disuse, and 2) the steroid concentrations (P, E2, cortisol) are increased in the controls but not in OC users during exercise. The latter point suggests that normal steroid increments are due to an increased rate of secretion rather than a decrease in hepatic clearance of these steroids. It also appears that transiently different alterations in insulin, cortisol, and hGH between the 2 groups are not significant at the level of muscle substrate metabolism. (author's modified)
Developmental status and AIDS attitudes in adolescence.
Researchers hypothesized that the development of consistently responsible attitudes among adolescents and young adults toward the prevention of HIV infection follows a pattern similar to that of developing a sense of identity. In the hope of gaining information useful for future education program interventions, they therefore explored attitudes regarding AIDS precautions among a group of youths aged 18-25 years with consideration of their developmental level. They conceptualized attitudes toward AIDS, developed items reflecting diffusion, foreclosure, moratorium, and achievement statuses in development, and assessed their relationships to identity and intimacy, while predicting overall that general maturity, as measured by high identity and intimacy, would relate positively to precautionary attitudes toward AIDS. 67 male and 195 female 1st- and 2nd-year college students volunteered to respond to 2 questionnaires on identity and intimacy formation, and attitudes toward AIDS. While asked if they expected to use a condom the next time they had sexual intercourse, respondents were not questioned about actual sexual behavior. Little relationship was found between AIDS attitudes and psychosocial development. Identity status and attitudes toward AIDS precautions were, however, predictive of future intention to use a condom. Intimacy level was negatively related to intended condom use, suggesting that those in long-term monogamous relationships, or those searching for them, might fail to see the need for protection against HIV infection. Such persons may constitute a special population at risk for AIDS.
AIDS heterosexual predominance in the Dominican Republic.
AIDS surveillance data from the Dominican Republic are described for 1983-89. A positive serologic test for HIV was required, and standard clinical criteria were used for defining AIDS. There were 1202 cases of AIDS (820 men, 372 women, 10 of unknown gender) reported to the Ministry of Health, for a cumulative case rate of 17/100,000 persons. Rapid growth of the epidemic is noted, with 43% of the total cases reported in 1989. Heterosexual exposure accounts for 53% (593) of all cases, with a male-to-female ratio of 2.2:1, resembling a World Health Organization pattern I/II country. Prevalence is highest in and around the urbanized tourist areas of Santo Domingo and Puerto Plata and in districts with a high concentration of sugar plantation barracks, where laborers from Haiti and the Dominican Republic work and live. The distribution of AIDS cases is described by transmission exposure category, sex, age, year of diagnosis, and district. The National AIDS Surveillance Programs can be improved by validation of exposure transmission categories through selected case investigation and by better reporting through training of healthcare providers. Surveillance data will assist in targetting future public health efforts to regions and persons at highest risk. (author's)
RU486 combined with PG analogs in voluntary termination of pregnancy.
In June 1990, Roussel-Uclaf conducted a clinical study of 10,250 women who came to Broussais Hospital in Paris, France to terminate their pregnancies. It wanted to determine if the success rate of RU-486 could increase when a prostaglandin analog (PGE) was administered with it. Some contraindications of RU-486 plus PGE included clotting disorders, chronic adrenal gland failure, and pregnancy with an IUD. After determining each patient meets certain criteria, the patient had to meet with a social worker and wait the obligatory 8 days before treatment. The 2nd visit consisted of confirming gestational age, signing a consent form, and taking 600 mg of RU-486. After being home with information on what to do in case of emergency, she returned 3 days later. A health worker either injected PGE intramuscularly or administered it via a vaginal suppository. She was monitored for 4 hours and the expulsion should have occurred within that time. If it did not occur within 3-4 days, a health worker would take an ultrasound and do a pelvic examination to determine if the pregnancy had indeed terminated even if the fetus remained. Then a health professional would perform a vacuum aspiration within the next 8 days to prevent infection. 8-12 days after successful expulsion, the patient would return for the 4th visit which included a pelvic examination and contraceptive counseling. Menstruation generally returned within 36 days after expulsion. The success rate was 95.3%. The pregnancy stopped in 2.8% of cases, but the fetus was not expelled. Pregnancy was not interrupted in 1.1% of cases. 0.8% hemorrhaged heavily and underwent a dilation and curettage or vacuum aspiration. Researchers did not know why the failures occurred. 92.8% were pleased with RU-486 and PGE. Only 7.4% found it to last too long and gave too much responsibility to the patient.
Bush blasts 'filth' on TV, school condom handouts.
President Bush complained yesterday about the "filth and indecent material" that Americans are exposed to through televised trials. Mr. Bush also criticized programs to combat AIDS that give condoms to teenagers and clean needles to drug addicts. He said such efforts undermine traditional values. He expressed hope that Earvin "Magic" Johnson's revelation that he is HIV positive "will teach people that wayward lifestyles or just kind of unsafe sex at random is not the way it ought to work." Mr. Bush made the comments in a series of satellite television interviews with ABC affiliates in major cities. In an apparent reaction to graphic testimony at the recent Palm Beach rape trial of William Kennedy Smith, Mr. Bush said, "I think the American people have a right to be protected against some of these excesses." Mr. Smith, a nephew of Sen. Edward M. Kennedy, D-Mass., was acquitted last week. The Cable News Network and Court TV provided virtually gavel-to-gavel coverage. Mr. Bush took a dim view of a plan to distribute condoms to juniors and seniors in Philadelphia city high schools as part of a program to combat acquired immune deficiency syndrome. "This is a disease that can be controlled for the most part by individual behavior," Mr. Bush said. "Indeed, I must tell you I'm worried about it. I'm worried about so much filth and indecent material coming in through the airwaves and through these trials into people's homes," he said. (full text)
Oral contraceptive-induced esophageal ulcer. Two cases and literature review.
A 19 year old female and a 21 year old female visited their physicians in Jerusalem, Israel because of pain in the esophagus and in the chest. Both were otherwise healthy and not taking any medication except for oral contraceptives (OCs) containing levonorgestrel and ethinyl estradiol. They would swallow the OCs without any fluids before lying down. Both physicians used an endoscope to view the esophagus. 1 physician saw 3 round esophageal ulcers 1-1.5 cm in diameter whereas the other physician saw 1 round esophageal ulcer 2.5 cm in diameter. The ulcers of 1 woman were 30 cm from the incisors and the other woman's ulcer was 25 cm from the incisors. Neither patient stopped taking the OCs. 1 physician advised his patient to take the OCs with plenty of fluids while in a vertical position. The symptoms stopped within 4 days. The other physician treated his patient with sucralfate suspension and ranitidine. Her symptoms subsided within 5 days. The ulcer of 1 patient and the ulcers of the other patient were completely healed by the time of the 2nd endoscopy 2 weeks later. The esophageal ulcers were probably caused by the uncoated and acidic OCs lodging in the esophagus. Even though the size of the OC is <0.5 cm and thought to be easy to swallow, peristalsis cannot effectively move such a small bolus. Moreover, many OCs are taken at night when salivation levels are reduced and swallowing occurs less often than during the day. In conclusion, physicians should stress to OC users the importance of swallowing them with plenty of fluids and not while lying down to prevent OC induced esophageal ulcers.
A woman's risk of ectopic pregnancy varies according to the contraceptive she chooses.
Researchers compared ectopic pregnancy rates of and type of family planning used for 249 cases and 835 matched controls from the Group Health Cooperative of Puget Sound in Washington between October 1981-September 1986. This was the 1st ectopic pregnancy for all the cases. All cases had a tubal pregnancy. Women with a postpartum sterilization had basically the same risk of ectopic pregnancy as those who used oral contraceptives (OCs) or barrier methods (relative risks [RR] 1.2 and 0.9 respectively). Yet women who underwent a postpartum sterilization were at a significantly higher risk than those who used an IUD or those who used no contraceptives (RR 0.9 vs. 0.3 and 0.1 respectively). When they used women who used OCs or barrier methods as the reference group, the RR for women who using an IUD was 0.8 and those who used no method was 0.2. Further women who underwent sterilization =or+ 2 months after childbirth (interval sterilization) had a significantly higher risk of ectopic pregnancy than the same reference group (RR 3.7 and 2.8 respectively). Indeed the risk of ectopic pregnancy for women who had an interval sterilization was 3 times the risk of those who had a postpartum sterilization. The researchers proposed that this increased risk occurred because electrocoagulation is most often used in interval sterilizations and it often results in incomplete tubal occlusion. They pointed out further that most postpartum sterilizations involve ligations which tie off then cut the tubes. In conclusion, interval sterilization demonstrates a significantly higher risk of ectopic pregnancy than use of OCs or barrier methods. On the other hand, postpartum sterilization poses the same risk as use of OCs or barrier methods. Moreover postpartum sterilization carries less risk of ectopic pregnancy than do IUDs or no contraception.
In Sudan, fertility rates are high, but few plan to use contraceptives.
Some results of the Sudan Demographic and Health Survey are highlighted in this article: marriage and fertility, fertility preference, contraceptive knowledge and use, and maternal and child health. The reference period is 1989-90. The survey population was 5860 ever married women aged 15-49 from 6 northern Arabic speaking regions; the south was omitted because of civil unrest. The median age at marriage is 17.8 years for those 25-49, but is 20.5 for 25-29 year olds. Rural women marry younger by 2 years than urban women. The median age is lowest among those with no education. 20% are in polygynous unions. The total fertility rate (TAR) is 5.0, or 1 birth lower than 10 years ago. There are suggestions that fertility is declining. TAR is lower for urban women (4.1). The median age at s birth is 20.5 years, with younger and urban women having a somewhat later age at birth. 54% of those having had a child within 3 years were breastfeeding, and 93% of those have given birth 10-11 months before. 25% say no to more children and the number increases with age and 66% say yes to more children. Ideal family size is 5.0 for those with no living children an 7.2 among those with >6. 71% of the women knew at least 1 contraceptive method. 25% have used a method at some point. 12% practice contraception either before or after their s birth, which practice decreases with increasing age. 9% currently use contraception (4% the pill, 2% periodic abstinence, and >1% other methods. Current use has doubled since 1978-9. Urban residence and higher education level are related to practicing contraception. 18% in tend to practice contraception in the next 12 months. 77% express no interest at all. 64% approve of practicing contraception. 37% say their husbands approve, 44% disapprove, and 17% are unsure. Among knowledgeable currently married couples, 35% approve of family planning and 25% disapprove, an 19% of the wives approve but husbands do not. 35% of deaths of sisters was attributed to pregnancy. Maternal mortality was 552/100,000 live births for 1983-89, which is an increase from 1976-82 (352/100,000 live births). Of the births over the preceding 5 years, 70% involved women in prenatal care with urban women receiving 90% and rural 62%. 69% of births were assisted by a professional and 25% by a traditional birth attendant. 89% of women are circumcised and 79% thought the practice should continue. 45% of children <5 are immunized (61% urban versus 47% rural), and 70% have had tuberculosis vaccinations.
Women in rural China want two children despite adherence to government one-child family policy.
The findings of the 1985 Survey of Rural Fertility and Living Standards of contraceptive behavior and motivation in the rural areas of Jilin, China, a central northeastern province is described. The sample included 5399 ever married women 14-60 years. Contraceptive practice was distinguished as a response to the government family planning (FP) policy or voluntary (not involved in a government campaign). Significant variables in the multivariate analysis used to explain the number of surviving children, the reasons for use or nonuse of contraception, and the choice of contraception were as follows: ethnicity, duration of marriage, number of surviving male children, experience of induced abortion, difference between the ideal and the actual number of children, FP source, and possession of a 1 child certificate for those with 1 child. Women's educational attainment was not significant for any use or nonuse or number of children, with controls for socioeconomic status and demographics. 78% considered 2 children to be the ideal, although in practice the total fertility rate for 1985 was 1.02. Enforcement of the 1 child policy is strong in Jilin. 84% of women with 1 child practiced birth control, 92% with 2 children, and just 3% with no children. 78% of the 1 child mothers were practicing contraception in response to the government campaign: 8% desired no more children and 6% wanted to space births. 51% of those with 2 children were using contraceptives in response to government policy and 46% were doing so voluntarily. Women's ethnicity and the child's sex, with controls for fertility and demographics, significantly influenced contraceptive behavior for women with 1 child; i.e., Han ethnicity was related to use due to government campaigns at the .05 level. Those with a son were more likely to use contraception due to the government policy. Having a 1 child certificate was significantly related to responding to government policy. The researchers assume that the 1 child policy is more strictly enforced among the Han and reversible methods are used by most with 1 child, and these women would have 2nd children without the policy. Current users of the IUD constituted 89% of women with 1 child, versus 27% for those with >1 child. 71% chose sterilization among those with >1 child versus <1% of those with 1 child. Sterilization over IUD use was significantly influenced by having at least 1 son and complying with government policy.
The impact of AIDS on the use of condoms for family planning in Mexico: a SOMARC special study.
Associated with sexually transmitted diseases and illicit sex, condoms suffer poor images as family planning methods in some countries. Research was therefore conducted to examine the effect of AIDS communications programs upon condom use in family planning in Mexico. Reaching samples of 1300 males and 1300 females aged 15-60 years in 36 Mexican cities, 5 questions regarding attitudes toward and knowledge of condoms were included in 6 waves of omnibus surveys over the course of 1988. The surveys were conducted concurrently with a governmental AIDS information campaign, and aimed to measure attitudinal changes over the period. Unprompted knowledge of condoms' use in protecting against HIV infection increased from baseline levels of 14% to a high of 37% in the 5th survey wave, while unprompted knowledge of condoms for both family planning and AIDS prevention grew to 32% from an initial 11%. Knowledge targeted for increase by the campaign, therefore, significantly increased over the campaign and survey period. The image of condoms has not been tarnished, and may have, in fact, been bolstered by the campaign and related media attention. These results suggest that AIDS information campaigns are likely to lead to increased demand for condoms.
The postpartum program of the Mexican Social Security Institute.
This report examines changes in the postpartum contraception program of the Mexican Social Security Institute (IMSS) since 1983, and reviews the quantitative and qualitative impact of these developments. In 1983, IMSS formally integrated a postpartum contraception program with the obstetric services of the family planning program. The program provided patients with information on postpartum contraception during both prenatal and delivery care, and offered the IUD and breastfeeding as a means of birth spacing and tubal occlusions for women who wanted no more children. After 1983, the following developments took place: the establishment of contraceptive guidelines for women release from the obstetrical service at IMSS; the establishment of training programs on contraception promotion and service delivery; and the initiation of clinical and operational contraceptive methodology studies of women released from the obstetrical service at IMSS. Theses studies suggested several avenues for improving IUD continuation rates, including increased education, follow-up, and better doctor-patient communication. Furthermore, the program began increasing the number of postpartum contraceptive options, including the use of progestin-only oral contraceptives (0.3 mg. of levonorgestrel). Between 1982 and 1986, the number of postpartum contraception acceptors increased from 175,000 to 326,000 (contraceptive prevalence among obstetrical releases increased from 30.7% to 50.5%). From 1986-89, the level acceptance remained virtually unchanged. But in early 1990, with the implementation of operational strategies to increase use (including the expansion of contraceptive options), contraceptive prevalence increased to 64.8% among obstetrical releases.
Contraception for postpartum use: non-hormonal methods -- intrauterine devices.
In this paper, the author discusses his experiences with immediate postplacental insertion of IUDS (IPPI), a technique which he recommends both after vaginal deliver and cesarean section. IPPI is defined as the insertion of an IUD within 10 minutes of placental delivery, at or about term. In 1974, the author and colleagues at the obstetrics and gynecology department at the University of Ghent, Belgium began conducting trials to assess the safety and effectiveness of IPPI. From 1974-83, a total of 2646 IUDs were inserted. Highly effective, IPPI had a continuation rate after 1 year of 72.9% and a pregnancy rate of 1% (a study of interval insertion of IUDs resulted in a continuation rate of 87% and pregnancy rate of 1.2%) IPPI's low removal rate for complications or other medical reasons (8.1%) suggests that the method is safe. IPPI, however, resulted in significantly higher expulsion rates than interval insertion -- 10.5% versus 3.0%. The majority of expulsions of IPPI occurred during the 1st trimester. The author and colleagues investigated possible reasons behind the high expulsion rate and identified 2 factors: 1) lack of experience of the operator, and 2) the type of IUD. 75% of the IUDs had been inserted by operators lacking experience with IPPI, and these operators scored lower in avoiding expulsion (and unwanted pregnancy) than the more experienced operators. Investigators also found that the Lippes Loop D IUD scored significantly worse in effectiveness and retainability, making it a poor candidate for IPPI. The author goes on to discuss attempts to design devices specifically for IPPI or to modify existing devices. Finally, the author mentions that the available evidence concerning intra-cesarean insertion of IUDs suggests that this technique is also safe and effective.
The injectable contraceptives: present and future trends.
This paper reviews the safety and efficacy of injectable contraceptives, focusing in particular on medroxyprogesterone acetate (MPA) -- also known as DMPA or Depo-provera. The most widely used injectable contraceptive worldwide, MPA comes in the form of microcrystalline suspension. A 150 mg dose is administered through deep intramuscular injection every 3 months. Although not approved for use as a contraceptive in the US, MPA is used in over 80 countries. In Thailand, MPA is the 2nd most popular family planning method. A highly effective contraceptive, MPA has a gross cumulative pregnancy rate of between 0.7-1.2/100 woman-years. The main drawback to the method is its high rate of unpredictable bleeding patterns. Irregular bleeding is most common following the first injection, decreasing after subsequent injections. The paper discusses several attempts to manage abnormal bleeding patterns, including the use of estrogen treatment. Contrary to initial assumptions, fertility is not seriously affected by use of MPA. The paper discusses other possible concerns associated with MPA uses, no important metabolic changes or effects on liver function, lactation, or carcinogenic effects have been found. The report discusses attempts to change the timing or dosage of MPA. The report then briefly reviews another injectable contraceptive, norethisterone enanthate (NET EN), a C-18 steroid dispensed in an oily solvent mixture. A dose of 200 mg is administered in deep intramuscular injections every 2 months. Although NET EN causes less amenorrhea and a more rapid return of fertility after termination, women find it less acceptable. Finally, the report mentions new research developments concerning injectable contraceptives.
Postpartum family planning in the 1990s.
This article is a transcript of the keynote address of the 1990 International Conference on Postpartum Contraception, a speech delivered by Pramilla Senanayake, assistant secretary general of the International Planned Parenthood Federation. In her speech, Senanayake discusses issues facing both postpartum programs and family planning in general. Senanayake draws attention to 3 developments that make this a crucial junction for family planning: family planning programs have achieved maturity, knowledge of methods has been refined, and the number of children desired by couples has declined rapidly over the past 10-15 years. In the 1990s, demand for contraception will explode. The speaker proposes that the global target should be the double contraceptive use by the year 2000. Throughout the speech, Senanayake stresses the importance of breastfeeding for birth spacing purposes -- a fact that did not gain attention until the 1980s. Prior to this time, efforts were concentrated on promoting modern methods -- especially oral contraceptives and IUDs. Senanayake then focuses on the issues facing postpartum programs. In order to institutionalize such a program, the larger family planning program must have clearly stated goals, a service delivery system capable of implementing those policies, and an effective monitoring system. Finally, the speaker raises the following programmatic concerns: What is the best timing for postpartum services? How can informed choice be guaranteed? How can family planning services be extended to women who have an abortion? What role can social marketing, community-based distribution, and woman-to-woman programs play in postpartum family planning? And do efforts to improve quality undermine the quantitative impact of postpartum programs?
Why abortion is immoral.
Little support has been given in the philosophical literature concerning the view that abortion is, with rare exception, seriously immoral. Certain issues of great importance will be neglected since a complete ethics of abortion is not the topic. The standard anti-abortion, pro-choice arguments suffer from similar shortcomings. They both either included or exclude other moral acts in an effort to support their position on the ethics of abortion. They also both suffer from the is-ought fallacy. The pro-choice view is based on psychological attributes, while the anti-abortion view is based on physical attributes. In both cases they attempt to take a property of the fetus and use it to support their position. An alternative moral argument rests upon wrongful killing, which is almost self-evident. Because fetuses have a future that contains value, it is wrong to deny that value. This is the very same reason why it is wrong to kill an innocent human being. It is this crucial moral property that clearly applied to fetuses. It does so while avoiding the usual philosophical pitfalls of terms like human being or person. It is also free of religious dogma or metaphysics. In addition it is compatible with our other moral attitudes towards suicide, euthanasia, and contraception.
Sexually transmitted diseases in Nigeria. A review of the present situation.
Gonorrhea is the most prevalent sexually transmitted disease (STD) in Nigeria. In fact, in 1963, WHO found Lagos to have the highest gonorrhea rate in the world. Recent surveys report gonorrhea prevalence to be as high as 28.1%. Further some studies show a clear association between gonorrhea and male and female infertility. Penicillinase producing Neisseria gonorrhea prevalence varies from 44.4% in Zaria to 80% in Ibadan. There is an increase in the prevalence of gonorrhea among girls, mostly due to sociocultural factors such as the belief that sexual intercourse with a girl who has urethritis cures the condition. Gonorrhea is not always the most common form of urethritis, however. For example, in a study in Ibadan, 61% of male urethritis cases had nonspecific urethritis. Further schistosomiasis often causes urethral symptoms like those of gonorrhea. Most women at STD clinics have vaginitis and vaginal discharge. Even though the prevalence of trichomoniasis and candidiasis are rather high (10.2-22.3% and 4.33.1% respectively), bacterial vaginosis is the leading cause of vaginitis and vaginal discharge in Nigeria. The predominant malignancy of women in Nigeria is cervical cancer which my be due to the high rates of infection of trichomoniasis and Herpes virus II. Another prevalent STD is syphilis, yet many people with the infection are asymptomatic. For example, a study reports that 10.3% of women in a prenatal clinic in Lagos tested positive for syphilis, but the physician believed only 1.5% had syphilis. Tropical venereal diseases still cause genital ulcers in Nigeria. Dermatophyte infection, genital warts, and pedicubsis pubis also occur, but scant data exist. Many people believe they have an STD and do not, yet they insist they do. This phenomenon may be a result of the common fear of infertility which results from STDs. In conclusion, the government should allocate adequate funds for health programs and research, particularly those associated with STDs.
Second quarterly report (April - June 1989): Social Marketing of Contraceptives Project, Pakistan.
Since the Executive Committee and Advisory Board of the Social Marketing of Contraceptives Project in Pakistan had not met, little had been accomplished in the period between April-June 1989. In fact, meetings were supposed to occur on March 7, 1989, March 16, 1989, and June 11, 1989. Each time it was postponed. After the June date, no future meeting date was rescheduled. A private sector manufacturing and marketing company, W. Woodward Pakistan (Pvt) Ltd. was able to distribute 22.2 million Sathi condoms during the 1st 6 months of 1989, however. Yet this number was down 3.7% from the same time period for 1988 (23 million condoms distributed). Even though Woodward had drawn up marketing plans, the company could not implement them until the Executive Committee and Advisory Board approved the plans. The Population Welfare Division of the Government of Pakistan did not approve routine line adjustments in a timely manner which also contributed to the slow progress of the project. Population Services International Marketing Associates (PSIMA) questioned this division's ability to implement the program since it had little marketing experience and is busy with other programs and priorities. Specifically the delay kept Woodward from continuing its promotion campaigns. Nevertheless consumers did participate in a survey on condom usage and in a SATHI advertising campaign test. The researchers had completed the reports of this market research, but were not yet prepared to formally present them. PSIMA had proposed a variety of relevant recommendations which encompass plans to conduct baseline research for the oral contraceptive campaign. The quarterly report provided a list of recommendations for the Social Marketing of Contraceptives Project in Pakistan.
[Demography and society. An analysis of the goals of the State Development Plan (Sinaloa) 1987-1992]
The State Development Plan for Sinaloa, Mexico, for 1987-1992 contains 7 important goals in its section on Demography and Society that have met with considerable success. Data from the 1990 general population census and projections by the state population council are the basis for an evaluation of progress. To contribute to lowering the fertility rate, the State Population Council for Sinaloa (CONEPOSIN), in coordination with the educational and health sectors, has developed family planning activities for all levels of care throughout the state. The emphasis is on population education, and a program to evaluate IEC programs has been underway since 1987. The crude birth rate declined from 51.9/1000 in 1970 to 39.8 in 1980 and 28.6 in 1990. In the area of regulating population growth and bringing it into balance with economic and social development, the 1st step was consideration of a population policy in the 1987-1992 state development plan. During the past 4 years, the gross state product increased by 2.9% annually, while population increased at 1.8% annually. Economic projections indicate improvement with the culmination of some major infrastructural projects. But demographic growth reduces the speed of economic and social improvement. The goal of reducing population concentration in the municipio of Culiacan will be furthered by a continuing decline in the natural increase rate and a gradual improvement in social development. The population of the municipio for the year 2000 is projected at slightly over 718,000 and the growth rate at about 1.8%. Even if the growth goal is achieved there will still be strong demand for employment because of the young age structure. The 4th plan goal is generating development strategies that will contribute to rationalizing population distribution in the state. The proportion of the population living in localities of over 15,000 increased from 33% in 1970 to 42% in 1980 and around 50% in 1990. 90% of the urban population and 45.5% of the total state population resided in the 5 main cities of Sinaloa. Concentration in the 5 cities has increased since 1980, when 81% of the urban population and 34% of the state population lived in them. CONEPOSIN in its study "Subsystem of the cities of Los Mochis-Culiacan-Mazatlan" has proposed a series of development strategies at the regional and sector is levels to balance economic growth and population distribution. The goal of strengthening the family planning and health program has been furthered through participation in the interinstitutional family planning program, preparation of educational materials, and publication of a review with articles on sex education and family planning. 16 municipal population councils have been installed to decentralize population policy. Various means have been used to promote the final goal of increasing awareness of population problems.
Sensitivity of falciparum malaria to chloroquine and amodiaquine in four districts of western Kenya (1985-1987).
Between 1985-1987, researchers recruited 419 5-60 year old persons with moderate falciparum malaria to take part in a series of studies in West Pokot, Rusinga Island, Busia, and Bungoma districts in western Kenya to determine malaria parasite sensitivity to chloroquine and amodiaquine. The subject received 25mg/kg of the antimalarial for 3 days. Chloroquine resistance was highest in Busia in May 1986 (51%) followed by Bungoma (45%), Busia in July 1986 (38%), West Pokot (27%), and Rusinga Island (19%). No RIII resistance (failure to decrease parasitemia by at least 75%) occurred in any of the 4 studies. In July 1986, researchers compared the different sensitivity levels of chloroquine and amodiaquine among 119 school children in Busia. None of the children exhibited RIII resistance. None of the falciparum malaria parasites in the 58 children receiving amodiaquine showed RII resistance (failure to clear parasites) compared to 3.3% of those receiving chloroquine. Yet 15.5% of students receiving amodiaquine harbored parasites with RI resistance (recurrence of parasitemia within 7 days), especially delayed RI resistance. Still this percentage was much lower than RI resistance among the students receiving chloroquine (34.4%). Total resistance was significantly much higher in the chloroquine group than the amodiaquine group (p<.01). Moreover in vitro studies revealed that the percentages of parasites with minimum inhibitory concentrations (MICs) for chloroquine >114 nM (indicating resistance) varied from 37% in Busia to 68% in Bungoma. Further 20% had MICs for amodiaquine >80 mM (indicating resistance). In conclusion, chloroquine resistant falciparum malaria parasites have established themselves in western Kenya. Despite growing resistance, amodiaquine should still be used in uncomplicated infections, if the health practitioner is able to follow up on the patients.
Technical assistance in preparation for focus group research in Burkina Faso.
A consultant of Johns Hopkins University's Population Communication Services (JHU/PCS) visited Burkina Faso between October 12-27, 1991 to assist the IEC (information, education, and communication) office of the family planning section of the Ministry of Health and Social Action (MOHSA) in developing research data through focus group discussions (FGDs) so it could produce IEC materials. He suggested the development of 3 FGD guides: revision of the 1989 FGD guide to include unmarried youth, a guide concentrating on obstacles of family planning, and a guide concentrating on needs of family planning field workers for IEC materials. The obstacle FGD guide was used for the 1st FGDs in Zagtouli, 1 consisting of 20-30 year old married rural men and the other consisting of same age married rural women. Both the men and women had limited to no education and had children. The 2nd FGD included family planning field workers (midwives and social educators). Results from this group showed that they hoped for more IEC support materials and, even though much of their time consisted of educational efforts, they had received little IEC training. Unmarried female adolescents with no children who were not going to school comprised the 3rd FGD in the Ouidi Social Center in Ouagadougou. The consultant found plenty of existing research data with which to develop IEC materials, but no one had interpreted the data or could apply it to IEC material development. MOHSA IEC staff did not appropriate sufficient resources to targeting adolescents and men. The consultant recommended follow up training in FGD research technique for moderators and supervisors. He also suggested that JHU/PCS assist the IEC office with data analysis of existing research data.
1990 annual report.
This report describes the accomplishments of the International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) during 1990, and examines the challenges still present in the region. As IPPF/WHR President Fernando Tamayo explains, Latin American and the Caribbean have the highest use of family planning than any other developing region in the developing world: almost 45% of all married women use a modern contraceptive. However, many women still lack access -- or easy access -- to family planning services. Chairperson Jill Sheffield echoes Tamayo's view, noting that 30 million people in the region want family planning but cannot get it. She discusses the risks that unwanted or multiple pregnancies pose to a woman's health. The incidence of unsafe abortion, she notes, is highest in WHR than in any other region. The report goes on to describe the service expansion that took place in 1990 and the challenges that remain. Looking for innovative ways to reach marginalized communities, IPPF/WHR initiated a number of services for men and for adolescents. The organization also explored ways of reaching people living in remote rural areas or in urban slums, using traveling promoters or encouraging doctors to establish practices in areas that lack health services. In order to confront the growing threat of AIDS, the organization conducted a series of activities to raise public awareness. IPPF/WHR also introduced management information systems in 11 countries which helped increase productivity. The report goes on to discuss the following issues: the increasing gap between knowledge and use of contraception; clinical services and cost effectiveness; institution building; quality of care; strategic planning; the involvement of women; and financial support. A special feature, the report contains a pictorial section which describes the impact of family planning on the lives of indigenous women in Guatemala.
Child survival and development with special reference to the girl child.
This article is based on plenary address given before the International Symposium on the Girl Child in Asia, a Neglected Majority. The author answers the question of how do the efforts in child survival relate to the real welfare of children. The statistics are grim. 40,000 children <5>50% of developing countries, universal primary education is decreasing. 57% of 10-14 year olds in Nepal are economically active. Daily, hundreds of girls are subjected to bonded labor, marriages without consent, sexual abuse and prostitution. 150 million street children are begging, picking rags, or engaged in underpaid, unhealthy and unsafe labor. The goal of ratifying the UN Convention on the Rights of the Child is not enough. Implementation is required. The rights of the child begin in utero. Women and girls are economically, politically, and socially powerless. Their complaints are frequently misunderstood, misinterpreted, or ignored. The development and education of the child must be appropriate to the historical, physical, sociocultural and demographic conditions of the country. Empowerment of women and participation in the social and political processes is necessary. It is hoped that concrete solutions to some of the problems will be actualized. There must be hope that reason will prevail and that all children, including girls, will grow up healthy informed, responsible citizens.
The sterilization of people with a mental handicap: the views of parents.
The historical aspects of sterilization among the mentally handicapped are briefly chronicled. Recent investigation of the issue was conducted in 1988 in Nottinghamshire, England among a sample of 374 households identified as having a handicapped person 13-25 years. Of the 274 households mailed the questionnaire, 138 responded (50.4%), or 37% of the original sample. Representatives may be unreliable. However, no differences were found in age, gender, and assorted other variables between the respondents, nonrespondents, and nonparticipants. Of the 62 couples replying, 10 had differences of opinion on sterilization, but no gender differences. 90% had severe learning difficulties, and 10% had moderate. results were based on perceptions of sexuality, use of contraception, sterilization, views on consent, and descriptive and qualitative aspects. <33% of the parents thought their child was interested in sex. <9% had a special relationship with the opposite sex. 5% were thought to be capable of participating in a discussion about sterilization. 25% of the females were taking the pill, among whom there was a significant relationship with parents who perceived their child to be interested in the opposite sex. The parents of those using contraception were significantly more likely to consider sterilization for their daughter, p<.05). 53% had or would consider sterilization for their child, and the remaining would not. The only significant variable related to the choice of sterilization or not was whether the parent thought the child capable of bearing a child, such that those parents were less likely to sterilize. 84% thought themselves or with a physician should provide consent for sterilization. Those against sterilization were grouped into those with pragmatic reasons such as "she is so well supervised that it would not be necessary" and those on principle opposing involuntary sterilization. This parental group would consider sterilization if the child was moving away from home (55%), displaying interest in the opposite sex (42%), or having difficulty with menstruation (14%). The questionnaire did not explore reasons other than concern about sexuality for consenting to sterilization, although several parents wrote about vulnerability or possible exploitation. Suggestions are made that in light of the changes in society, consent laws need to be changed to avoid expensive legal action. Sterilization should be an option.
Population dynamics and rural development in Nigeria.
Before the 1980s, rural development strategies in Nigeria did not include population dynamics of rural areas, so targets were not realized. In fact, a vital registration system did not exist and most existing data were not representative. Yet the 1965-1966 National Rural Demographic Survey and the 1971-1973 Survey on Fertility, Family, and Family Planning had wide coverage and were more representative than other surveys. The crude birth rate (CBR) in the mid 1960s in rural Nigeria was 50.2 and the crude death rate (CDR) was between 20.4-25.6. By the 1970s, the rural CBRs ranged from 48.5-49.8 and the CDRs from 21.1-22.9. Rural infant mortality was between 109-126. Population growth during the 1971-1973 survey was 2.9% in the rural southwest and 2.6% in the rural east. The subsequent Rural Demographic Sample survey showed it to be 2.6% in southern rural Nigeria and almost 2% in northern rural Nigeria. This survey also was the only source on rural migration. Almost 600,000 persons left rural areas than moved to rural areas. Overall birth, death, population growth, and migration rates were high in rural Nigeria. Further rural health services were poor or nonexistent. Even though health conditions controlled the number of people working and the quality of their labor, data did not exist in rural Nigeria to determine sickness or disability. This knowledge coupled with the fact that mortality in rural areas was high meant about 1.5 million lives of economically active people died each year. Unlike many developing countries, some researchers expected only a modest future fall in mortality in rural areas and a high rate of future fertility. Thus, in the early 1980s, they stressed the importance of offering more medical services and introducing family planning services in rural areas to bring about effective rural development. They concluded that planners should not ignore population elements when trying to develop rural areas.
Behavioral determinants of maternal health care choices in developing countries.
Behavioral researchers need to examine what women in developing countries do and are willing to do to preserve their health and that of their newborns instead of concentrating on use of formal maternal services. They need to do so not only because mothers in developing countries underutilize maternal services, but because most poor women do not have access to quality formal maternal health services and probably will not have access to them for many years to come. Even in the event these services were more accessible to women, they often are culturally inappropriate and do not understand the women's needs and expectations. Thus maternal health services must improve appropriateness and effectiveness to make them acceptable and educate and motivate women to use these services properly to improve maternal health care and pregnancy outcomes. Health planners must base any steps to achieve these goals on detailed, well designed formative research which explored beliefs, attitudes, and behaviors of women, communities, and health workers. The MotherCare project lists what efforts are needed to implement a successful program once the research has been reviewed. For example, the program should provide women only those facts needed to bring about desired changes in behavior at the precise time the facts are needed. Review of the literature and results of unpublished small field projects and studies shows that ways to identify and address why women do not seek prenatal care early. Further it reveals the most feasible way of encouraging pregnant women in developing countries to seek prenatal care is at critical points in the pregnancy. It also points out that nonformal care is an important source of maternal care and health specialists should identify and promote the strong points of nonformal care.
Peer interaction and traditional and modern influences on adolescent sexuality in Nigeria and Kenya: findings from recent focus group discussions.
In sub Saharan Africa 50% of births are to women <20 years. This study was conducted to provide a better understanding of how peer interaction and societal factors (traditional and modern) influence adolescent attitudes toward sexuality and family planning. Focus group discussions (FGDs) were conducted in Kenya and Nigeria in 5 sites: 1) 3 mixed sex FGDs from a rural secondary school near Mombasa, Kenya, 2) 1 group of female peer counselors from the Family Planning (FP) Association of Kenya youth center, 3) 1 male and 1 female group of graduates (mostly married) from Gabari, Nigeria (Muslims near Zaria), 4) 2 single sex groups of secondary school students from Zaria, Nigeria, 5) 2 single sex groups of school leavers and 2 single sex groups of in school youth (10-18 years) from Ibadan, Nigeria (southern area). Leaders from FP organizations randomly selected participants. The focus topics included sexuality/sex education, perceptions (causes and dangers of early childbearing), male responsibility and early childbearing, knowledge and attitudes regarding family planning, knowledge and attitudes toward induced abortion, knowledge and attitudes regarding sexually transmitted diseases (STDs) including AIDs; sugar daddies, sugar mommies and prostitution; and program recommendations from youth. The conclusions reached were that peers were the chief source of information on sexuality and this results from the absence of traditional sources of information. In a traditionally functioning society, the beliefs regarding sexuality and FP were controlled by elders and family members. Urbanization and social change has brought with it few options for replacing the traditional system. Myths and misinformation were widespread regarding the side effects of FP and contraceptives, particularly among women. Males were more favorably disposed to FP. The response to unwanted, out of wedlock births was reliance on abortion, which was many times fatal. The patterns were widespread and youth were knowledgeable about the methods of induced and self induced abortion and places to acquire an abortion. In spite of each of the groups being conducted in a different language, there were many similarities in the terminology used and shared anecdotes regarding sexuality, FP, and abortion. There was unanimity of opinion and apparent mistrust of adults, but gratefulness when information on sexuality and FP were provided. One implication is that peer counseling may be a an effective strategy for reaching adolescents and have the most potential for success.
Family welfare educational activities in industrial sector -- experiences and an operational guideline.
Industrial sector experiences and an operational guide are presented in this book chapter on the corporate sector and family welfare in India. Sections are devoted to background, strategy, the industrial sector, family welfare programs efforts, experience in the organized sector, and a guideline of what can be done. The effects of family welfare programs have been modest and more is needed to achieve a birth rate of 29 by 1990 an 21 by the turn of the century from a level of 32/1000. The 2000 goal also is a crude death rate of 9, couple protection rate of 60 from a level of 40, and an infant mortality rate of <60. The strategy is to improve the infrastructure. Information, education, and access to a broad range of FP methods is desired. The industrial sector which employs 25.3 million (11%) workers of the 222 million labor force and the cooperative and semiorganized sector (4-9%) make it a unique priority group. Group characteristics, cost effectiveness, accessibility of the client population, and availability of medical and health facilities make the population conducive to educational and motivational FP activities. There are examples from the industrial sector of early pioneers in FP; i.e., the TVS-Lucas group of companies in 1938 in Madras and the Tata group of industries later in the 1950's. Tata Iron and Steel Company began educational activities in 1951 and by 1958 freely made contraceptives available and by 1967 offered incentives. Since 1970 other industries have followed suit. Defense Services in the public sector set up FP units in 1951 and Railways, Post and Telegraphs also joined the effort. The International Labor Organization (ILO) gave impetus to the movement by sensitizing agencies to the issues, preparing educational materials, and executing research and action projects. The Ministry of Health and Welfare has a unit to coordinate these efforts, provides funding, involves organized sector organizations, and seeks international support. The approach is to build upon existing infrastructure. Suggested guidelines are to involve industrial, commercial, and employer organizations; support of top level and middle level management; activate motivator workers at the plant level; and take trade unions as partners.
Role of employers' organisations in promoting family welfare programme.
The role of employers' organizations is explored in this book chapter on management's role in promoting the family welfare program in India. Organizations that have been involved in family planning (FP) are identified and the family planning activities on plantations by the Indian Tea Association (ITA) and the United Planters Association (UPASI) are described. An organization involved in FP was the All India Organization of Employers (AIOE) which instituted FP in 1978 in Ludhiana, Kanpur, and Patna. The goal was to motivate members to promote family welfare among their workers. The achievements were to establishment of population and welfare cells in the Secretariat of the Bihar Industries Association and Employers' Association of Northern India, involvement of 607 establishments with 80,000 workers with 700 trained motivators, and the establishment of FP activities in several enterprises. 3 more centers were established in Jaipur, Begusarai, and Coonoor with 90,000 workers covered. Underway are programs in Alwar, Bokaro, and Mangalore. The Employers Federation of India (EFI) for 30 years has encouraged employers to undertake FP activities. In 1971 a committee was established and in 1973 a nationwide survey of 345 industrial units was conducted. In 1974 a training course in FP was given for medical officers in industrial units. A family welfare cell was established in national headquarters in 1979 and initiated 2 projects. In 70 units, family welfare officers were appointed and 1300 worker motivators trained. Money incentives and distribution of contraceptives were employed. The Standing Conference of Public Enterprises (SCOPE) began in 1983 with a seminar on FP and family welfare education in public enterprises which involved other countries as well. Educating workers to accept small family norms was accomplished but there was impetus to educate high level officers and managers. The IPA with plantations in Assam began FP in 1950 due to the constraints of living on a plantation where excessive growth had a direct impact. Estate medical officers were trained, but it was not until 1957, when government adopted a formal policy, did the estate promote the small family with the help of the Rose Institute. By 1963, progress was made in reducing the birth rate. UPASI in 1966-7 conducted a survey to collect birth rate and mortality data; FP followed. Leadership were trained and educated and 6 district were involved in meeting the stated goals.
Management techniques in furthering family welfare programme.
Involvement of the corporate sector in family planning (FP) in India is discussed in terms of management techniques in this book chapter. The corporate effort is based on problem recognition, development of alternatives, obtaining resources, defining tasks in effective ways, developing skills, motivating people to accept objectives, scheduling, and monitoring and control. This management process acts as a continuous cycle with interaction between the components, and acts as the rules of choice. Management techniques are the choices themselves such as work study, network analysis, cost analysis, camp approach vs fixed clinic approach, sales bonuses vs mobile communication teams, and other techniques such as queuing theory, linear programming, and computer simulation. Each of these techniques is discussed as its appropriate to the goal of FP. An example of network analysis is given for the organization of a mass family planning camp for workers in an industry, listing all major activities and scheduling. Work study is used to identify tasks and prepare job descriptions and curricula for a variety of health workers. Evaluation of the effectiveness and efficiency of health services is also conducted. Job, function, and task and defined. Cost benefit and cost effectiveness analysis is a technique used to identify which programs are the most beneficial at the least cost. It can combine all costs and benefits into a single index and/or investigate the distribution of costs associated with specific functions, programs, and constituencies. Opportunity cost is determined as the loss of value for other uses. The National Institute Health and Welfare has used a computer program to estimate the internal rate of return in 4 sectors. Cost Effectiveness Analysis (CEA) is used to determine which programs are least costly when the alternatives are equally effective, and which alternatives achieve the objective when equally costly. Network analysis technique is used to diagram the logical sequence in which events must take place. Examples are the Program Evaluation and Review Technique (PERT) and Critical Path Method (CPM). Other operations research technique deal with the choice of a combination of activities with constraints and an optimum objective or solutions to congestion problems.
Role of unions / workers in promoting family welfare among the employees in plants and outside.
This paper discusses how family welfare serves the interest of trade unions and its members workers in India, and examine the role of unions in promoting family welfare. The author begins by pointing out how population growth affects not only national progress, but also the living standard of workers. Creating a surplus labor force, population growth undermines the collective bargaining power of organized labor. Increased unemployment, depressed wages, fewer educational opportunities---these are only some of the other adverse effects of population growth on the well-being of workers. Trade unions have acknowledged the importance of family welfare, yet have only made limited contribution to the national effort. The author notes that while trade unions do not have the infrastructure or resources to actually provide services to its members, they can use collective bargaining to obtain such services from employers, arouse workers' confidence in family welfare, provide workers with information, motivate them to avail themselves of services, and get involved in policy formulation. The paper provides specific suggestions on how trade unions can educate and motivate their members, suggestions that were drafted by representatives of trade unions during meetings held to discuss the population problem. The author explains that in order to promote family welfare, the trade unions can seek advice and assistance from agencies such as the National Family Planning authority, non-governmental organizations, etc. Finally, the author discusses what type of support the Central Board for Workers' Education can provide trade unions in their efforts to promote family welfare, support that includes training and educational assistance.
Role of incentives and disincentives in promotion of family planning in corporate sector.
Discussion focuses on the role of incentives and disincentives in the promotion of family planning (FP) in the corporate sector from this chapter of the volume on corporate involvement in FP in India. Cash incentives were 1st begun by Tata Industries in 1964 in Jamshedpur. Sterilized workers received Rs. 100, which was increased to Rs. 200 in 1967 and implemented in all Tata Industries. In 1982 a survey was conducted to assess the extent of use of incentives in industry. Of the 134 industries responding, 100 offered cash incentives which ranged from Rs. 50 - Rs. 500 with a high of Rs. 2000 at Steel Authority of India for a tubectomy. 95 industries provided leave of 2-11 days for performance of sterilization. The impact was studied comparatively in 1969 in Tata Industries and others. Results were that incentives were related to higher adoption of sterilization, but there was ambiguity in zone analyses. Another study confirmed the results, and found that the more important factor was the level of motivational facilities in the industries. An ILO study in 1982 found managers to perceive the incentives to be effective in promoting the small family norm. The author concludes from a review of the literature that even though research is contradictory, there is sufficient weight to prefer incentives. Considerations are the sustainability at what cost, usefulness to the workers, administration in the industry, degree of impact, the reactions of workers and trade unions, ethical issues, and benefits to management. There is the opinion that incentives may be given to those who already would choose smaller families. Careful consideration of the population of acceptors could reflect higher incentives to those demographically more included, and providing no motivation or incentives to those less fertile or infertile. A detailed analysis of cost/birth averted for difference categories of acceptors working for the central government was developed. The higher the age of acceptor, the higher the cost/birth averted, which suggests that no inventive be provided to the higher age group. In populations that are already well paid, there is little justification such as the mines and tea plantations that are already well paid, there is little justification to offer incentives. Tangible monetary benefits accrue to some industries such as the mines and tea plantations and long term benefits are received from fewer socioeconomic problems and less absenteeism. The FP Foundation has 6 recommendations for incentives and disincentives and the InterCountry Seminar on Incentives offers 5 recommendations. The impact is not easily quantifiable, but implementation of various schemes is possible under the appropriate circumstances.
Role of cooperatives in promoting family welfare planning.
This article on cooperatives in India and their contribution to family planning (FP) is a chapter of a book on the corporate sector and the family welfare program in India. Cooperatives are unlimited in their opportunity to advance FP objectives. Determination and commitment are important ingredients. Government and voluntary organizations should cooperate and coordinate activities with cooperatives. Cooperatives work to improve the quality of life and the economic betterment of its members. Principles of equality, nonexploitation, nonviolence, mutual respect, fraternal feelings, and freedom from poverty and deprivation form the basis of the group. The cooperative movement is profiled. There are nearly 350,000 cooperatives of the following types: credit, marketing, agricultural, sugar, oilseeds processing, spinning mills, fruits and vegetables, storage, consumer, specialized cooperatives, handloom, and housing. The populations involved are the most vulnerable. Cooperatives are under statutory obligation to promote social welfare, but, unlike cooperatives in Japan which are involved with individuals from childhood through adulthood, there is a need to expand beyond the construction of public institutions and managing public services. In 1974, a national seminar focused on the role cooperatives could play in integrating family welfare programs with cooperative training and educational programs. In 1979, subjects and topics were identified for inclusion into the cooperative educational curricula. The National Council for Cooperative Training (NCCT) proceeded to hold a trainers workshop. The Cooperative Training Colleges allocated funds to prepare training materials for promoting family welfare among the cooperative membership, and began teaching family welfare education at its 18 colleges. The NCCT link with 95 Junior Cooperative Training Centers should be taken advantage of in promoting education through its ranks. 120,000 members of cooperative societies are exposed to 7 day training classes in the ideology of cooperatives; family welfare needs to be introduced, in order to bring about social change, through individual and group communication. Changes in bylaws need to be made. FP camps, a subcommittee on family welfare, coordination with district agencies, placement of FP on organizational agendas, discussion groups, contraceptive distribution centers, and publicity materials need to be established. Also provided is an outline of a possible charter for National Family Welfare Cooperative with objectives, membership, and funding details.
Indonesia: the organization and financing of health care services. Abstracts of five consultant reports sponsored by the Resources for Child Health Project, the Enterprise Program and John Snow, Inc. USAID / Jakarta.
This volume is a set of 5 abstracts covering consultancies to Indonesia in 1986, each focusing on a domain of the health sector, all directed to provide information on how organization of health care policy affects efficiency of health care delivery. The 1st 3 consultancies were sponsored by REACH (Resources for Child Health): on health care financing, increasing the efficiency of health services, and information for private sector health and family planning. By The Enterprise Program was health and family planning policies and laws in relation to provide sector expansion. JSI (John Snow, Inc.) contributed a study on prospects for health insurance and pre-paid delivery. Financing and management of the ASKES (health care insurance for civil servants) and PKTK (social security funded health insurance for employees of private firms) was assessed. Inefficiencies in the hospital sector open up possibilities of deferring funds to preventive care. The most glaring inefficiencies are unused beds and poor cost recovery; the greatest needs in private hospitals are preventive services. Information needs for a private sector hospital-based scheme include facilities for policy analysis and the mechanics of data acquisition and management such as provider and household surveys, computerization, data bases. Policies and laws as related to expansion of service delivery by the private sector were discussed. The government should make a permanent commitment toward privatization, but the process is best done stepwise. The last abstract focused on policies for private health insurance development, after a thorough review of existing and prospective health insurance and pre-paid delivery systems. It was suggested that a central health insurance organization be established, that several model plans be studied for fit to the policy, and that an analytical health economics data base be put in place to monitor efficiency. The abstracts pointed out recommendations for USAID, among the overall suggestions.
Fertility of American women: June 1990.
In the U.S. during the period between 1960-1964, 52.2% of all single 15-34 year old women who were carrying their 1st child married before delivery whereas only 26.6% did in the period between 1985-1989. During 1960-1964, 30.75% of all black women who had conceived their 1st child before marriage married before the child was delivered, but by 1985-1989, this percentage fell to 8%. The corresponding percentages for white women were 61-34%. In 1985-1989, 23% of all Hispanic women who premaritally conceived their 1st child married before the child was born. The greatest rise in fertility in the 1980s occurred among women in their 30s. For example, between 1980-1990, it climbed from 60-80. 4 births/1000 women for women 30-34 years old. It rose from 26.9-37.3 for 35-39 year old women. Further 53.1% of 18-44 year old mothers with infants were working in the period in June 1990 while only 38% were working in June 1980. The overall fertility rate for all 15-44 year old women in June 1990 stood at 67. Hispanic women had significantly higher fertility rate (93.2) than non-Hispanic women 65.2, and Asian or Pacific Islander women 58.1. Even though more women married >1 time during their life, most experience their 1st birth before or during their 1st marriage (28.5 and 64.3 respectively). In June 1990, for all women between 18-34 years old, the lifetime expected births was 2273/1000 women. Based on the results of the 1990 census, the US Census Bureau concluded that a considerable fall in the preference of unmarried couples to marry before the birth of a child just to refrain from having an out of wedlock birth contributed to the increase in premarital births in the U.S.
Sociodemographic factors influencing the home treatment of diarrhea: a comparison of the Philippines and Zaire.
Researchers used 1987 and 1990 data on 1200 caretakers of <5 year old children in rural and urban areas of the Philippines and 1153 similar caretakers in Lubumbashi, Zaire to determine if individual qualities or past use of medical services was the better predictor of home treatment for children with diarrhea. They could only compare ever use of oral rehydration therapy (ORT) packets, Oresol, and sugar sale solution (SSS) in both countries. Health workers promoted home mixing of SSS in Zaire while in the Philippines consisted of distribution of Oresol through medical services. More caretakers ever used ORT in Zaire (64.4%) than in the Philippines (29.9%). In the Philippines, a positive significant link existed between past use of private medical services and home use of antibiotics/antidiarrheals (p<.05), but a less significant positive association existed between health centers and antibiotics/antidiarrheals (<.12). Media exposure also had a positive association with antibiotics/antidiarrheal use (p<.1). Further if caretakers used private medical services, they tended to not use herbal medicine (p<.05). If they visited health centers, however, they tended to use herbal medicine (p<.05). There were significant positive relationships between ever use of Oresol/SSS and past use of modern medical services in both Zaire and the Philippines (p<.05). Specifically, in the Philippines, the relationship between Oresol and past use of private medical services was less strong than it was with health centers (odds ratios 1.34 vs 2.52). In terms of other variables, ever use of Oresol/SSS was positively linked to media exposure and negatively linked to wealth in the Philippines (p<.05). Yet, in Zaire, ever use of Oresol/SSS was only significantly related to education (p<.05). In conclusion, the single strongest predictor of home treatment of diarrhea was part contact with medical services.
Long-term injectable use does not increase risk of breast cancer, but it may lower bone density.
1 hospital in Nairobi, Kenya; Mexico City, Mexico, and Chiang Mai, Thailand and 2 hospitals in Bangkok, Thailand took part in a WHO sponsored collaborative study to examine the association between depomedroxyprogesterone acetate (DMPA) and breast cancer. The researchers compared 1979-1988 data on 869 hospitalized women with breast cancer with 11,890 hospitalized women with unrelated conditions. 12.5% of cases and 12.2% of controls had ever had an injection of DMPA. Overall ever users had no significant increased risk of breast cancer (relative risk [RR], 1.2) In addition, risk did not rise with duration. Nevertheless current users who began receiving DMPA within the past 4 years did have a significantly higher risk (RR 2.6). On the other hand, current users who began receiving DMPA >5 years earlier were not at increased risk at all. For example, the RR for those who began 8-12 years earlier was 0.8 and for those who began >12 years earlier was 0.5. Further even though the current users <35>2 times as likely to have breast cancer than their corresponding counterparts who did not use DMPA (RR 2.2), the risk according to duration was not significant. The researchers listed some possible reasons for the discrepancies. They concluded that there is only a weak association between DMPA and breast cancer--comparable to that between oral contraceptives and breast cancer. In New Zealand, a case control study of 30 25-51 year old women who used DMPA for at least 5 years showed that long term use of DMPA significantly reduced bone density. For example, for DMPA users, the spine and femoral neck bone densities were 8% and 7% respectively lower than the premenopausal controls. The researchers found the same effect even when they restricted the analysis to nonsmokers.
Tubal sterilization may confer some protection against ovarian cancer.
As part of the Cancer and Steroid Hormone Study, researchers compared data from 494 women who had ovarian epithelial cancer with data from 4238 women who had at least 1 ovary to examine the association between ovarian cancer and earlier tubal sterilization and hysterectomy. Women who experienced only a tubal sterilization had a decreased risk of ovarian cancer than never sterilized women (relative risk [RR]=0.69), but this risk was only statistically significant for women who had the sterilization 5-9 years earlier (RR=0.55). Indeed, for women who underwent sterilization 15 years earlier, the RR was >1. Similarly women who had only a hysterectomy had a decreased risk of ovarian cancer (RR=0.55), but this risk was only statistically significant for women who had the hysterectomy 5-9 years earlier. Specifically, regardless of age at the time of hysterectomy, women who underwent the hysterectomy <9 years earlier had a significantly lower risk of developing ovarian cancer than nonsterilized women (RR=0.31 for women <40 and RR=0.51 for women =or+ 40). Women who underwent the hysterectomy =or+ 10 years earlier were no less likely than nonsterilized women to develop ovarian cancer. Besides women who had a hysterectomy and 1 ovary removed were no less likely than nonsterilized women who still had both ovaries. Other analyses revealed that women sterilized at <35 years old and =or-9 years earlier were much less likely to develop ovarian cancer than nonsterilized women (RR=0.45), but the RR for women =or+ 35 years old, regardless of duration, was not lower than that of nonsterilized women. The researchers concluded that the 2 pelvic surgeries may have caused hormonal, mechanical, or circulatory changes that reduced the risk of developing ovarian cancer.
An analysis of etiological risk factors and subsequent fertility.
The incidence of ectopic pregnancies has increased significantly in the region around Oulu, Finland from 10.9-20.9 between 1973-1982. Increased use of IUDs and a comparable increase in the percentage of 2-paras correlated with the increase in ectopic pregnancies in Oulu. A Finnish researcher examined retrospective and prospective age and parity matched case control studies among 552 women with ectopic pregnancy and a follow up study of infertile women to determine the risk factors for ectopic pregnancy. Previous pelvic surgery, particularly tubal surgery and treatment of an earlier ectopic pregnancy; entry of the uterine cavity with medical instruments; gynecological infections; infertility; and an IUD were significant risk factors for ectopic pregnancy. For those women who had suffered an ectopic pregnancy and were infertile, the risk factors included ectopic pregnancy; tubal surgery, especially surgical restoration of a Fallopian tube, and working in industry. The study could not determine reasons nulliparous women experienced and ectopic pregnancy. Infertile women who had pelvic infections, tubal surgery, and/or an earlier ectopic pregnancy had a high risk of ectopic pregnancy. 70% of the ectopic pregnancy patients underwent a salpingectomy. Of the 323 women who wished to conceive again, the conception rate was 82%, delivery rate 64%, and recurrent ectopic pregnancy rate 11%. The operation method was not as an important predictor of subsequent fertility as were condition of the tube and parity. Research is needed to identify risk factors for ectopic pregnancy for nulliparous women. Physicians should consider any woman who is infertile and had a previous ectopic pregnancy, tubal surgery, and works in industry to be at high risk for ectopic pregnancy and use modern diagnostic tools to distinguish between ectopic and intrauterine pregnancy during the 5th week of amenorrhea. As for fertile and parous women with an IUD in situ, they should consider an ectopic pregnancy if pain and bleeding develops.
Parentage determination on aborted fetal material through deoxyribonucleic acid (DNA) profiling.
The feasibility of using DNA typing to identify the probable biological father of the fetus is rape cases was assessed in 10 abortuses, 4 abortions by vacuum aspiration and 6 by prostaglandin. In 2 cases chorionic villus material, and in 6 cases fetal material such as lung, blood, muscle or ribs was used, but in 2 mixed maternal and fetal tissue had to be used. DNA typing was performed by standard techniques using purchased DNA probes (Lifecodes Corp, Valhalla, New York). After visual inspection of matching alleles, results were verified by computer-assisted image analysis. A randomly selected French population of 300 constituted the reference database. In Case 1, maternal and fetal tissue was mixed, but a definite paternal band was evident. In 8 other cases there was strong evidence of paternal DNA bands. In the last case, a paternal band was apparent, but no suspect was available at the time.
Contraceptive needs and logistics management.
This report provides an overview of the Follow-up Consultative Meeting on Contraceptive Requirements in Developing Countries in the 1990s, a meeting convened by UNFPA on May 31, 1991. Over 40 representatives from donor countries, developing countries, intergovernmental organizations, and nongovernmental organizations attended the consultative meeting. The report first summarizes the proceedings and then presents 4 technical papers that were prepared for the meeting. The meeting itself focused on the following agenda items: 1) country-specific estimates of contraceptive requirements, including current status, methodological problems, and future plans and options; 2) program needs for logistics management of contraceptives; 3) options for local production of contraceptives; 4) coordinated procurement of contraceptives; and 5) future resource needs for contraceptives. As it was pointed out during the meeting, just to maintain the developing world's combined contraceptive prevalence of 51% will require providing contraceptives to an additional 108 million married women of reproductive age. A recurring theme at the meeting was the impact of AIDS on the logistics management of contraceptives. The report provides a summary of the discussions and conclusions reached by the participants. The 2nd section of the report contains the following papers presented at the meeting: County-Specific Estimates of Contraceptive Requirements, Programme Needs for Logistics Management of Contraceptives, Options for Local Production of Contraceptives, and Coordinated Procurement of Contraceptives.
Norplant in Brazil: implantation strategy in the guise of scientific research.
An investigation of Norplant clinical trials conducted in Brazil uncovered serious irregularities, contraindications, and methodological errors. With authorization from the Ministry of Health, the University of Campinas' Mother-Child Disease Control and Research Center initiated Norplant trials in 1984, at a time when the country lived under a military dictatorship and the public had little knowledge or influence over government decisions. But with the political change and increased democratization that occurred the following year, feminist groups succeeded in pressuring the government to establish a Committee for Studies of Human Reproductive Rights within the Ministry of Health. Researchers began evaluating the Norplant clinical trials and discovered a host careless and unethical practices. While the project had planned to try the implants on 2000 women, it ended up involving 3589 women (some of whom were as young as 14). Interviews with participants revealed that many did not know that they were taking part in research. Not only was there no informed consent involved, the women were actually required to sign documents giving them terms of responsibility -- in effect, passing on to them all the responsibility of any harm caused by Norplant. The women were given little information of possible side effects (such as weight gain and bleeding irregularities) and were induced to commit themselves to long-term use of the contraceptive. The investigation also revealed that the study had failed to set up criteria for participation and kept poor follow-up records. Because many of the women were poor and transient, the study simply lost contact with many participants. These and other findings prompted the Ministry of Health to cancel the trials in 1986.
Biologic features of HIV-2: an update.
The history, serology and epidemiology of the new human T-lymphocyte retrovirus HIV-2 are reviewed. This relative of HIV-1, the cause of AIDS, was discovered in Senegal in 1985. Sera from persons harboring HIV-2 have antibodies more closely resembling those against SIV, the primate immunodeficiency virus, than HIV-1. HIV-2 shares 40% of its genome with HIV-1, binds to the same lymphocyte CD4 receptor, and binds by a similar viral envelope glycoprotein, gp120. In contrast to HIV-1, HIV-2 replicates more slowly, and demonstrates less cell killing and syncytial cell formation than HIV-1. People with HIV-2 react positively to about 80% of the early ELISA tests for HIV-1. Many HIV-1 positive patients have high antibody titers to some of the shared antigens. In some countries, e.g., Burkina Faso and Ivory Coast, significant proportions of sera react to both HIV-1 and HIV-2 tests, and are called "dual reactors." To tell whether a person is really infected with both viruses, the definitive diagnosis would be virus isolation or polymerase chain reaction studies. ElISA tests are being designed to distinguish both viruses. There are at least 4 patterns of dual infection according to prevalence of each HIV type. Generally HIV-2 is endemic in West Africa, and less common in the former Portuguese colonies, Mozambique an Angola, while HIV-2 is prevalent in East Central Africa. HIV-2 is spreading to other countries by travellers. There is very little information on the natural history of HIV-2 infection. No large case-control or prospective population-based studies are available. HIV-2 infection is transmitted by the same routes as HIV-1, except the perinatal transmission rate is low. Rates of ARC and AIDS-like disease are believed to be low, and the prevalence in the population, predominantly in older adults, suggests that HIV-2 has been endemic in West Africa for at least 18 years.
Environmental health conditions and cholera vulnerability in Latin America and the Caribbean.
Epidemic cholera reached South America in January 1991 and later spread to Central America and the United States. It afflicted 312,000 people and claimed 3200 lives. Since cholera had not been in Latin America for almost 70 years, health authorities allowed environmental health barriers to cholera collapse. For example, the Governments of the Region agreed in 1961 to abide by the Charter of Punta del Este to provide water and sewerage to 70% of the urban population and 50% f the rural population by 1971. They did not achieve their goals for the rural population. In fact, at the end of 1988, water was piped to 79% of the urban households and an additional 11% of the urban population had access to a public water source. Sewerage services served 49% of the urban population and, with other methods of excreta disposal, 80% of the population had adequate excreta disposal. On the other hand, only 55% of rural inhabitants had access to either piped water or public standpipes. Further sanitary excreta disposal services only covered 32%. Besides the water quality of existing water supply systems was poor. Since feces of infected people have as many as 1 billion Vibrio cholerae and , in some of Vibrio, up to 80% of carriers exhibit only mild symptoms or no symptoms at all, it is easy to understand how cholera took hold in Latin America. Researchers identified the points of contamination responsible for the cholera outbreak in Piura and Trujillo, Peru to be wells, distribution systems, and house. Annual population growth in Latin America at 2.6% poses specific problems to providing enough water and sanitation services to all in need, especially those in marginal areas around the cities (who will make up 40% of the population by 2000).
Postpartum contraception: perspectives from clients and providers in six countries.
This article presents preliminary findings of a study conducted by the Association for Voluntary Surgical Contraception (AVSC) designed to investigate women's interest in postpartum contraception and the preferred timing for getting information. A pioneering study, AVSC's research took place in Colombia, the Dominican Republic, India, Kenya, Mali, and Turkey. In each countries, AVSC conducted 4-6 focus groups with pregnant women, interviews with 100 postpartum women, and interviews with 30 service providers. While a final report is due out in January, AVSC has established some preliminary findings. Except in Turkey, more than 1/2 the postpartum women said that they would have been interested in receiving family planning information before and during pregnancy. In nearly all the countries, the unmet need for information was great. Only in Mali and Kenya, where AVSC introduced postpartum IUD projects last year, was there less of an unmet need. While 40% of Kenyan women leaving the hospital after delivery had adopted a contraceptive method, only 3% and 2% of the women in the Dominican Republic and Turkey, respectively, were leaving the hospital with a method. The overwhelming majority women thought that family planning should be provided prior to pregnancy or during prenatal care. Focus group discussions revealed that virtually all women thought that during labor was a bad time to get information, and that information could be given during postpartum visits or before a woman leaves the hospital after delivery. Responses by service providers were similar to those of women, except that most thought it would be appropriate to discuss family planning during labor. AVSC will use the findings of this study to design informational materials for postpartum contraception programs.
Catholics against the Church: anti-abortion protest in Toronto, 1969-1985.
In the first systematic sociological and historical investigation of the Canadian anti-abortion movement, Professor Michael Cuneo examines the deep ideological divisions within the Canadian Catholic Church over this explosive issues. Cuneo's central thesis holds that, paradoxically, the anti-abortion movement views the institutional Catholic church with contempt, and that the abortion issues serves as the point of fracture for a widening ideological rift within Canadian Catholicism. The anti-abortion movement has given rise to competing conceptions of what constitutes proper episcopal leadership, of what it means to be and what is required of a Catholic, and of what the church's relationship is towards Canada's pluralistic ideal and political culture. The first 3 chapters of the book trace the deteriorating relationship between the anti-abortion movement and the Catholic church over the past 2 decades. What began as a enterprise of political reform, explains Cuneo, has become a religious crusade. Nowhere is this more evident than in toronto, where militant Catholic activists (Catholic Revivalists) have condemned mainstream Catholics as apostate. The 4th and 5th chapters focus on the internal composition of the anti-abortion movement, which is itself not monolithic. Chapter 6 examines more closely the ideological and organizational tensions within Canadian Catholicism that have been raised by the abortion issue. Cuneo notes that perhaps the most significant contribution of his study is the discovery that militant Catholic anti-abortion activists form a distinct subculture within Canadian Catholicism. Finally, Chapter 7 examines the cultural and ethical views of the Catholic Revival subculture.
Post-partum family planning in Honduras.
This report describes the postpartum family planning program of the Honduras Social Security Institute (IHSS), outlines the problems facing the program, and provides possible solutions. IHSS facilities include 1 hospital, 3 out-patient clinics, and 1 family planning clinic open to the general public. IHSS attends to 2 types of clients: insured (regular workers with full coverage) and uninsured (dependents of regular workers, covered until 42 days postpartum). The hospital offers sterilization services, while temporary contraceptive methods are available at the family planning clinic and out-patient clinics. Problems for postpartum services include: acceptance of postpartum services is low (9.1%); less than 20% of women return to for their scheduled 40-day postpartum visit; uninsured women lose services after 42 days; risk of subsequent pregnancies means increased health risk for mothers and children and larger expenditures for IHSS; and there remains a large demand for family planning services. The report provides data on reproductive risk factors and demand for family planning among women in the postpartum recovery area of the hospital. Several factors are involved in the low acceptance rate of postpartum contraception, including: no systematic orientation is provided on reproductive health; contraception is offered only immediately postpartum; there is a limited number of contraceptive options available, but many requirements for sterilization; and there is little effort to ensure follow-up care. To address these problems, the report suggests: obtaining reliable periodic data for project monitoring; increasing contraceptive options; providing education during prenatal care; providing reproductive health counseling; and increasing the rate of follow-up visits by offering a wider range of services.
Chronic maternal morbidity in developing countries: data synthesis and policy suggestions.
Chronic conditions induced by pregnancy complications and labor or delivery are termed chronic maternal morbidity. A Nigerian gynecologist suspects that for every maternal death 10-15 women experience permanent damage as a result of pregnancy or childbirth which equals 5-7.5 million women annually worldwide--1 in 250 reproductive aged women. A 1989 WHO working group suggested that researchers conduct community based studies to examine the extent of morbidity which lasts >42 days after delivery to get a more accurate picture of chronic maternal morbidity. Based on data from East Africa, the leading chronic maternal condition is genital prolapse, often a direct result of high parity, which results in more bladder infections, urinary continence, or intra-abdominal pressure. The average incidence ratio for genital prolapse is 2300/100,000 live births (range 180-4200). Based on studies from India and West Africa, the 2nd most common condition is secondary infertility (1200-1300) mainly caused by septic abortion and puerperal infection. A study from Ethiopia reveals genital fistulae (55-80) as the next most common condition which are generally a result of prolonged obstructed labor. The next 3 leading causes are postpartum hypopituitarism (30-60), obstetric palsy (6), and gynatresia (0.4-0.7). Based on a review of the literature, the overall incidence ratio of chronic maternal morbidity stands at 3592-3747 which equals 5.75-6 million women worldwide and for every maternal death 12 women experience chronic maternal morbidity. Use of family planning services prevents multiparity thus genital fistulae. Except for genital fistulae, 4 of the leading causes of chronic maternal morbidity match the leading causes of maternal mortality (abortion, infection, hemorrhage, and obstructed labor). Thus efforts aimed at preventing maternal mortality will also prevent chronic maternal morbidity.
Risk factors for HIV among low-income women undergoing voluntary sterilization.
The family planning clinic at the Baylor College of Medicine in Houston, Texas participated in a blind surveillance project administered by the local health department to determine city wide and site specific HIV prevalence rates. In 1989, clinic staff spoke to 468 women who came to the clinic for a tubal sterilization to determine if they would have a lower incidence of some HIV related risk factors than the general population. Most of the women (43%) were Hispanics. Almost all the remaining women were either Black or White. The household income of 75% of the women who reported income was <$10,000/year. The age of 63% was <30 years old with 28% of all women <25 years old. The fertility rate stood at 2.7 compared to the US rate of 1.8. 24.8% of the women revealed at least 1 risk factor for HIV. Further, 20 of the 116 women who did report a risk factor reported 2 risk factors. 61.2% of women with at least a risk factor for HIV and 15.2% of the total study population mentioned previous sexually transmitted disease (STD). The STDs included gonorrhea (34%), syphilis (22%), chlamydia (22%), and herpes (12%). The next highest risk factor was high risk partner (27.6%) and earlier blood transfusion (21.6%). Only 11% of all subjects did not use contraception before tubal sterilization and 3% used oral contraceptives compared to 13% and 22% respectively the percentages the researchers expected. Only 23% used condoms and/or spermicides, however. The researchers were concerned that this percentage would fall after sterilization since these methods would no longer be needed to prevent pregnancy. The researchers concluded that this population was at no greater risk of HIV than the general population. Nevertheless they emphasized the need for researchers to examine interventions targeting behavioral change for sterilized women.
Managers, mothers, health workers and improved immunizations services in the Central African Republic.
Between 1988-1991, the Department of Preventive Medicine of the Ministry of Health in the Central African Republic implemented a training program for health workers, mothers/caregivers, and program managers to improve vaccination coverage. It had conducted 5 workshops with 325 health workers from 135 vaccination sites during this period. Pre-and post health worker practices assessments revealed that even though patient education improved considerably, it remained the weakest performance indicator. Nevertheless the training program of health workers was successful and the Department adopted this training strategy for all national programs including diarrhea control. The Department follow up the training of health workers with a culturally appropriate national education program encouraging mothers/caregivers to use the improved immunization services. It designed a popular mobilization strategy consisting of the oral tradition of interpersonal communication and a media mobilization strategy including radio, television, and the press to reinforce oral messages. The 2 strategies occurred at the same time. About 2000 community mobilizers spread messages via popular theater, stories, and songs in markets, churches, homes, and village gatherings. Health workers imparted immunization education via the warmth chain approach--a series of educational encounters, e.g., congratulate the mother for the immunization visit. Trained observers noted that the immunization program managers made optimal use of resources, established strong institutional and human relationships with donor organizations, managed effectively its budget, and reported often and communicated openly among themselves. In conclusion, development of institutional and human capacities can increase vaccination coverage and sustain success in the long term effectively than mass immunization campaigns.
Strategies for the evaluation of in-service training in child survival.
A behaviorist shares lessons learned about evaluation techniques from inservice training in Nigeria and the Ivory Coast. She stresses the need to evaluate implementation of training activities in addition to outcomes. This helps in understanding why the training works or does not work. For example, in Niger State, Nigeria, workshop leaders assess skills and knowledge of participants when they attend the workshop by using stations where participants must perform a target activity and by standardized checklists leaders use to observe participants. After undergoing similar post-tests, workshop leaders discuss the evaluation with everyone. Skills assessments help trainers know skill levels of participants and deficient content areas. They also allow the participants more opportunity to practice new skills under supervision. Another lesson is that as valuable as facility based assessments are they may not be worth the considerable resources and expertise that go into them. In the Ivory Coast, she trains health workers in supervisory and managerial skills. She observes them before and 6 months after the training. The training sometimes results in a large increase of trainees who read reports from health facilities and provides feedback, but a decrease in those who design programs and only a slight rise in those who forward information to the supervisor, Facility based assessment needs to be simplified to result in its implementation by program managers. This should assist them to increase their understanding and interpreting of data. The 3rd lesson was, in addition to evaluating program objectives, the system need to be evaluated. For example, shortages of commodities and medicines often exist at health facilities in Nigeria and the Ivory Coast, so no matter the skills and knowledge levels, proper treatment cannot occur. Thus when researchers evaluate the system, barriers to reaching goals can be identified.
Current and future dimensions of the HIV / AIDS pandemic: a capsule summary.
Drawing from most recent data available to the WHO Global Programme on AIDS in April, 1991, the current status and future trends of HIV infections and AIDS worldwide are summarized. The report opens with general information and comments on the pandemic, then examines HIV infections and AIDS regionally for Australasia, North America, and Western Europe; Latin America and the Caribbean; Sub-Saharan Africa; South and South-East Asia; East Asia and the Pacific; Eastern Europe and the USSR; and North Africa and the Middle East. Estimates and projections of HIV infections and AIDS are then presented in graphical format. This HIV pandemic is highly dynamic, and expected to have a selective and major impact on the mortality of young and middle-aged adults in both industrialized and some developing countries over the next 10 years. HIV infection incidence and AIDS are far from confined to certain groups perceived to be at high risk of infection, but is increasingly spread among heterosexuals worldwide. 70% of HIV infections worldwide are estimated to have been spread through vaginal intercourse. Children are not left out of the epidemic; child mortality from AIDS will most likely offset gains in child survival achieved over the past 20 years. For now, HIV incidence is decreasing in Australasia, North America, and Western Europe, while on the rise in many developing countries. Educational strategies to modify or eliminate risk behaviors remain the primary interventions available to prevent and control the continuing spread of HIV.
Risky sex. The onslaught of sexually transmitted diseases.
A specialist in obstetrics and gynecology, the author of this book seeks to educate the public about the alarming problem of STDs and to provoke action. Including his own experiences in confronting the crisis, the author outlines the extent of the problem, its implications, and strategies for confronting STDs. Chapter 1 explains the need for a book on STDs, a problem that has gone largely unnoticed but which is responsible for great human suffering. Examining how often STDs occur, chapter 2 reveals the staggering dimensions of the problem: 1 in 20 teenagers and young adults worldwide contract some type of STD each year; it is estimated that in the US alone some 26-31 million people are currently infected with genital herpes; 4 million cases of chlamydial infection occur each year in the US; the AIDS epidemic has already devastated many African villages and has become one of the leading causes of death in many US and European cities. Chapter 3 discusses common STDs, including gonorrhea, chlamydia, syphilis, human papilloma virus (HPV), genital herpes (herpes simplex virus), AIDS and HIV, and nongonococcal urethritis. The remaining chapters go on to discuss what the experts and statistics say about the problem, how one can recognize an STD, how one can get rid of an STD, the possible complications arising from STDs, condom use, whether STDs can affect newborn children, and teenagers' risk of contracting an STD. The las chapter of the book discusses ways of addressing the STD crisis, focusing on the value of sex education and the ethical issues involved in such a venture.
Developing communication strategies and programs: a systematic approach.
This handbook is intended help improve the effectiveness of development programs through the appropriate use of communication and social marketing strategies and techniques. UNICEF developed the handbook in order to better utilize communication and social marketing in the achievement of Child Survival and Development goals. The handbook has 3 functional uses: it can serve as a guide for planning and implementing development programs; it can be used as an evaluation and monitoring tool by both program administrators or outside evaluators; and it can serve as a textbook in training workshops designed to improve communication skills -- particularly with respect to public health issues. The handbook begins with an conceptual discussion of communication and social marketing. The handbook then provides 10 interdependent modules involved in the development of a communication or social marketing program: problem identification, audience analysis, examining social factors, identifying obstacles, setting objectives, developing a strategy, material production, pretest and piloting, launching and monitoring, and evaluation. Additionally, the handbook contains the following appendices that can be useful in fulfilling one the handbook's 3 functions: exercises, a sample of a survey questionnaire, a sample of a pretest questionnaire, a sample of a moderator's guide for a focus-only group, request for proposals, a sample request for proposals, a sample of a proposal evaluation sheet, audit of evaluation research, an assessment checklist for research and evaluation reports or proposals, a checklist of contract provisions, media selection and mix matrix, and other additional aids.
Trip report. Information, education and communication programming and evaluation technical assistance. The Arab Republic of Egypt.
This publication reports on a visit to Egypt by a team from the Johns Hopkins University/Population Communication Services (JHU/PCS), which provided technical assistance on information, education, communication, and evaluation to several agencies. The JHU/PCS team consisted of Ms. Bushra Jabre, chief of the Near East Division, and Dr. Mohamed Wafai, senior research and evaluation officer. From December 6-25, 1991. Jabre and Wafai: 1) helped write the 1992 workplan for the State Information Service Information, Education, and Communication (SIS/IEC) Center; 2) helped SIS/IEC start a baseline and evaluation service (the survey is to be conducted by the Al-Ahram research center); 3) finalized a plan for the Minya IEC Initiative; 4) monitored the Ministry of Health (MOH/SDP) training workshop; 5) assisted the Clinical Service Improvement project (CSI) in developing a plan for evaluating its counseling training program; 6) and helped The Egyptian Junior Medical Doctors' Association (EJMDA) seek bids for evaluating its media campaign. The report presents the following observations: all parties involved were enthusiastic about the Minya IEC Initiative; the new SIS/IEC director, Mrs. Sawsan El-Bakly, shows strong support for the IEC campaign, and favors delegation and decentralization, and increased IEC management training for the staff; MOH feedback indicates that the Center for Development Services has emerged as an excellent training organization. Additionally, the report suggests that it is more efficient to contract an outside agency to conduct research than having the organization itself carry out research. The report provides recommendations for JHU/PCS.
The use of anthropology for policy and program development: acute respiratory infections (ARI) in Lesotho.
The Children <5 years old of Lesotho have long experienced a high rate of acute respiratory infection (ARI) since they live in a mountainous country. The mountains hamper their access to health facilities for treatment. In 1989, researchers used an anthropological approach to design and implement a community wide study to determine if caretakers of children <5 years old understood ARIs. The study also intended to ascertain how caretakers define, diagnose, and treat ARI and to authenticate the customs, traditions, beliefs, and behaviors surrounding Lesotho definitions of ARI. Even though the caretakers claimed letsoejana (pneumonia) was not as common as sefuba (common cold), letsoejana had the higher mortality rate (16% vs. 3.1%). The predominant form of treatment caretakers used for ARIs were aspirin (56%) and herbal medicines (30%). 78% of the caretakers changed the way they dressed their child who had difficulty breathing. In fact, 71% covered the child's breast to conserve heat. Other forms of treatment included wrapping the section of the body which was shaking and removing clothing. The ARI Program of the Ministry of Health in Lesotho applied these findings to develop health education messages. The messages concentrated on making the distinction between ordinary sefuba and severe letsoejana, using Lesotho terms when describing the continuum of ARIs, promoting the proper use of antibiotics and other modern medicines, and disseminating information on positive traditional treatments and health seeking practices for ARI. The ARI Program identified the following groups at target groups: caretakers, the community, community health workers, and clinic staff.
Dietary inadequacy in El Salvador.
Researchers conducted a dietary survey of 59 households selected at random in the marginal community of Peralta in San Salvador, El Salvador to ascertain nutritional needs of the families and identify factors which affect intrafamilial distribution and consumption of food. A nutritionist weighed all the food consumed by each family member in 1 day. >50% of the family members consumed just grain, sugar, oil, and/or beans. 93% of the people ate <90% of the required quantity of vitamin A. 88% ate inadequate amounts of riboflavin, 77% iron, and 40% protein. Moreover 58% of the households spent 61-100% of their income on food. No association occurred between caloric sufficiency and family size and between age and dietary adequacy. Therefore each family evenly distributed food among family members. Further poorer families consumed less food than the families of the higher socioeconomic group.
Sperm hyperactivation as quality control for sperm penetration assay.
The sperm penetration assay (SPA) performed on patients having in vitro fertilization (IVF) is subject to wide individual variation, so a sperm hyperactivation assay was explored as a quality control check for SPA results. Sperm hyperactivity (HA) refers to helical, thrashing, circling or star-spin, with wide amplitude head and tail activity, but no forward motion of human sperm. HA occurs 2-6 hours after incubation in washing medium during the precapacitation phase. The SPA test uses zona-free hamster, oocytes, and involves 3 spin washes in medium, a 3-hour preincubation or 21-hour preincubation, before incubating sperm with hamster eggs for 3 hours. HA was estimated by observing and counting sperm under light microscopy. Linear regression SPA in the 0-50% range and HA tests produced a significant correlation of 0.688 (p=0.001) for the 3-hour preincubation sample, but no significant correlation for the raw semen, 1st washing, or 21-hour preincubation samples. 20% of greater SPA is considered acceptable for doing IVF, therefore 20% on the HA assay would be an acceptable quality control result. A mean of 20% HA was reported by others.
Epididymectomy for post-vasectomy pain: histological review.
Epididymectomy was performed on 10 men with intractable post-vasectomy pain, on 7 with chronic epididymo-orchitis and 7 with epididymal cysts. The vasectomy patients had pain of mean 6 years duration, 6 months-20 years after surgery. In 9 the pain was a constant, dull ache. 5 had unilateral, and 5 bilateral epididymectomy. Only 5 were relieved of pain: 1 subsequently had orchidectomy with symptomatic improvement. The other 4 were offered orchidectomy. There was no obvious association of clinical findings with results. All 7 patients with epididymo-orchitis were relieved, although 1 required orchidectomy. 4 of the 7 with cysts had complained of pain, and all were asymptomatic after surgery. The most common pathological findings in the vasectomy patients were obstruction and dilatation of the efferent and epididymal ducts with interstitial fibrosis, and perineural inflammation and fibrosis around nerves, particularly in the tail of epididymis. So-called "late vasectomy syndrome" or unremitting pain is rare, and probable related to sperm granuloma.
Against a sea of troubles: AIDS control in Uganda.
The government of Uganda began its anti-AIDS campaign in 1986. A year later with AIDS Support Organization opened its doors as the situation worsened. Today it provides counseling and health care services for AIDS patients and trains counselors. It operates support centers in 8 districts. Staff make home visits to AIDS patients who reside within 20 km of a support center. Women and children comprise the majority of patients. Even though changes in behavior could restrict AIDS, social, economic, and cultural obstacles exist. For example, in some areas of Uganda, society expects the brother of a decreased man to have sexual intercourse with the widow and to be responsible for her and her children. His life and that of his wife or wives are in danger if the brother died of AIDS. Community workers encourage people to engage in practices that do not spread AIDS. This program provides training on AIDS awareness and community mobilization, counseling by community members, medical services, educational materials, and promotion of income generating efforts. Even though the most effective way of preventing the spread of HIV when having sexual intercourse is using a condom, cultural reasons and cost hinder its use. Counselors find it difficult to discuss sexual relations let alone condoms. Further promotion of condoms is often interpreted as promotion of immoral behavior. These obstacles have not stopped the AIDS Support Organization from providing information on condoms and it has targeted traditional healers and tribal and religious leaders to help in this effort. Women play a major role in AIDS education. They need to be informed of their rights and empowered to exercise them to improve their status and that of their children. Indeed their empowerment would improve the whole of society.
[Family background, parity, breastfeeding and cancer of the breast]
The possible role of parity, lactation, and family history in the etiology of breast cancer were studied in women aged 40-98 years who were diagnosed with breast cancer through a biopsy at a hospital in madrid. Although the epidemiology of breast cancer has received extensive study throughout the world, a majority of studies were conducted on Anglo-Saxon or Northern European women. Epidemiologic factors in breast cancer have received relatively little study among Southern European women. The variables examined in this work were a maternal or paternal family history of breast cancer, the number of children, number of abortions, and lactation history. 194 women met the requirements for cases including completion of an interview. 288 controls were selected from among 437 women aged 40-98 in the central hospital records who underwent routine examinations to exclude breast cancer. The control were the 288 who returned completed mail questionnaires. The average age was 67.9 for cases and 67.5 for controls. 66.5% of cases and 64.8% of controls were urban residents. A strongly significant association was found between development of breast cancer and history of breast cancer in the mother or sister. Nulliparous women were at increased risk of breast cancer. The cancer risk decreased as parity increased. No epidemiologic or statistical relationship was found with abortion, but only 106 women reported a history for abortion. Women who had been breast fed had a lower risk of cancer. A strong inverse association was found between breast feeding of a woman's own children and development of breast cancer. The duration of breast feeding was also associated significantly with a decreased risk of breast cancer.
Demographic and Health Surveys World Conference, August 5-7, 1991, Washington, D.C. Executive summary.
This report summarizes the highlights and major findings presented at the Demographic and Health Surveys (DHS) World Conference, held on August 5-7, 1991 in Washington, D.C. Funded by USAID and administered by IRD/Macro International, the DHS Program has conducted 36 surveys in Africa, Asia, Latin America, and the Caribbean since 1984. The objectives of the conference were to: disseminate the findings of the DHS Program; consider the policy implications of the findings; and provide an forum for interaction among researchers, managers, and policy makers. The conference attracted over 650 participants from 63 countries. Nigeria's minister of health, Olikoye Ransome-Kuti, delivered the keynote address, which focused on the impact of DHS data on Nigeria's national population policy. Ransome-Kuti emphasized the need for a "new culture" in which information guides population policy and goals. During each of the 3 days, the conference focused on the following: demographic trends in the 1980s, components of demographic and health patterns, and policy issues for the 1990s. Data from 1965-85 reveals a 30% decline in the combined total fertility rate of less developed countries, as well as significant declines in child mortality. The decline in fertility is primarily due to increased contraceptive prevalence -- about 48% in developing countries as a whole. Despite these gains, demand for family planning is high in many places, and most infant deaths are preventable. Priority areas for the 1990s include: concentrating USAID's family planning resources on developing countries with the largest populations; meeting the unmet need for family planning; strengthening the infrastructure and management of health systems; developing improved programs in maternal health and morbidity, perinatal infections, newborn care, and breastfeeding; and identifying high-risk groups.
Dietary vitamin-A deficiency: effects on growth, infection, and mortality.
A vitamin A deficiency condition, xerophthalmia, affects 8-10 million children in developing countries annually. Vitamin A deficiency also has other adverse effects. For example, studies in children show that vitamin A deficiency limits growth. Almost all children with corneal xerophthalmia in cross sectional studies exhibit wasting and stunting. Moreover they also tend to have a preceding severe infection. Researchers do not yet understand the specific mechanisms which lead to wasting and stunting. Increased risk of infection appears to be another adverse effect of vitamin A deficiency. Many studies show a dose-response effect in risk of acute lower respiratory and urinary tract infections in children with xerophthalmia. Further children with corneal xerophthalmia often have a recent history of measles, diarrhea, and both acute and chronic malnutrition. A prospective study in west Java reveals that children with mild xerophthalmia tended to have a respiratory infection and diarrhea and had a 4 fold risk of dying than children with no xerophthalmia. Some trials show that an association existed between vitamin A supplementation and reductions in child and infant mortality (range 10->70%). Even though these studies document the benefits of vitamin A supplementation, in the long term, improving dietary quality is preferable. In fact, weaning foods should consist of yellow fruits and vegetables, eggs, and dark green leaves. Moreover food preparation practices affect vitamin A retention. Breast milk provides a critical amount of vitamin A, which presumably enhances hepatic stores, for weaned children thus allowing them to have sufficient quantities during the 1st to 3rd years of life.
Fermented cereal gruels: towards a solution of the weanling's dilemma.
Contaminated weaning food contributes to an increase in diarrhea for infants in the transition period between exclusive breast feeding and a mixed diet. Further 2 public health specialists believe that between 15-70% of diarrhea episodes are linked with improper food preparation, handling, and storage practices and feeding methods. Since breast feeding does provide some protection against diarrhea, some health workers advise mothers to breast feed as long as possible. Yet long term breast fed children can become malnourished as breast milk cannot sustain growth. So health workers must weigh the relative risk of starting and delaying weaning--the weanling's dilemma. In many developing countries, mothers prepare fermented foods as weaning foods. These acidic foods (
Antibiotic interference with oral contraceptive steroid efficacy.
Dentists prescribing antibiotics to women of childbearing age should be aware that current lower dosage oral contraceptives may fail and cause pregnancy, putting the practitioner at risk for damage claims. The most common antibiotics used in dental practice that may compromise oral contraceptive efficacy are penicillins, such as penicillin V, penicillin G, ampicillin, flucloxacillin, tolampicillin, amoxycillin and cloxacillin, and tetracyclines, such as tetracycline, oxytetracycline, doxycycline and chlortetracycline. Other common antibiotics include sulfonamides, erythromycin, metronidazole, griseofulvin and cephalosporins. The physiological basis for failure of the combined pill is loss of gut bacteria, and decreased enteric recycling of estrogen metabolites. The reason why progesterone-only pills may fail is unknown, and probably not related to drug interaction. Studies on blood levels of estrogens are conflicting; furthermore, it is impossible to predict which woman is at risk. Dentists should inform all women of childbearing age of possible failure of oral contraceptives. They should attempt to get an accurate drug history from female patients, and insert a signed copy in patients' record. It would be helpful to remind the pharmacist to label oral contraceptive prescription bottles with warnings about concurrent antibiotic usage.
Human immunodeficiency virus-related connective tissue diseases: a Zimbabwean perspective.
A review of patients presenting at the rheumatology clinic of the Parirenyatwa Hospital, University of Zimbabwe School of Medicine, revealed 14 with HIV infections. Over a 6-month period, 141 patients had been diagnosed with rheumatic diseases, including 49 with rheumatoid arthritis, 18 with systemic lupus erythematosus (SLE), 5 with dermatomyositis and 3 with scleroderma. Rheumatic diseases were thought to be rare in this population, of whom only 0.2% carry the HLA B27 antigen. Recently a marked increase in patients with reactive or Reiter-like illness, the most common arthropathy in HIV+ patients, were referred. These 14 patients, mostly males, all had acute onset arthropathy, 5 with polyarthritis and 9 with oligoarticular diseases, usually of the knees and ankles, usually symmetrical, or asymmetrical in the small peripheral joints. Synovial fluid was negative except for leukocytosis. The duration of the illness was usually 3-6 months. In addition there were 3 HIV+ patients with complete Reiter's and 7 HIV+ with incomplete Reiter's syndrome, out of a total of 16 Reiter's patients. Among the associated symptoms were urethritis, cervicitis, conjunctivitis, balanitis and oral ulceration, but not psoriasis. These patients had elevated sedimentation rates, but otherwise negative blood findings, other than anemia. In contrast 36 patients with rheumatoid arthritis and 12 with SLE were HIV-. 2 HIV patients also had septic arthritis, a common condition in Zimbabwe.
Intra-familial relations and the woman's situation: a cross sectional study in two settlements.
This pilot study examines a population attending health centers, Etimesgut (366) and Yapracik (358), in Turkey. The objective was to explore the relationship between age, education, work status, marriage duration, total number of living sons and daughters, ideal number of children, head of the household, and family type, and other variables such as opinions about marriage and having children. The context was rural versus semiurban. Another objective was to investigate the decision making process by specific topics and by what % the woman, husband, both, in-laws, and others contribute. The sample was selected on the basis of a probability proportional size method for rate of use of various contraceptive methods, and the proportion of women aged 15-49 in each health center area. Authority, power, and social status tend to dominate in male heads of households. A statistically significant difference was found for the following variables between semiurban and rural households. Rural women were less educated and had more children and longer marriage durations than semiurban women. It is suggested that marriage age is lower for rural women. Rural women desire more children, which is interpreted as a high fertility preference. Semiurban spouses want more children, which may be due to the low actual childbearing. The father in law as household head is more common in rural areas, as well as the extended family as the type of family structure. Approaching marriage in terms of love is more common in semiurban areas. In rural areas, children are viewed in terms of economic rewards, and as a source of security during illness and old age. Rural women thus reflect more traditional patterns within a large kinship/community system. Decision making findings show that conjugal interaction is comparatively weak for the study population. Women in either areas have little power in decision making, but particularly so in rural areas. In rural areas, in laws contribute substantial power in areas such as visiting friends (33%), communication at home (31.5%), and purchases of clothing (22.5%), daily routine (20.3%) or big items (22.8%) compared to wives 12.7%, 13.2%, 11%, 2.2%, respectively. The author concludes that the results may help determine policies related to women, and suggests further detailed analyses of women's situation and fertility determinants.
Intergenerational patterns of teenage fertility.
Data from the 1988 National Survey of Family Growth IV are used to test the relevance of direct or indirect mechanisms for intergenerational patterns of teen fertility. Mechanisms include biological heritability, intergenerational transmission of values regarding family, the mother's level of fertility, the indirect impact of socioeconomic and family environment through educational deficits or low opportunity or aspirations, and directly through the mother's role modeling. In the analyses, daughter's of teen mothers risk of a teen birth is assessed, the patterns by race over time determined. Logistic regression methods are used to measure the extent to which intergenerational effects can be explained by differences in biological predispositions, and the socioeconomic and family context. The sample of women of childbearing age (15-44 years) overrepresents blacks and teenagers, and this analysis is restricted to blacks and whites <20 years. Dependent variables are whether the respondent had a teen birth, and the pattern of teenage family formation (no teen marriage or birth, teen marriage only, teen marriage and birth, premarital conception followed by marriage, and premarital teen birth). The key explanatory variable is age of the mother at 1st birth, but variables also include religious affiliation, urban residence, birth cohort (1944-48, 49-53, 54-58, 59-63, and 64-68), age at menarche, mother's years of education, having both natural parents at age 14, working mother while growing up, strict home rules, talk with parents about pregnancy, church attendance 1 time/week, having had intercourse <15 years, and use of contraception at 1st intercourse. The results are provided and summarized. The finding are that daughters of both black and white teen mothers face a significantly higher risk of teen childbearing. Differences occur in the marital pattern where most white teen births occur within marriage, and most black teen births do not. The biological explanation for teen childbearing is not supported by the analyses. Racial differences appear in the socioeconomic and family contextual explanation of intergenerational patterns. The multinomial logistic regression supports a strong net effect in all teen pregnancies due to the repetition of marital teen births across generations. Differences in the socioeconomic and family context explain almost completely white premarital fertility, but only partially black fertility. White marital teen fertility and black nonmarital fertility perhaps may be explained by neighborhood and peer environments, but may be affected by the changing role of women and greater opportunity; i.e., recent cohorts are less likely to marry as teens and society accepts childbearing outside of marriage. Unless premarital birth is viewed as limiting life options, the overall trends will remain the same.
Diversity in experiences of parental structure during childhood and adolescence.
Diversity in experiences of parental structure during childhood and adolescence is reported based on data analyses of the National Survey of Families and Households (NSFH) in 1987-88 and the 1988 National Longitudinal Survey of Youth (NLSY) sections on parental structure from birth to age 19. Greater analytical detail is provided than previously reported. The analysis is limited to blacks and nonHispanic whites by birth cohorts in the 1930's, 40's, 50's, and 60's and family structure (mother/father, mother only, mother/stepfather, father only, father stepmother, grandparents, other relatives, other). The other includes those changing a living situation within the year, living with adoptive parents, foster parents, nonrelatives, in institutions, on their own, or none of the options. Findings are reported by living arrangements by age, family type at birth, marital disruption, and family type at age 15. The authors conclude that children living in nonintact types of families at 15 had lived in a combination of intact and nonintact family types. Also, children with nonintact family experiences were grouped 2 ways; those whose mothers were unmarried at the child's birth, and those who lived with a mother and father from birth but marital disruption occurred later. Comparing the 2 groups reveals that those with a birth traditional marriage type lived about 50% of their lives that way, but children of unmarried mothers did not live in mother/father families to any extent. The implications for future research are that nonintact families to any extent. The implications for future research are that nonintact families are diverse and measures should reflect that children with nonintact families have lived in a variety of situations and for differing amounts of time. Also, measures must reflect that children enter nonintact families in 2 ways: nonmarital birth and parental marital disruption. This is an important distinction because a child of a unmarried mother may have little contact with the biological father. Subsequent life course events may be affected. More recent cohorts with higher rates of nonmarital births create a greater necessity to discriminate nonintact families. The limitation of the research is that recent cohorts are excluded; the pattern is likely to be the same but the proportions starting out in mother only families will be greater.
Forms of treatment.
The 2 most common types of malaria, primarily a rural disease, in humans are vivax and falciparum malaria. Health workers can either use antimalarial drugs to kill the parasites or relieve the symptoms and signs of malaria. Primary health care systems in developing countries should have health workers in rural health centers who can treat mild and uncomplicated cases. They should be able to identify severe cases and have them transferred to higher health care levels for treatment. Hospital staff can treat these cases with an injection of quinine, chloroquine, artemether, or sulfadoxine-pyrimethamine. Chloroquine is the predominant antimalarial of choice for uncomplicated cases since it is inexpensive, effective, and safe. Yet many malaria parasites in almost all endemic countries have become resistant to it. In fact, in South East Asia, parasites have even developed resistance to another antimalarial, sulfadoxine-pyrimethamine, so the drug of choice is often quinine. Quinine is also used often in Francophone Africa even though resistance to other antimalarials have not yet developed. Quinine has adverse side effects, however, such as dizziness, ringing in the ears, blurred vision, and shaking. Too much quinine can effect loss of sight and hearing. Nevertheless it is the preferred choice for cerebral and other severe complicated malaria cases. Further many health workers are using injections of the Chinese herbal medicine, qinghaosu or artemisinin, for severe cases since it rids the blood of malaria parasites faster than other antimalarials. Health workers are beginning to use a new drug to treat uncomplicated malaria, mefloquine. Yet resistance to it has already occurred. The ability of parasites to develop resistance highlights the need to screen for drug susceptibility and change treatment appropriately.
Ideas for action.
WHO provides relatively inexpensive and simple ways to combat malaria at the household and community level. An important way of preventing malaria is to avoid contact with malaria parasite carrying mosquitoes. Mosquito nets (bednets) tucked under bedding protect people from mosquito bites while sleeping. They can be sewn by hand of fine mesh cotton or synthetic fibers (nylon or polyester). Individuals can carefully impregnate them with an insecticide such as pyrethrin to make them more effective. Insecticide impregnated bednets also protect against other insects such as bedbugs and cockroaches. Whole communities can participate in reducing insect exposure by buying large numbers of bednets which makes them cheaper than if individuals buy them, by having a joint insecticide impregnation project, or by making them and selling them locally. Primary and secondary schools can incorporate malaria prevention and control into their curricula. It can be part of the natural science courses (life cycles of the malaria parasite and the mosquito) and health education courses (recognizing the signs and symptoms of malaria). Teachers should use active malaria. They can involve the students on field trips where they identify mosquito larva in standing water and/or eliminating breeding places. Teachers should also detect fever cases and report them to health workers. They can also do so by taking note of the length of absence of students and, when the students are absent often and for long periods of time. The best way of combatting malaria in a community is involving everyone to help in the fight.
Changing patterns of disease and mortality in Sub-Saharan Africa.
Since countries in Sub-Saharan African have become independent, researchers have developed relatively inexpensive, simple, and rapid demographic and epidemiologic techniques to collect and present data; to measure the magnitude, distribution, and cause of health problems; and to allow clear evaluation of intervention efficacy. These methods applied to existing data on Sub-Saharan Africa permit a broad overview of epidemiologic and demographic trends and current conditions. Yet many countries do not have the mechanisms to assess basic epidemiologic and demographic conditions which allows them to formulate and implement effective and efficient health sector policies. Countries that have this infrastructure like Zimbabwe can address the broad range health problems. Botswana, Congo, Kenya, Sudan, Zimbabwe have been successful in closing the health gap with other regions which occurs much more quickly than does increasing income. Mortality has fallen considerably in Sub-Saharan Africa, but it has not fallen evenly over time and among and within countries. For example, between 1955-1975, the average annual rate of decrease in mortality for <5 year old children ranged from 3.1 in the Ivory Coast to 0.4 in Malawi. Further, even though life expectancy at birth has increased from 43-51 years in Sub-Saharan Africa between 1965-1988, Sub-Saharan Africa has the lowest life expectancy in the world. Yet mortality among children <5 years old has risen in Ghana and Nigeria and remains poor in the Gambia, Malawi, and Sierra Leone. Maternal mortality and tuberculosis are leading preventable causes of death among adults in Sub-Saharan African. Diarrhea, acute respiratory infection, malnutrition, and vaccine preventable diseases remain predominant causes of death among children.
Acute respiratory infections.
A review of 13 studies on morbidity of acute respiratory infections (ARIs) in Sub-Saharan Africa revealed that a child may have an ARI 25% of the time and 8-13 ARI episodes/year. 3 studies showed daily prevalence to peak between 2-3 years while it peaked during infancy in other studies. Regardless of the peak, it decreased with age. A study in Burkina Faso exhibited the highest incidence (13.2 episodes/year) and the highest prevalence (30.8). The lowest comparable rates occurred in a study in Ethiopia (7.6 and 6.9 respectively). Lower ARIs, especially coughs, accounted for >50% of the ARIs in the Burkina Faso study while lower ARIs, particularly pneumonia and bronchitis, accounted for just 16% of the ARIs in a study in the Gambia. ARIs were responsible for 25-66% of all child morbidity, 9-42% of hospital admissions, and 17-41% of health facility attendances. Pneumonia accounted for most ARI mortality. For example, a hospital study in Kenya found >90% of ARI deaths were attributable to pneumonia. Case fatality rates for pneumonia ranged from 10.3-20.5. Further the cultures of 40% of pneumonia patients in the 7 studies that investigated the etiology of pneumonia grew bacteria. Moreover the isolation rate in 4 of the studies >65%. The predominant pathogenic bacteria was Streptococcus pneumoniae. Penicillin did not ameliorate pneumonia in 10.8% of the adult patients in a study in Zambia and 6.7% of the adult patients in a study in Kenya. Some leading risk factors of ARI among the studies included chronic malnutrition and low humidity. In the Bagamoyo ARI Case Management Intervention Program in Tanzania in 1983, the pneumonia specific mortality rate fell 30.1% over 2 years which equalled only a 39.4% reduction in overall mortality. Despite the information from these studies, insufficient data on ARIs exist in Sub-Saharan Africa.
Malaria.
The highest malaria transmission levels in the world occur in Sub-Saharan Africa due to mosquito vectors Anopheles gambiae and An. funestus which feed often, prefer to feed on people instead of livestock, and live relatively long lives. Further the basic case reproduction rate can be >1000, yet the goal of malaria transmission control is to reduce it to <1. 4 ecological zones identified by degree of malaria transmission exist in Sub-Saharan Africa: continuous and intense in former tropical forests; seasonal and intense in the savanna; it falls as aridity increases in the Sahel; and erratic and epidemic at high altitudes. Acquired immunity in these areas are characterized by very high immunity by age 5, very high immunity by age 10, limited immunity, and negligible respectively. Changes in malaria transmission does occur, however. Water storage dams and irrigation extends the breeding season for malaria vectors and increases their populations. Even though urban development traditionally reduces mosquito densities, An. gambiae, which like other anopheline mosquitoes usually breeds in clean water, is adapting to breeding in sewage and dirty water in Accra, Ghana. Use of antimalarials has reduced the severity and duration of malaria and malaria parasites are growing more and more resistant to these drugs, so cerebral malaria which used to be confined to infants are now occurring in adolescents in Banjul, the Gambia. Due to the lack of accurate and complete data on malaria mortality in Sub-Saharan Africa, it has been difficult to really know its impact. Nevertheless some field research projects have collected reasonably accurate data. For example, in Kisumu, Kenya in the mid 1970s, use of Fenitrothion reduced malaria transmission 96% and infant mortality fell 40%. This overview also covers malaria vaccines, heterogeneity of the sickle cell trait, and research and methodological issues.
The epidemiology and projected mortality of AIDS.
Researchers tested blood collected in 1976 and in 1986 from rural Zaire for HIV. the study revealed that HIV infections were most likely present and kept at a low endemic level in this rural area for sometime before 1976. The researchers thought that the higher prevalence of HIV later evident in large urban areas of central Africa was probably associated with sexual lifestyle which was more active in cities than in most rural areas. Other researchers have since applied HIV serologic survey data and observed and estimated annual progression rates from HIV infection to the development of AIDS to the WHO AIDS Projection Model. It estimated that the total AIDS expected cases in the 1990s will not reverse the projected population growth rate, even for the most severely affected central African countries. The model could not make projections beyond the 1990s, so the long term demographic impact of AIDS in central Africa could not be determined. It did predict, however, that a sizable and very selective decrease in the projected increase among the very young and among the sexually active who have multiple sexual partners will occur in urban areas. In other words, AIDS mortality will reduce the national population growth rate of 3-4% for most central African countries by 1%. Further the increase in pediatric AIDS mortality cases will undo any reduction in child mortality realized by child survival programs. Public health specialists expect tuberculosis prevalence in Sub-Saharan Africa to increase as do AIDS cases, such as already occurred in Burundi and Tanzania. Since no vaccines or effective treatments against AIDS exist, public health professionals in AIDS prevention programs face their greatest challenge. After 2000, the imminent endemic level of HIV/AIDS will be a standard of the commitment and effectiveness of current AIDS prevention programs.
AIDS and its demographic impact.
A researcher uses simple age structured mathematical models combining demographic and epidemiologic parameters based on data from Sub-Saharan African countries such as the Gambia, Kenya, Rwanda, Uganda, and Zaire to crudely assess the probable impact of AIDS on the size and structure of a population as it spreads. Key demographic and epidemiologic parameters include fraction of healthy infants born to HIV infected mothers, mean incubation period of AIDS, fraction of persons infected with HIV who will develop AIDS, population growth rate in the absence of HIV infection, death rate of noninfected persons, rate of spread of HIV infection in the early states of the epidemic, maturation delay of humans, and birth rate. The models reveal 3 significant predictions. 1st, AIDS can change positive population growth rates to negative growth rates. Even based on low to moderate rates of HIV infection, this reversal will probably not occur for many decades. 3rd, major demographic and epidemiologic parameters in a community determines whether or not AIDS will decrease or increase dependency ratios. The models predict that HIV infection may bring about a beneficial change, albeit small, in the dependency ratio because of counteracting forces of adult deaths due to horizontal transmission and a reduction in the effective birth rate due to vertical transmission. Nevertheless, since these models were simple and quantitative data were scarce, one should interpret these predictions with caution. Longitudinal cohort studies of HIV seroprevalence, surveys of sexual partner change rates, research on the incubation and infectious periods, and the fraction of persons infected who will eventually develop AIDS within communities in Sub-Saharan Africa are definitely needed.
The Danfa Comprehensive Rural Health Project, Ghana, 1969-79: health sector teaching, service, and research.
The Danfa Comprehensive Rural Health Project operated in southern Ghana between 1969-79 as a service, research, and training center. The University of Ghana Medical School in collaboration with the University of California, Los Angeles designed the project to solve health problems and to demonstrate workable methods of delivering effective health and family planning services. Phase I consisted of gathering data on health status; mortality; demography; and health knowledge, attitudes, and practices by compiling health center data and a variety of surveys. Common infections afflicting mothers and children were malaria, measles, whooping cough, diarrhea, respiratory infection, helminths particularly roundworm, polio, tuberculosis, guinea worm, tetanus, and skin infections. The Regional Medical Field Unit had undertaken BCG, measles, and smallpox immunization campaigns before the Project began. Baseline infant mortality ranged from 54-99/1000 in the 4 areas. Malaria prevention and family planning services comprised Phase II. An aim of malaria control was to administer pyrimethamine chemoprophylactic to at least 80% of the children. Even though pyrimethamine had promise since it had been widely used in children in Africa and it had a lower toxicity than chloroquine, 7% of parasitemia after 2 years was fully resistant. The highest acceptance rate of family planning occurred in those villages which had a good maternal and child health program, a community health education program, and trained traditional birth attendants. This was achieved with only a good service and educational program and no financial incentives. This Project proved that Ghana had effective planning and managerial professionals. It also was able to accomplish its goal of collecting accurate demographic and epidemiologic data.
Annual summary of vital statistics -- 1990.
Between 1989-1990, the number of births increased 4% in the US. This was a result of more women in the childbearing years and higher fertility. The fertility rate peaked in 1990. Natural increase was 2.017 million--the 1st time it exceeded 2 million since 1964. The number of marriages increased about 2% and the marriage rate increased from 9.7-9.8--the 1st upturn since 1980. Even though the number of divorces increased, the divorce rate held steady at 4.7. The lowest divorce rates were in the north central and northeast areas (mean 3.2) and highest in the west and south (mean 5.7). Before divorce, the median length of marriage was 7.1 years in 1988 and most divorces happened to people married 3 years. Between 1989-1990, the number of deaths rose 0.3%, but the crude death rate fell somewhat. Moreover the age adjusted death fell about 2% to a low of 515.1/100,000 during the same period. The 5-10 year old age group still had the lowest mortality rate in the life span (1). Even though life expectancy for black males has consistently increased since 1900 from 32.5-66 years, their life expectancy was 10% lower than that of white males in 1990. Overall the leading causes of death were cardiovascular diseases (41.7%) and malignant neoplasms (23.4%). The age adjusted death rates for these 2 categories fell, however, between 1989-1990. On the other hand, HIV infection related deaths increased in every grouping, except Whites <15 years and 15-24 years old. Infant mortality fell more quickly between 1989-1990 than in any year since 1977. In fact, it fell 6.2% from 9.7-9.1 and most of the decline was attributable to the 8% reduction in neonatal mortality. Surfactant therapy was responsible for the sharp fall in neonatal mortality. People in most of the countries with lower infant mortality than that of the US have better access to health care than do those in the US.
Femodene / minulet -- how different is gestodene?
The occurrence of flare-up of systemic lupus erythematosus (SLE) in relation to use of oral contraceptives was studied in 85 SLE patients of 2 rheumatology clinics at the Helsinki University Central Hospital, Helsinki, Finland, from interviews taken from March 1989-April 1990. 37 (44%) ever used oral contraceptives containing ethinyl estradiol, 30-50 mcg, for a mean duration of 41.7 months (range 1 month-37 years). 10 women had stopped the pill before onset of SLE. 38% of this group had nephritis at least once. 32 (38%) had used progestin-only pills for mean duration of 17.5 months (range 1 moth-11 years). Initial symptoms of SLE appeared during the 1st 6 months of oral contraceptive intake in 2 women. Initial symptoms developed within 1-6 years after starting orals in 12 women. 6 began taking pills after the 1st symptoms but before diagnosis of SLE. 11 women started pills after SLE was diagnosed, and 4 of these patients had flare-ups of the disease during the 1st 6 months of oral contraception. The incidence of flare-ups during the study in never-users was 1.3% of patient-months, compared to 2.1% for the pill users (n.s.). The data do not suggest that oral contraceptives cause SLE, but possibly that orals may unmask latent lupus. Similarly, oral contraceptives do not exacerbate SLE in most patients, except possibly in women with active nephritis or in those with high anti-phospholipid antigens.
Population, eco-system and the environment: an Indian scenario.
India is characterized by 6 major geographic regions each of which has a different capacity to provide food for its population. They range from the northern mountain regions to the hot and cold deserts. Further the climate of almost 85% of the land (270.5 million hectares) is suitable for agriculture. According to FAO estimates based on low level of inputs, in 1975, India's lands could not support 19% of its population. But if India could efficiently develop its irrigation potential, it could support a population density of 3.24 people/ hectare in 2000. Indeed its population has been estimated to reach 1036.7 million (population density=3.23/hectare) in 2000 so, in theory. India could support its population. Yet India has many environmental problems, especially the discharge of industrial and human wastes into water. These problems emerge either from poverty and underdevelopment or negative effects of development. The 7th Plan states that environmental factors should be incorporated into the design of all developmental projects. Further 3 major environmental laws call for protection of the environment in India, but political will is missing and the laws are not enforced. The population and pollution of the environment are growing substantially in India combined with urbanization resulting in unprecedented deterioration of the environment, especially deforestation. Moreover slums and squatter settlements make up 40-60% of the urban population. It is here where very infectious human wastes accumulate since the soil cannot absorb or drain them. This leads to high morbidity and mortality. In conclusion, more scientific research examining the relationship between the present and future populations and the environment is needed.
Factors in the analysis of the population of Anatolia, 1800-1878.
An historical demographer tried to provide general estimates of the population of Anatolia before 1878 since only poor, readily available data exist. Besides Ottomans only collected data on males. Obstacles to collecting existing data include collection of district vital events registers and tying them with a summary population register would be overwhelming for scholars and the Bas Bakanlik Arsivi in Istanbul, Turkey has not catalogued many remaining uncatalogued population registers. The Ottomans did compile registration data, however, but only the 1831 census provided the most valuable and extensive data even down to the local level. The other 2 complications included the 1844 census and population data in the 1877-1878 government yearbook. The historical demographer used 8 vital events registers to observe the distribution of male deaths by age groups and found an unexpectedly high number of deaths in the 15-34 year old age group. He estimated that about 50% of the population died before age 5. Further the data showed a life expectancy at birth of 25-30 year. Data on endemic diseases in Anatolia were essentially nonexistent, but data from Istanbul in the early 1900s showed tuberculosis to be a leading cause of death. The 1847-1848 cholera epidemic claimed more lives than the other 4 cholera epidemics in the 1800s. The plaque occurred so often in Anatolia that it could be considered an endemic disease. Despite many men being in the many Ottoman wars in the 1800s, fertility in Anatolia remained relatively high due to serial polygamy and husbands periodically returning to their homes. Injuries and disease caused more deaths than did enemy fire. After the Crimean War, Muslim migrations from the Crimea and the Caucasus to Anatolia and Armenian migration from Anatolia to the Caucasus occurred. Estimated mortality among refugee populations was about 30%. Due to large scale migrations into and out of Anatolia, the 1800-1878 population remained relatively stable.
The prevalence of Gardnerella vaginalis, Trichomonas vaginalis and Candida albicans in the cytology clinic at Ibadan, Nigeria.
Between October 1, 1986-April 30, 1989, laboratory staff at the University College Hospital in Ibadan, Nigeria tested the cervical smears of 2224 women (>20 years old). 50.3% of the women underwent a smear for routine reasons and 49.7% did due to indications such as cervical erosion, cervicitis, vaginal discharge, postcoital bleeding, and intermenstrual bleeding. 14.5% of the smears revealed specific vaginal infections. Overall prevalence for Gardnerella vaginalis was 9.76%, 2.52% for Trichomonas vaginalis, and 2.2% for Candida albicans. The staff detected G. vaginalis in 63.4% of the 322 women who had a vaginal infection. 17.4% had syphilis and 15.2% candidiasis. 30.44 year old women comprised the largest group of women (46.8%) with these sexually transmitted diseases (STDs). Yet there was a sizable percentage of women >45 years old with an STD (22.1%), especially the uneducated women. This could be due to the economic necessity of husbands leaving wives to find work and who consequently have several sexual partners. It may also be a result of increased contraceptive use among older women which fosters multiple sexual relationships. 43.13% of women with a vaginal infection had a discharge. 24.51% of all women who presented with vaginal discharge tested positive for G. vaginalis while only 8.86% of the asymptomatic controls did. All women with abnormal smears other than those with cervical intraepithelial neoplasia were treated with oral metronidazole and vaginal clotrimazole. Only 8.9% of the women still had abnormal smears after 3 months. In conclusion, the researchers believed that cervical cytology, both identification of the organism or of characteristics cellular changes, can easily diagnose these 3 STDs.
Gemeprost for second-trimester termination of pregnancy.
Gemeprost, a synthetic analog of PGE1, marketed in the United Kingdom under the brand name Cervagem (May & Baker) is a non-invasive medical abortifacient in vaginal suppository for 2nd trimester. It is less objectionable to patients than urea and prostaglandins injected intraamniotically, or prostaglandins given extraamniotically. One pessary is inserted into the posterior fornix every 3 hours until expulsion, or until a maximum of 5 doses (12 hours). A comparative randomized trial of Gemeprost and extraamniotic PGE2 (dinoprostane) and intraamniotic PGE2 with urea, found similar induction-abortion intervals and success rates, about 80% within 24 hours for the vaginal and extraamniotic routes, but 93% success and shorter intervals with the intraamniotic route. The proportion of successful abortions rose with gestational age. Women not aborting with the vaginal pessaries were offered a second course of treatment or oxytocin infusion. The incomplete abortion rate was not available since all women were curetted routinely. Gemeprost caused vomiting in 14-35%, diarrhea in 12-20%, and apparently less pelvic pain than did PGs by other routes. The vaginal pessaries are expensive, at 80 pounds for 4 doses.
The sequelae of induced abortion.
The complications and sequelae of induced abortion, as practiced in Great Britain in 1989, are reviewed, with incidence rates where available. The techniques are menstrual regulation with anaesthesia up to 8 weeks gestation, vacuum aspiration at 6-12 weeks, dilatation and evacuation at 13-16 weeks, and extra- or intraamniotic prostaglandins after 20 weeks. The major types of complications are operative (trauma, hemorrhage, anesthetic), early post-operative (sepsis, hemorrhage, retained products), venous thrombosis and psychiatric. For 1st trimester reported complication rates range from 1-4%. Long-term sequelae are cervical incompetence, subfertility, ectopic pregnancy, Rhesus sensitization and psychiatric reactions. Cervical incompetence has not been a problem in recent series of women who had vacuum aspiration. Subfertility is related to sepsis, which can be reduced with prophylactic antibiotics. Insufficient data are available on whether women who abort are at increased risk of ectopic pregnancy. Psychiatric sequelae are much more common after birth than abortion, and are mitigated in abortion patients who have a supportive partner and non-judgmental care. Those having late abortion for medical or genetic reasons are more likely to have guilt feelings.
Safety of depot medroxyprogesterone acetate [letter]
The overall risks and benefits of a 5-year course of depot medroxyprogesterone acetate injectable contraception (DMPA) were computed for Mexico and Hong Kong taking into account the recent WHO report on increased risk of breast cancer. The calculation also included age and cause specific mortality rates, prevalence of DMPA use, age specific population size, and disease rates. It was assumed that the relative mortality was 0.5 for endometrial cancer, 0.8 for ovarian cancer, and 0 for cardiovascular disease. Results were reported in days of life expectancy lost or gained. Most users of DMPA would live 4-18 days longer than nonusers, showing that the benefits of DMPA for maternal mortality and other reproductive cancers outweigh the slightly higher risk of breast cancer. The benefit was much greater in Mexico than in Hong Kong because of Mexico's higher maternal mortality. The figures amounted to virtually no change in risk, compared, for example to a 4.6 year loss of life expectancy estimated for 30-year old male smokers of 1-9 cigarettes/day compared to nonsmokers. This type of computation is useful for setting public policy on safety of contraceptives.
The Nova-T IUD -- a review of the literature.
A review of trials of the Nova-T IUD, concentrating on interval insertions, in comparison with other T-IUDs releasing copper or levonorgestrel, and final results of significant English papers from peer reviewed journals, is presented. The Nova-T, originally marketed by Outokumpu Oy, Pori, Finland, is now used in Western Europe, Canada, Latin America, South Africa, Taiwan, Australia and New Zealand. It resembles the Copper T-200, but is loaded with its arms up, and has a silver core under the copper wire, and a larger tail loop. The Nova-T in most studies has a better efficacy than the TCu-200 series of IUDs, but lower efficacy than the MLCu IUDs. The levonorgestrel-leasing IUDs also generally performed slightly better than the Nova-T in efficacy, bleeding, spotting, pain, and anemia. Nova-T and Progestasert were comparable in efficacy. Even though the manufacturer of Nova-T claims that it is designed to be easier and safer to insert than similar models, the large WHO trial obtained poorer results with Nova-T than with the TCu-200C, possibly due to lack of training of providers. No differences in infection or ectopic pregnancy rate or return to fertility were evident from the literature. 5 large studies, with the notable exception of the large WHO trial, found that the efficacy of the Nova-T lasts for at least 5 years. Other issues reviewed were tolerance by young users, by lactating women, need for provider training and patient counseling, and timing of insertion.
Relationship of perceived maternal acceptance-rejection in childhood and social support networks of pregnant adolescents.
The purpose of this study was to examine the relationship between the perception of maternal acceptance/rejection in childhood and the nature of supportive relationships perceived by at risk pregnant adolescents in the US. The sample was selected from pregnant adolescents who were determined to be at risk for child abuse and neglect or low birth weight or prematurity; the respondents were outpatients of the obstetrics and gynecology department of a large Rochester, New York hospital. The 53 respondents were residents of inner city neighborhoods, and had a mean age of 16 years. 78% were black, 20% white, and 1 Hispanic. 60% lived at home with parents. 40% received public assistance, and 56% reported at least 1 parent employed. About 50% had a history of difficulties such as truancy, suspension, or expulsion. By the 3rd trimester, 46% were not in school. Antecedent social problems revealed 15% child abuse or neglect, 13% suicide, 27% running away from home, 13% psychiatric counseling, 16% criminal probation, and 24% residential placement. The Parental 24 Item Acceptance/Rejection Questionnaire (PARQ) was administered in the 3rd trimester and requested information about mother's or caretaker's treatment when they were 7-12 years of age. 4 scales measured warmth and affection, aggression and hostility, indifference and neglect, and undifferentiated rejection. 10 items measured acceptance and 14 measured rejection; in the discussion, statistical reliability of measures is reported. A social support network measure was developed from a University of Rochester questionnaire. The research findings were that receiving warmth and acceptance in the early relationship with one's mother encourages similar behavior in relationship with others. Feeling rejected by one's caregiver tends to inhibit the formation of effective relationships with others in the social network. Perceived maternal acceptance during childhood was related to more social interaction with and higher expectations from social network members, particularly the baby's father and his family. It was not related to social interaction with mothers during pregnancy. The findings corroborate prior research and theory on the social isolation of pregnant teenagers from close supportive relationships. Public policy implications are that intervention strategies must help teenagers develop supportive relationships within their social networks.
[Adolescent pregnancy]
The number of adolescent pregnancies brought to term in France has continued to decline while the number of abortions remains stable. Adolescent pregnancies cannot be considered "accidents" either in their social or psychological aspects. Pregnant adolescents carrying to term tend to be more disadvantaged than those seeking abortions. Early pregnancy may be a response to difficult life conditions. Despite appearing to constitute an infraction of a social code, adolescent pregnancy may in fact represent an attempt at social integration through motherhood. Adolescents failing in school, with poor employment prospects and feeling family pressures may view pregnancy as a means of social recognition. But such factors by themselves do not explain pregnancy; the primordial role of psychological factors must be examined. For some adolescents, pregnancy may represent an attempt to understand their own sexual identity as the transformations of puberty unsettle their previous self-images. Or they may be failing to perceive or actively denying the possibility of pregnancy. Adolescent pregnancies may be the result of transgressions of prohibitions. The traditional prohibition of sexual activity has relaxed to the degree that it is being replaced by a new prohibition on adolescent pregnancy and a prescription to use contraception. But contraception deprives an adolescent in search of sexual identity of proof of fertility as well as of the image of spontaneity and naturalness. Use of contraception is in conflict with the questions, doubts, and anxieties of adolescence. For adolescents in a reactivated oedipal stage, heterosexuality is often at the service of incestuous fantasies involving the mother. Abortion and perhaps pregnancy itself may assume the character of a rite of passage into adulthood for some adolescents. The important thing for many is the ability to become pregnant, to be a mother like their own mother.
Seroepidemiology of human T-cell lymphotropic virus type I/II in Benin (West Africa).
Researchers enrolled 2625 >15 years old healthy individuals from the general population and 1300 blood donors of Benin to determine the extent of HTLV-I infection in Benin. They followed the recommended laboratory techniques of the US Public Health Service Working Group (1988). No blood donors were HTLV-I seropositive. The sera of 1.5% of the general population sample tested positive for HTLV-I. This rate was comparable to other western African countries. A significantly higher percentage of females were seropositive than males (2% vs. 1%; p<.05), especially among the rural population (2.6% vs. 0.6%). No significant difference in seroprevalence existed between urban and rural areas overall (1.3% vs. 1.7%) and between urban males and females (1.4% vs. 1.1%), however. Further HTLV-I seroprevalence increased significantly as one went from south to north (0.6% in the 3 south coastal provinces, 1.1% in the central province, and 3.2% in the 2 northern provinces; p<.001). In fact, the northern province of Atakora had the highest HTLV-I seroprevalence rate (5.4%), especially among females (p<.0005), and was significantly higher than the other provinces (p<.001). Research have since begun in several villages in Atakora to detect possible clusters and analyze associations between HTLV-I seroprevalence and life style, environmental and geographic factors, and concomitant infections such as filariasis. Seroprevalence also increased with age. For example, 0.4% of males <30>30 years old (p<.02). In addition, 0.4% of females <20>30 years old (p<.05). The researchers noted that other epidemiologic studies in Benin have begun to assess the prevalence of tropical spastic paraparesis with or without the association of HTLV-I and adult T-cell leukemia.
Evaluation of the effect of butyl p-hydroxybenzoate on the proteolytic activity and membrane function of human spermatozoa.
The potential of butyl-p-hydroxybenzoate as a vaginal contraceptive was explored by testing its ability to inhibit sperm acrosin in a gelatin hydrolysis assay and by testing sperm membrane integrity, in comparison with sodium-p-tosyl-L-lysine chloromethyl ketone (TLCK), a known inhibitor of acrosin. Acrosin is a proteolytic enzyme in the sperm head needed to penetrate the ovum. Butyl hydroxybenzoate completely inhibited acrosin activity at 0.25 mg/ml, while TLCK was completely inhibitory at a concentration of 5 mg/ml. The ability of sperm tails to exhibit hypo-osmotic swelling, an indicator of functional cell membranes, and the eosin-Y vital staining assay of viability were highly correlated at rising concentrations of butyl hydroxybenzoate, with complete immobilization at 0.5 mg/ml.
Demography and policy: an Asia experience.
Through both a theoretical discussion and case studies of 4 countries, this report examines the factors that influence the use of demographic knowledge in the formulation, implementation, and evaluation of public policies. Following an introductory section, section 2 of the report discusses the following conceptual issues: 1) the nature of the market for demographic knowledge; 2) the components of demographic knowledge; the complex issue of defining "utilization;" and 4) the role of population policies in development planning. The last issue discussed, population policy, is divided into 2 components: 1) the setting, which examines factors such as demographic transition, mortality, fertility decline, population redistribution, the experience of more developed countries, and the role in international agencies; and 2) policy corners, which include 2 conflicting views -- the standstill scenario and the invisible hand scenario. The theoretical section of the report supports the proposition that significant social policy problems are the outcome of imbalances between the demographic and non-demographic components of society, and that such imbalances can and need to be modified by policy. On the whole, the on-going process of integrating technical demography in a social science framework has been a beneficial development, and further investments in demographic knowledge -- especially knowledge that suits the needs of policy analysis -- will provide additional positive returns. The 3rd section of the report contains case studies of Bangladesh, India, Malaysia, and the Republic of Korea. For each country, the report provides a demographic background and examines the demand, supply, and utilization of demographic knowledge.
Should opinion polls be more widely used in developing countries?
Explaining that public opinion polls can be useful tools in health and policy planning in developing countries, the author argues that they should be used more widely. Health administrators have long been reluctant to rely on opinion polls, viewing their results an unscientific or often contradictory. It is true that opinion polls suffer from several weaknesses. Polls can often be biased, reflecting the views of the pollster. Moreover, an uninformed public may produce results that lacks any serious depth. Despite these objections, it is possible to conduct a poll that overcomes these weaknesses and which serves as a useful tool for health planning. The first step in this direction is establishing an anchor point from which new findings can be compared. This can be accomplished in the following way: 1) single poll items can be compared over time to determine the stability of opinion; 2) slightly different but related items can be compared to reveal distinctions in public opinion; and 3) similar questions with subtle differences can be used to gauge the strength of opinion on a particular issue. Pollsters must carefully consider the wording and contextual effects of a question. Administrators and planners are well aware of the need for more information, and such information can be found among the public -- especially since the communications revolution has increased the public's awareness of health care issues. Not only can a poll yield useful information, it can also increase public awareness and interest in health care and meet the responsibility of health professionals to advance public understanding on health care issues.
Maintaining village water pumps by women volunteers in Bangladesh.
In 1984, the Mirzapur Handpump Project in Bangladesh installed 148 handpumps and 754 pit latrines in 2 villages. 2 reasons for the project included to field test newly developed pumps and to examine the effect on health of combining these pumps and latrines with hygiene education. In March 1987, the project initiated classroom and pumpsite maintenance training of 21 groups of 3 women volunteers. Community members chose the 63 women. Project staff incorporated the fact that men are dominant in the society, the needs of the women, and the nature of the task, when they designed the training. Researchers observed these women for 15 months (April 1987-June 1988). They compared the pumps maintained by the women with 49 pumps maintained by project mechanics. The mean number of people drawing water per volunteer pump was 31 compared to 32 per project pump. Further the mean rate for water drawn/person/day for the volunteer pumps was 36 1 white it was 33.7 1 for the project pumps. Both sets of pumps were between 46-47 months old. Only 1 volunteer pump and 1 project pump broke down during the study period. Further pump inspections ranked 89% of the volunteer pumps in fit condition compared to 86% of the project pumps. Moreover the component replacement rate for the volunteer pumps was less than that of the project pumps (2.6 vs 3.2 parts replaced/pump/year), but the difference was not significant. All of the volunteer women could accurately compare the handout sketches with a suggested pump repair. This study showed that the women could maintain the pumps at least as well as project mechanics and at a substantial rate of savings. Further the male members of the households and the extended family within the homestead accepted and supported the women pump mechanics. In conclusion, women involved in rural development by maintaining pumps was culturally acceptable and cost effective.
Retarded fetal growth patterns and early neonatal mortality in a Mexico City population.
Researchers used 1981-1983 data on 9660 infants born at the Maximino Avila Camacho Maternal and Child Health Center in Mexico City, Mexico to examine the relationship between early neonatal mortality (mortality in the 1st 3 days of life) and various retarded fetal growth patterns. Overall early neonatal mortality rate (ENMR) stood at 7.9/1000 live births. ENMR for premature infants was 37 and that of full term infants was 4.1 ENMR for all small for gestational age (SGA) infants (<10th>10th percentile by crown heel). The ENMRs for premature proportionate and disproportionate SGA infants were 74.3 and 48.6 respectively. Premature disproportionate SGA infants experienced the highest ENMR (208.3), but the full term disproportionate SGA infants experienced the lowest of any group with intrauterine growth retardation (7.6). In conclusion, the researchers pointed out the need to assess types of growth retardation and etiologic factors when determining mortality risk in neonates.
IgA testing for diagnosis of retroviral infections in the Caribbean.
Researchers wanted to determine whether they could do a more specific ELISA HIV test directed at IgA rather than IgG antibodies. So they 1st used streptococcal protein G to remove IgG from serum samples of 10 follow up patients from Guadeloupe who previously tested positive via ELISA for HIV-1/2 IgG and HTLV-I IgG. They did this to test sera for IgA. The protein G treatment resulted in a 99.9% reduction in the IgG concentration (12.21.7 mg/ml to .007-.017 mg/ml). After IgG depletion, the researchers noted no ELISA positive samples for HIV-1/2 or HTLV-I IgG. In fact, all the values were well below the cutoff levels. This result indicated that streptococcal protein G treatment followed by IgA ELISA is more specific than testing for IgG. The sera of 8 patients tested negative for HIV-1/2 IgA, but all tested positive for HTLV-1 IgA. This result showed that IgA may be more useful than IgG for also confirming retroviral infections. The sera of 2 patients were 44% and 27% above the cutoff level indicating that these patients had HIV-1/2 IgA antibodies. The researchers observed that protein G treatment suppressed all HIV-1/2 and HTLV-I IgG Western blot reactivity which confirmed the effectiveness of protein G treatment. Further the HIV IgG bands in the 8 false positive sera did not materialize at all suggesting that the IgG reactivity observed was most likely nonspecific. These results indicated that nonspecific HIV-1/2 IgG caused the false positive HIV-1/2 IgG ELISA results. In conclusion, in Caribbean countries where HTLV-1 infection can be as high as 13%, the more specific HIV IgA ELISA test should be used since its use saves time and money. Further it can do generalized testing for HTLV antibodies.
Steroid metabolism by germ cells and spermatozoa in men after vasoepididymostomy.
Metabolism of testosterone and estradiol by primary spermatocytes, spermatids and spermatozoa of 6 fertile men, 6 men infertile due to immobile sperm, 8 men who had vasovasostomy, and 11 men who had vasoepididymostomy because of obstruction, was studies by thin layer chromatography. Germ cells were collected at 3-month intervals after surgery, and separated by Percoll gradients. Results were reported as percentages of total counts in substrates and products. Germ cells of normal and post-operative subjects converted testosterone primarily to androstenedione, and their spermatids also formed dihydrotestosterone and androstanediols. Spermatozoa and spermatids also formed estrone from estradiol. Spermatozoa from infertile men primarily produced dihydrotestosterone from testosterone.
Students' demand for condoms seems limited but steady.
For 2 months, New York City has conducted a condom distribution program in 16 of its 120 schools, an experiment which has seen a modest but steady number of students requesting condoms. Despite the limited number using the services, the students who regularly avail themselves of the service appreciate the access to free condoms. Some teachers and students suspect that not many students are asking for condoms because the heightened fear over AIDS has prompted many students to abstain from sex altogether. Other, however, believe that student simply feel uncomfortable asking teachers for condoms. The school condom distribution program, the first large scale effort of its kind in the US, has taken a quiet approach. The school board has not publicized the program too much, fearing that it would create a carnival atmosphere. This quiet approach may also explain the limited number of requests, since many students remain unaware that the condom distribution program exists. In addition to the condom program, the schools have also conducted AIDS education classes. Teachers say that these classes have enables students to candidly discuss the issue of sexuality. Because many students know of other students who have contracted AIDS or have lost a parent to the disease, the students have taken the classes seriously. These classes don't just instruct about sexuality; they also counsel that there is nothing wrong with abstaining from sex. Although the school board has found nothing to deter it from expanding the program to the rest of school system, a number of parents have brought a suit to the State Supreme Court in Staten Island to halt the condom distribution program, claiming that such a service should require parental consent.
Families, women and HIV / AIDS in Africa.
The effects of HIV/AIDs on women in Africa is examined through the nature of the stresses on family organization and identification of the problem, estimation of the probability of becoming infected and discussing the relevant factors, and discussion of the impact on children, females, and family. General mechanisms of transmission are described in order to reduce the complexity of the problem. 2 assumptions are made: that the probability of infection is dependent on women's roles and positions within the family, and that the magnitude and direction of HIV/AID effects is contingent on familial relations that define permissible behavior for women and children. Magnitude of exposure is influenced by the timing of entrance into sexual unions or sexual activity, the likelihood of sexual contact which is related to the age gap between the spouses or sexual partners, the level of age specific prevalence among males, women's roles and socioeconomic status of the family, and the norms regulating remarriage and sexual behavior of widows. The lifetime reduction in risk of contracting HIV by postponing the initiation of sexual contacts is estimated for women between initiation age and 40 years and 5 different ages of initiation of sexual contact. If infectivity is low at .001/contact, the probability of avoiding infection is .975 at initiation age of 10 years and .983 at 20 years. When infectivity is high at .10/contact, a 10-year postponement doubles the probability of escaping HIV. At intermediate levels, a 10-year postponement yields an 8% increase in probability of remaining HIV free. The reduction in age gap between partners influences the probability of not becoming infected also. For intermediate infectivity, there is an increase of 24% in the probability of avoiding infection. The reduction in a 1-year age gap difference yields higher gains than a 1-year initiation age postponement. Social conditions constraining female sexual behavior may lead to incubation process differences in health deterioration and reduced expected survival rates for those infected. Increases in adult mortality will affect the incidence of orphanhood, widowhood, and incomplete residence units. Female children, mother, and grandmothers will bear the bulk of the personal, social, and economic costs unless interventions reallocate the burden.
Simplified and less expensive confirmatory HIV testing.
After HIV antibodies had been detected by various assays in the sera of 164 people (Europeans, Africans, and South Americans), microbiologists from the Institute of Tropical Medicine in Antwerp, Belgium used simple and inexpensive assays to confirm HIV infection. They retested sera that were positive in the 1st screening with a different assay. They used the Western blot assay only if contradictory results occurred in the 2 assays. The alternative approach developed 100% sensitivity and specificity. Further the cost of this approach averaged 6.1 times less than if they confirmed positive results with the Western blot and 9 times less than if they used this conventional approach if a 3rd assay, different from the 2 previous assays, replaced the Western blot. In addition, when the researchers retested positive sera with the same assay as the 1st, the accuracy of the results did not improve. In fact, the researchers highlighted that the 1st assay should be more sensitive than the following assays, since the 1st assay is the factor that limits the sensitivity of the combination. Researchers should follow this study with similar research in resource limited settings with different epidemiologic patterns of HIV seroprevalence. In conclusion, this alternative approach may result in accurate, less expensive, more rapid and/or less equipment reliant testing for HIV infection.
Comparative evaluation of 36 commercial assays for detecting antibodies to HIV.
Microbiologists at the Institute of Tropical Medicine in Antwerp, Belgium used sera from 537 people (65% Africans, 26% Europeans, and 9% South Americans) to compare commercial assays for detecting HIV antibodies. These assays included 20 ELISAs, 11 simple assays, 4 supplemental assays, and 1 discriminatory assay. HIV-1 seroprevalence was 39.1% and 15.7% for HIV-2. Basically the sensitivity of the assays were very good and equal, except the sensitivity of the Peptide HIV ELISA assay was considerably lower. In fact, on the most part, the sensitivities were higher than the specificities. But only 4 assays had significantly lower specificities than sensitivities. A high number of false positive reactions occurred in the African sera with these 4 assays which emphasizes the need to use African sera to evaluate HIV antibody kits. The higher the positive and negative Delta values the more likely the assay can accurately identify antibody positive and antibody negative sera respectively. The Elavia Mixt (HIV-1+2) and the Wellcozyme HIV-1+2 had the highest positive Delta value while Abbott recombinant HIV-1/HIV-2 EIA had the lowest positive value. Du Pont HIV-1/HIV-2 had the lowest negative value. No significant difference existed in determining sensitivity and specificity by visually reading the results between the simple assays. Interreader variability ranged from 0.8-31.7% with Recodot and Genie HIV-1 and HIV-2 having the highest variability. Further no significant difference existed in sensitivity and specificity between the ELISAs. The Ancoscreen supplemental assay did not have high sensitivity and specificity when used on African sera. Further INNO-LIA HIV-1/HIV-2 Ab test detected both HIV-1 and HIV-2 antibodies at the same time and ranked lower in indeterminant results than the Western blot.
Household size, food intake and anthropometric status of school-age children in a highland Mexican area.
Researchers involved in the Collaborative Research Support Program on Food Intake and Human Function analyzed longitudinal anthropometric, socioeconomic, and demographic data on 110 7-9 year old children living in Solis Valley in a highland region of Mexico who had survived earlier threats to their health to determine the extent to which nutritional status indicators are related to household size. Children from larger households were significantly shorter for their height and ate poorer quality diets than children from smaller households (p<.005). Moreover animal ownership, house value, and household size explained 30% of total variance and household size played a considerate independent role. Thus the researchers believed that economic status could not only explain the significant associations of household size to anthropometric status and food intake. Indeed children from larger households remained significantly shorter for their height and ate poorer quality diets than children from smaller households even when the researchers controlled for household economic status. Further, for the entire sample, the mean Z score for height for age was -1.6 of the WHO reference standard which indicated widespread growth faltering in the Solis Valley. These findings suggested that the resources available to households in the Solis Valley Were inadequate to protect even the more advantaged households from the stresses of maintaining larger families.
Roles, work, health perceptions and health resources of women: a study in an Egyptian delta hamlet.
This article deals with the health and welfare of women workers in the developing world. The reported study is based on participant observation, informal interviews, and structured observations of women in a small Egyptian hamlet, "Gamileya" in 1985-86. Women's health is seen in the context of women's life cycles and daily life and work experiences. The purpose was to describe and analyze women's work, health and development, and to discuss the relationship between their daily experiences and health perceptions and resources. Central to the discussion is the question of gender's association with health and experience, of role expectations and the effect on health, and of the ways daily life affects access to health resources. The 104 household farming community is described as primarily Sunni Muslim with a 9% female literacy. A government health clinic, private physicians, and traditional healers are 4 km away. Main transportation is donkey used to obtain water from 2km away, fertilizer, and animal feed. Wash water is available from schistosomiasis infested canal water. The author cautions that the emphasis is on women, not men by design and necessity, and not on morbidity and mortality levels. The discussion focuses on the following topics: the meaning of gender in the hamlet; female life cycles, roles, and health (at birth, circumcision, menstruation, marriage, pregnancy, and motherhood, violence, power, and widowhood); women's work; health perceptions; and health resources. The author's conclude that women's lower status negatively affects girls access to food and health care, and thus to differential mortality. The health risks of young girls are infectious diseases and accident; or married women, pregnancy related morbidity and burns; and of older women, respiratory infection, trachoma, and other aged related chronic conditions. Women's perceptions were that frequent childbirth and hard work worsened their health; ethnomedical beliefs such as heat and drafts were the cause of disease is also believed. Health resources are affected by age and gender. Child survival and fertility reduction should not be the only concerns of interventions. The hidden contributions of women as informal workers need to be recognized as more than just a housewife in official documents and in project design. Clinic hours in the afternoons are needed. Rehydration needs must take into account the mother's schedule. Consideration must be given to situations of limited resources. Do not publicize avoiding contaminated water unless a safe water supply is provided. Family planning programs must focus on reproductive health not population limitation. Health services must empower women.
New estimates of maternal mortality.
Recent community studies and better information systems have made it possible for WHO to reassess maternal mortality and calculate new estimates. These new estimates indicate that pregnancy and childbirth are somewhat safer for women in parts of Latin America and most of Asia than they were in 1983. In Sub-Saharan Africa, however, a rise in births have resulted in an equal rise in maternal deaths. Further, it is in Sub-Saharan Africa where the only real increases in maternal mortality occurred since 1983. Thus deteriorating economic and health conditions in Sub-Saharan Africa have resulted in maternal mortality here being the worst in the world. Like in 1983, >500,000 women still die annually from pregnancy related causes and childbirth because there has been about a 7% increase in the number of births, but the risks are around 5% lower than in 1983. In developed countries, maternal mortality and number of maternal death have decreased 13% since 1983. In the Caribbean, the rise in maternal mortality is actually due to better information. In Latin America, maternal mortality in most countries, except Haiti and Bolivia, stand <200/100,000 live births. In fact, the number of maternal deaths has declined by almost 25%. A recent nationwide study in China reveals that the former maternal mortality figure of 50 was inaccurate and was actually almost 100. Except for China, however, declines in risks or pregnancy and number of deaths have occurred in all subregions of Asia. Country specific data, estimates, and explanations of how statisticians arrived at estimations appear in either 1 of 2 WHO reports entitled Maternal Mortality; A Global Factbook (US$45) and Maternal Mortality: A Tabulation of Available Information (free).
Cyclofem: a new once-a-month injectable contraceptive.
This report describes a new one-a-month injectable contraceptive called Cyclofem, discussing the findings of clinical studies. Unlike progestin-only injectables such as Depo-Provera and NET-EN, a dose of Cyclofem contains a combination of the progestin medroxyprogesterone acetate (25 mg) and the estrogen estradiol cypionate (5 mg). Advantages of Cyclofem use over progestin-only injectables include: bleeding disturbances are less common, and fertility returns faster after the method is discontinued. However, Cyclofem is not appropriate for women who are breastfeeding or who have contraindications to estrogen use. Cyclofem works by inhibiting ovulation and causing changes in the endometrium and cervical mucus. Administered through deep intramuscular injection, Cyclofem protects from pregnancy immediately after the first injection. Clinical trials involving over 1100 women in 12 countries indicates that the cumulative life-table pregnancy rate at 12 months was 0/100 woman years (it is expected that the effectiveness will be somewhat lower once the method is tried in a less strictly monitored setting). Continuation rate after 1 year was 64.5%. Less than 25% of the women in the trials reported side effects after the first injection, a number that decreased to 8% after 1 year. The most common side effect was changes in menstrual bleeding patterns. The report goes on to discuss service delivery considerations involved in the provision of Cyclofem, consideration such as access, supplies, and cost. Cyclofem will be available for distribution in Mexico and Indonesia in 1992, and Thailand in 1993. Introductory studies are currently being conducted in Chile, Jamaica, and Tunisia.
1 of 3 pregnancies unwanted.
UNICEF's 1992 State of the World's Children Report observes that family planning is one of the most effective and least expensive ways of improving quality of life on earth. If all women were able to determine the size and spacing of their families, the report notes, there would be 1.3 billion fewer people in the world by the year 2025. A recent World Fertility Survey underscored the demand for family planning, pointing out that 1/3 of all pregnancies in the world are unwanted. Increased access to family planning services could go a long way toward decreasing maternal and child mortality and improving the quality of life for women and children. Family planning could save the lives of up to 1/3 of the 1/2 million women who die every year from pregnancy and birth related causes. Family planning could also prevent many of the 50,000 illegal abortions which are performed around the world every day, and could decrease the incidence of high risk pregnancies involving women under 18, over 35, or who already have more than 3 children. The report says that women who practice birth control have more time for education, earning income, child care, and leisure. And as parents are able to devote more time and resources to less children, the quality of child care rises. Unfortunately, as UNICEF executive director James P. Grant notes, the benefits of family planning have been obscured by controversy. But as recent experience has demonstrated, family planning can be promoted and practices in a way that is sensitive to the religion and culture of almost any society. The failure to realize the potential of family planning, the report says, is one of the greatest mistakes of our time.
A Kenyan mission hospital.
In this article, Karen Ruthman of the Massachusetts Medical School tells of her 2-month visit to a large, rural mission hospital in Chogoria, Kenya. This rural region possesses fertile lands, and is inhabited by families who own small tracts of land. To a US-trained physician, the hospital atmosphere is alien. Even when the ward has been cleaned, there remains a pervasive odor. The hospital can seem chaotic. In the pediatric units, patients share a bed. The mothers or siblings often live in the hospital with the sick infant, providing most of the nursing care. Diagnoses are made quickly, without extensive records. The kenyan staff believes it unwise to spend resources and effort on patients who, even if resuscitated, will not lead productive lives, preferring to devote their energies to preventing a patient from lapsing into a critical condition. The hospital walls abound with posters promoting family planning. The number of wives and children determine the wealth and status of a man, and women need children to help them work in the fields. Since men are less receptive to family planning, the hospital targets services to women. The hospital, however, does not encourage the use of barrier methods, since they require the cooperation of the man. Unfortunately, the clinic does not encourage the use of condoms even if the woman is at risk of AIDS. Noting that she was disappointed with the hospital's view of family planning, Ruthman enthusiastically tells of a community-based family planning program she witnesses, a program which encourages the use of condoms and male participation, and which appears to be overcoming cultural barriers to family planning.

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