[The military census of Galicia in 1808 (conclusion)]
Tabular data are presented on the population of particular localities of Galicia in 1808, based on the military census of that year. (summary in ENG) (ANNOTATION)
[A demographic policy for Brazil]
One of the basic problems in the tracking and appraisal of demographic policies resides in the unavailability of experts who specialize in demographics in Brazil. Consequently, an intensive program of specialized courses for university graduates must be initiated, in particular for students with training in economics, sociology, geography and statistics, financed by the CNPq and other organizations, in cooperation with various universities as well as with technical assistance from the United Nations, for example. The effective definition of policy and the corresponding AAP must be formulated and centralized in the CDS (or an organization to be created with cooperation from the Office of the President of Brazil), which would ultimately have a national Committee of Population Experts. Furthermore, various government departments and agencies must have employees who are technical experts in the field. These experts would be responsible for conducting a demographic appraisal of the projects of their respective agencies and for maintaining constant contact and communications with the National Committee of Population Experts. (excerpt)
Designing census public use samples for aging research
The author attempts to identify questions and issues relevant to the development of public use samples for aging research using U.S. census data. (ANNOTATION)
Hong Kong 1981 census: tertiary planning unit population by age
Data are included on natural increase of population by ethnic group in Czechoslovakia, 1950-1979; and natural increase of the total population, 1975-1981. (ANNOTATION)
Data are included on total population, area and population density, and dwelling stock for each Dutch municipality and its territorial subdivisions. (summary in ENG) (ANNOTATION)
[Federal census of population, December 2, 1980. Resident population of communes: final results]
Provisional population and dwelling counts from the 1981 New Zealand census are presented for local authority areas. Comparable data from the 1971 and 1976 censuses are also presented. (ANNOTATION)
[Characteristics of the age pyramid of the Tunisian population]
The age and sex structure of the Tunisian population is analyzed using data from the 1946, 1956, 1966, and 1975 censuses. Both age pyramids and tabular data are presented. (ANNOTATION)
[Longevity: statement of a theme]
Evolutionary, biological, experimental, and clinical aspects of human longevity are considered. (ANNOTATION)
Investigations on the changes of sex ratio in Germany from 1826 up to 1978
This publication consists of 30 individual parts, one for each province of Morocco. Data are from the complete tabulation of the 1971 census. (ANNOTATION)
[Population projections in South Africa up to the middle of the twenty-second century]
Population projections for South Africa are presented up to the year 2150 by ethnic group and by various alternative hypotheses concerning fertility. (ANNOTATION)
[Migration in the light of Poland's 1978 national population census]
Internal migration trends in Poland are reviewed for the pre-1939 and post-World War II periods using 1978 census data for voivodships. (ANNOTATION)
[On the aged population: with regard to the Year of the Elderly]
A statistical profile of the elderly population of Poland is presented in this two-part article. (ANNOTATION)
[Population: regions, provinces, and communes]
Population estimates for Chile for the period June to December 1982 are presented by region, province, and commune. The figures are provisional and are not based on data from the 1982 census. (ANNOTATION)
[The main causes of infant mortality in Kinshasa]
[The results of the census of January 1, 1830, in Brussels]
The surviving data from the Belgian census of 1830 are presented. The data relate primarily to the city of Brussels. (summary in ENG, FRE) (ANNOTATION)
[Crude mortality quotients for the Netherlands, 1980]
Life tables for the Netherlands for 1980 are presented by sex. Improvements in life expectancy since 1956 are noted. (summary in ENG) (ANNOTATION)
[Competitive risks used in the analysis of causes of death]
A review of the relative impact of various causes of death by sex is presented. Data are for Romania for the period 1976 to 1978. (ANNOTATION)
[The thirty-fourth abridged life tables, 1980-1981]
[Population projections for Greenland, 1981-2005 (persons born in Greenland)]
Population projections for Greenland are presented for the years 1981 to 2005. Three alternative variants of both fertility and mortality are considered. (ANNOTATION)
[Life tables for the Netherlands, 1976-1980]
Life tables for the Netherlands population are presented by sex and single year of age for the period 1976-1980. (summary in ENG) (ANNOTATION)
Cancer mortality in Barcelona, 1960-1978
Age-adjusted cancer mortality rates specific for sex and cancer site are presented for the municipal area of Barcelona, Spain, for the period 1960 to 1978. (ANNOTATION)
On "A catastrophe model of regional dynamics".
A comment on an article by Emilio Casetti concerning the relationship between economic and population shifts in the United States is presented. A reply by Casetti (pp. 556-7) is also included. (ANNOTATION)
Bibliography of vital statistics in Australia: a third list
This bibliography of publications on the vital statistics of Australia covers the years 1974 to 1980. The list is unannotated and brings up to date the author's two previous lists on the topic. (ANNOTATION)
The decline of seasonal labour migration to the coffee forests of South-West Ethiopia
The author describes the impact of land reform on patterns of internal, temporary migration in Ethiopia following the revolution of 1974. (ANNOTATION)
Initial results from the 1980 census of Switzerland are presented in summary form, and major population changes over the past decade are reviewed. (ANNOTATION)
This supplement contains updates and an appendix to "Part A: Text" of the 1980 U.S. census. The appendix includes a list of organizations that provide assistance to census data users. (ANNOTATION)
The costs of children in Austria in 1982 are analyzed using data from the 1974 Consumer Survey. Only direct costs are considered. (ANNOTATION)
Summary data from the complete tabulation of the 1980 census of Indonesia are presented by province, regency, and municipality. Population estimates are also provided for 1961 and 1971. (ANNOTATION)
The challenge of surveying nomads on the move
A method of sampling and interviewing nomads that was used in a demographic survey in Somalia in 1980-1981 is described. (ANNOTATION)
[Suburbanization in the Taipei metropolitan area, 1962-1979]
The urban population density function and its derivatives are applied to the analysis of population redistribution in the Taipei metropolitan area during the period 1962-1979. (summary in ENG) (ANNOTATION)
[Viral epidemics and their relationship to the excess of males at birth: divergent data]
The relationship between viral epidemics and the sex ratio at birth is explored using data from various surveys conducted in Greenland and Senegal. (ANNOTATION)
[The Albanian population of Yugoslavia: numerical growth and spatial distribution]
[Parishes and communes of France. Dictionary of administrative and demographic history: Drome]
This is one of a series of publications that present statistical data for the French departments, including available historical and current census data at the parish and communal level. (ANNOTATION)
[The population of France: 1982 review]
A review of basic demographic indicators for France for 1982 is presented. Comparative data for the period 1946-1982 are also provided, and some questions concerning the data are answered. (ANNOTATION)
Under-enumeration in Indian censuses
A critique of a previous article by S. Mukerji on under-enumeration in the census of India is presented, with particular attention to interpreting the results of the 1981 census. (ANNOTATION)
1981 census of population and housing: geographic code list
Eight tables on population and cultivated acreage in China during various historical periods are presented, together with the sources for the data included. (ANNOTATION)
[Population projections for Czechoslovakia up to the year 2000]
Population projections for Czechoslovakia are presented up to the year 2000. The projections are shown separately for the two constituent republics. (summary in ENG, RUS) (ANNOTATION)
Standardized mortality ratios for selected cancer sites are presented by sex for the main ethnic and Chinese dialect groups in Singapore. (ANNOTATION)
[Population projections for Koreans in Japan]
Population projections for Koreans in Japan are presented by age and sex up to the year 2050 using data from the 1975 census. (summary in ENG) (ANNOTATION)
[The limit to lowering the mortality of the Swiss population]
Recent changes in causes of death in Switzerland are reviewed, and their implications for life expectancy by sex and for the age distribution of the population are assessed. (ANNOTATION)
Rural nonfarm employment and migration: the case of Costa Rica
The effect of rural nonfarm employment on rural migration in developing countries is examined using aggregate area-level and individual-level data from the 1975 census of Costa Rica. (ANNOTATION)
Inter-regional migration in New Zealand during the decade 1966-76
Data from the 1971 and 1976 censuses are used to analyze internal migration in New Zealand. The primary focus is on the level of migration and migration between regions. (ANNOTATION)
[Complete life tables for Cuba, 1977-1978. National level: methodology and results]
New Zealand census of population and dwellings, 1981. Vol. 4: labour force
Data from the 1981 census of New Zealand are presented for the resident population aged 15 and over, excluding visitors, that makes up the labor force. (ANNOTATION)
[Changes in marriage patterns in Greece over a four-year cycle]
Trends in marriage patterns in Greece from 1952 to 1976 are examined. In particular, the impact of the popular belief that it is unlucky to marry during a leap year is explored. (ANNOTATION)
[Consensual unions in Denmark: changes between 1976 and 1981]
Trends in unmarried cohabitation in Denmark between 1976 and 1981 are summarized using official published data from an annual series of surveys. (ANNOTATION)
[A model for analyzing and projecting inter-regional migration]
Extrapolation and factor models are combined in order to provide more precise estimations of inter-regional migration in the USSR. (ANNOTATION)
[Bibliography of Czechoslovak statistics and demography, 1981]
This is a selective listing of the literature on statistics and demography published in 1981 in Czechoslovakia. Selected items are provided with abstracts in Czech. (summary in ENG, GER, RUS) (ANNOTATION)
An analysis of mortality trends in Romania during the last 30 years of the nineteenth century is presented. The analysis includes a review of the causes of death, infant mortality, and stillbirths. (ANNOTATION)
The first part of this paper is devoted to a study of the characteristics of unit concentration on figures ending in 0 and 5 in demographic statistical distributions by age as shown in data from the parish registers of Perugia, Italy, for the eighteenth and nineteenth centuries. The second part contains a code list of demographic characteristics contained in the status animarum of the parish, plus directions for codifying data and a program for the automatic preparation of tables showing families by their components and individuals by sex, age, religion, and marital status. (summary in ENG, FRE)
Regional differences in population development during the industrial revolution are examined for the Kingdom of Prussia. Data are presented on population size and density in 1831, 1852, and 1871, and areas with intensive increases in population density are identified. The development of different settlement size classes is then analyzed. (ANNOTATION)
These three volumes include the printed text of the solicited papers presented at the formal sessions of the 19th General Conference of the International Union for the Scientific Study of Population, held in Manila, December 9-16, 1981. (summary in ENG, FRE) (ANNOTATION)
Perceptions of marital partner's desire for children
"This paper considers three processes that may contribute to the mutual perceptions or misperceptions wives and husbands have of one another's desire for children. Using data from 373 couples surveyed in the U.S. Value of Children Study, [the authors] find that both empathy and projection may significantly affect these perceptions. The effects of stereotyping are only indirectly assessed and do not appear to be important. Although the majority of wives and husbands accurately perceive their partner's desired family size, these analyses indicate that we cannot assume complete accuracy in partner perception, even in the United States where marital roles may be relatively well integrated." (EXCERPT)
[Short demographic history of the Netherlands from 1800 to the present]
Population trends in the Netherlands are examined from the beginning of the nineteenth century to the present day. In particular, the author examines the factors that produced a pattern of population growth unique to the Netherlands, in that an initial period of slow population growth was followed by a rapid increase toward the end of the nineteenth century and into the twentieth century. Separate chapters are included on marriage and reproduction, mortality, and migration. Extensive statistical data are presented in tables and figures. (ANNOTATION)
This publication presents statistics on mortality in Hungary between 1950 and 1979, with summary data extending back to 1876. Data are included on number and rate of deaths by sex, age, marital status, and cause; deaths by month; regional distribution of deaths; and life expectancy. A companion volume analyzing some features of mortality in Hungary in the 1970s is also being published. (ANNOTATION)
Comparing 1970 and 1980 census data: an automated approach
"The primary purpose of this publication is to acquaint data users with the tools available for the automated comparison of 1970 and 1980 [U.S.] census summary data. Additionally, this publication illustrates a general data processing procedure for making these comparisons. "The demonstration of this data processing procedure produces tables and maps showing age distributions by census tract." Data for the demonstration are from the 1970 census and from the 1978 dress rehearsal census of the Richmond, Virginia, area. (EXCERPT)
1980 National Census Project: summary technical report.
This report is concerned with the technical aspects of the 1980 census of Papua New Guinea, the first complete enumeration of the country attempted. The report, which is designed for an international readership, contains sections on census design and execution, including preparation and planning, publicity and training, and the main enumeration; data processing; definitions used; tabulation and publications; and census evaluation, including the post-enumeration survey. (ANNOTATION)
[Out-migration of the population in rural areas: direction, distance, and motivation]
In this book, written as the author's dissertation, an attempt is made to analyze rural out-migration in the Federal Republic of Germany. Data are derived from a 1976 survey of 1,107 persons aged 18-65 who had migrated from rural areas of Baden-Wurttemberg between 1970 and 1975. An overview of the problem of rural out-migration is first presented, and theoretical and methodological aspects of the study are discussed. Empirical results are then analyzed, with a focus on the socioeconomic structure and selectivity of migrants, the direction and distance of migration, and reasons for migration.
Mortality by income level in urban Canada.
"Mortality by income level in Canada was studied based on analysis of deaths by census tract in twenty-one census metropolitan areas during the decennial census year, 1971. Mortality rates for all diseases combined varied substantially by income level and this resulted in major differences in life expectancy. Males and females in income level 1 (high income) had life expectancies at birth that were, respectively, 6.2 and 2.9 years greater than those in income level 5. Similarly, persons in lower income levels experienced relatively high mortality rates for most individual diseases or groups of diseases." The authors note that "particularly large mortality differentials by income level were observed for cirrhosis of the liver, alcoholism, tuberculosis, pneumonia, chronic respiratory disease, peptic ulcer, fires, accidental falls and motor vehicle traffic accidents involving pedestrians." (EXCERPT)
Report on demographic survey of households, housing and living conditions in Lagos.
This report is concerned with one of a series of surveys undertaken in 1976 in Nigeria to provide demographic data relevant to the planning of a new federal capital at Abuja. The present survey of households is designed to be the first in a multi-round inquiry to monitor demographic trends in Lagos and includes data on a random sample of the population of the city. Information is provided on demographic and socioeconomic characteristics of the survey population, families and households, housing and living conditions, transport to work, and willingness to move to Abuja. Estimates of the total population of Lagos and of the likely population of Abuja are also included.
1980 population census of Japan. Final count: population and households.
"This report presents the final count of the population and households for the whole of Japan, Prefectures, Shi (cities), Ku (wards), Machi (towns) and Mura (villages), obtained from the 1980 Population Census of Japan taken as of October 1, 1980." The data on population are also broken down by sex. (EXCERPT)
Labour migration from Pakistan to the Middle East and its impact on the domestic economy.
This three-part report is concerned with the results and methodology of the International Migration Project, which was designed to analyze the costs and benefits of labor migration from Pakistan to the Middle East. The fieldwork for the project was carried out in 1979-1980 and involved interviews with over 15,000 migrant workers and their families. In Part 1, an attempt is made to determine the total number and occupational profile of Pakistani emigrants in the Middle East, to analyze the impact of labor migration on various sectors of the Pakistani economy, and to examine the flow of remittances. In Part 2, a cost-benefit analysis of labor migration is presented. The methodological aspects of the study, including details of the sample design and fieldwork, are described in Part 3.
Modernization and childlessness in the states of Mexico
The relationship between modernization and childlessness in the state of Mexico in 1970 was examined. Considerable variation is demonstrated in childlessness among the Mexican states. A theoretical framework based on theories of modernization and socioeconomic development is shown to provide a satisfactory interpretation of this variable. Among the Mexican states, the higher the levels of modernization, the lower the childlessness. Empirical studies conducted on childlessness relevant to this particular inquiry are reviewed, followed by a presentation of the theoretical model focusing on modernization. The data on the number of children ever born were obtained from the 1970 Mexican Census. Other data on which the indicators of modernization and development were based were obtained from the 1970 Mexican Census, the "Anuario estadistico de los Estados Unidos Mexicanos 1970-1971," and the 1975 "Atlas of Mexico." The major question asked is about the relationship between modernization and childlessness among Mexico's 32 states. It was hypothesized that among the 32 states of Mexico in 1970 levels of modernization would be negatively related to childlessness. Since childlessness is primarily involuntary in developing countries such as Mexico, increasing modernization should directly and indirectly impact subfecundity which is the more proximate cause of involuntary childlessness because of its influence in reducting disease and nutritional deficiencies. It was hypothesized that the health variables would be more highly associated with childlessness than the structural economic development indicators. All of the independent variables were shown to be associated with childlessness in the expected direction at the bivariate level. The input variables were than factor analyzed, and 4 factors were obtained, one of which reflected health conditions and 3 which were identified as various dimensions of structural economic development. When childlessness was regressed on these 4 modernization factors, the health conditions dimension was shown to have the highest standardized regression coefficient. The analysis support both the general hypothesis that modernization is related inversely with childlessness among the states of Mexico and the more specific hypothesis that the health conditions dimension of modernization is more influential than factors dealing mainly with structural economic development.
The effect of marital dissolution on contraceptive protection
Monthly contraceptive histories, collected for a period of about 3 years immediately preceding both the 1973 and 1976 US National Surveys of Family Growth (NSFG) were used to analyze the effect of marital dissolution on contraceptive protection. The respondent was questioned about what method of contraception she used in each month during these periods. Respondents were also asked about periods in which they were not having sexual intercourse. The specific study question was whether a marital dissolution (i.e., a separation of spouses for reasons of marital discord) was associated with a change in contraceptive use. The strategy used was to randomly select a reference month (R) from the monthly histories of women who were married throughout the observation period. This resulted in a set of reference months that were distributed in approximately the same fashions as the separations. The number of cases at R was 1232 for those with separations and 14,237 for those who were married throughout. Marital dissolution did have an effect on contraceptive use, but despite this effect contraceptive use patterns following separation were remarkably similar to those of individuals who remained continuously married. Although separation was an important factor, it was not the dominating factor. Separation had a consistent effect on contraceptive use both before and after the marital dissolution: coitus dependent methods were avoided and sexual relations were less likely. Prior to the marital dissolution the disagreement between the spouses which ultimately resulted in a separation also was likely to result in a cessation of sexual relations. If the couple was still having intercourse, they were less likely to use methods that require cooperation, i.e., coitus dependent methods. The combination of a higher perceived cost of becoming pregnant in the intermarital period, along with the sporadic nature of coitus, probably led to avoidance of the less effective coitus dependent methods during the intermarital period, but less stable relationships with partners may also be a factor. These effects of separation were statistically significant. The unexpected result was that, on balance, the contraceptive behavior of the separated (before and after separation) was similar to that of continuously married women. The percent continuing to use oral contraception (OC) 3 months after R was 75 for those who separated and 85 for the continuously married. The difference was significant, but the proportions were little different substantively. Following separation, most women continued to use contraception in a pattern that was similar to the continuously married.
A computer-program for the printing of age-sex pyramids
"This research paper attempts to document and to explain the working of a computer program which prints age-sex distribution diagrams of population; or as they are generally called, 'age-sex pyramids'." "The program, called AGESEX is, in basic terms, designed to read place names (from data cards), to read age-sex data (from data cards), to calculate percentages, to print the age-sex distribution diagrams, to print place names and to print additional information which is needed for interpretation of the diagrams." Applications to Australian data are included in an appendix. (EXCERPT)
Inventory of marriage and family literature, 1981
The present volume contains citations to 2,965 articles on marriage and the family published in English in 1981. The bibliography, which is unannotated, is presented in three sections: author index, subject index, and key word in title (KWIT) index. A list of periodicals cited is also included. (ANNOTATION)
[The estimation of the total population of African countries]
In this collection of studies on individual African countries, the different methods that can be used to arrive at estimates of the total population are examined and their results assessed. The studies are presented in a standardized format. The first part lists the available sources of data, including historical estimates, administrative censuses, censuses, demographic surveys, surveys in other subject areas with demographic components, health statistics, and vital statistics. The next part considers problems such as how to define the population to be estimated, geographical variations, nomads, validity of data, and census evaluation. In a final part, suggestions are made for improvements in estimating procedures. Countries covered include Angola, Cameroon, Chad, Djibouti, Egypt, Ethiopia, Gambia, the Ivory Coast, Kenya, Liberia, Madagascar, Mali, Mauritius, Mozambique, Namibia, Niger, Nigeria, Reunion, Rwanda, Sierra Leone, Togo, Zaire, and Zambia.
This report is the first in an annual series that will present statistical data on marriages in Singapore. Data are included on: marriage trends, 1961-1980; average age at first marriage; age-specific marriage rates; Muslim marriages by ethnic group, age group, and previous marital status of bride and groom; and marriages under the Women's Charter by ethnic group, age group, and previous marital status of bride and groom and by place of marriage and year of previous marriage. (ANNOTATION)
This is the first in a planned series of bibliographical publications concerned primarily with the population of Peru. The bibliography is divided into two parts: the first part consists of 145 bibliographical citations without abstracts; the second part provides abstracts for selected items from Part 1. The citations are organized by subject using the classification system from the CICRED "Population Multilingual Thesaurus". Author, institution, and subject indexes are provided. (ANNOTATION)
[Mortality among elderly persons, 1960-1980]
Mortality trends among elderly persons in Denmark from 1960 to 1980 are analyzed. The effects of the observed mortality decline on the number and age distribution of the population aged 60 and over are discussed. (summary in ENG) (ANNOTATION)
Serum cholesterol and mortality: the Yugoslavia cardiovascular disease study
"The relationship of level of baseline serum cholesterol to the [seven year] incidence of death from all causes and from specific causes was examined in a cohort of 11,121 Yugloslav males aged 35-62 [years] at the time of their initial examination (1964-1965). Serum cholesterol was negatively related to mortality, i.e., those with a lower cholesterol experienced a higher mortality than those with a higher cholesterol. The negative relationship was significant (as assessed by logistic regression) and remained significant after adjusting for obesity, systolic blood pressure, cigarette smoking, age, history of intestinal parasitism and socioeconomic status (as measured by years of education). The authors suggest that "the negative association of serum cholesterol and subsequent mortality appeared to be due to the relationship of cholesterol to deaths due to cancer and to deaths due to respiratory disease (tuberculosis and cor pulmonale). The cancer death-serum cholesterol relationship was not statistically significant but the respiratory disease death-serum cholesterol relationship was. Serum cholesterol, as expected, was positively related to the incidence of coronary heart disease death." (EXCERPT)
Population mobility and development: Southeast Asia and the Pacific
This publication contains papers from an international conference held in 1980 to examine internal migration and its implications for economic development in Southeast Asia and the Pacific region. Papers in Part 1 are concerned with the variety and forms of population mobility, with a focus on circular or temporary population movements. In Parts 2 and 3, findings are presented from micro-level studies of population mobility in the region as a whole and in Malaysia, northern Thailand, Yogyakarta, and Papua New Guinea in particular. Emphasis is placed on the variety of mobility patterns and on the analysis of linkages between areas of origin and destination through family ties, remittance patterns, return migration, and employment. Part 4 concerns policy issues relating to urbanization and transport. Papers are included on the adjustment of aborigine migrants to Adelaide, Australia; the role of medium-sized towns in mobility trends in Papua New Guinea; rural-urban migration in Fiji; and the relationship between population mobility and changing transport patterns in Indonesia. In Part 5, policy issues relating to employment and mobility are considered. The evidence for rural labor shortages in the region is reviewed, and migration-related policies in Peninsular Malaysia are evaluated.
Stabilising the USSR's rural population through development of the social infrastructure.
This study is concerned with the problems caused by rural-urban migration in the USSR and with the policies that have been developed to deal with those problems. The author suggests that "the increase in the material prosperity of collective farmers since the Revolution, although a necessary condition for discouraging rural migration, has not in itself been sufficient to prevent the occurrence of rural manpower shortages. He points to the need for an all-round approach to improving conditions of life in the countryside, with due regard for cultural/utilitarian and socio-psychological factors, and suggests that the solution to the problem lies in agro-industrial integration, the improvement of public transport and the extension of the all-weather road network." (EXCERPT)
[Fertility of the Coloured population in South Africa: a demographic analysis]
4 variables in fertility trends are: 1) annual birth rate (improved among colored population because of better perinatal care); 2) total population (fairly accurately recorded); 3) age-specific female population (corresponds to figures for developed populations); and 4) female marital status. The latter variable is harder to ascertain because couples "living together" may or may not be registered as "married" or "not-married". In rural areas more young couples are "living together," however census numbers may reflect biases of census taker. This makes it difficult to analyze the marital fertility among colored population. Birthrate remained constant till 1965, declined by 40% to 1979. Number of deaths increased till 1974, declined by 19.4% till 1978 (mostly due to decrease in infant mortality). Population growth peaked in 1966 after which it declined to 1977; slight increase seen since then due to decreasing mortality. Age-specific fertility shows slightly declining birthrate for all ages except those in the 15-19 year and 20-24 year old groups up to 1965; there is a sharp decline thereafter except for the oldest age groups (mostly constant). There is an age-specific decline in fertility rate in 15-19 group (34%) and 2 oldest age groups (62%). Total Fertility Rate (TFR) is more than 6 children up to 1965; 3.36 children in 1978 demonstrating the effect of available contraceptives. Rural and urban fertility declined from 1960-1970 though sharper in rural women where the greatest decline was seen in the younger category. The overall rate of contraception protection (clinical contraceptive methods and sterilization) is about 50% for the colored population. By 1931 the Family Planning Association of the Western Cape (British) started the spread of birth control methods whereas the spread of modern clinical methods by public health departments started in 1965. Although the effectiveness of these programs is the single most important factor in the rapid decline in colored fertility, the social and cultural factors play a big role in this. Improved socioeconomic conditions and a culturally receptive climate toward birth control among the colored population of South Africa are important factors in fertility decline.
Lorazepam and oxazepam kinetics in women on low-dose oral contraceptives.
Women taking low-dose estrogen oral contraceptives (OCs) and drug-free control women matched for age, weight, and cigarette smoking habits, received single 2-mg intravenous doses of lorazepam or single 30-mg oral doses of oxazepam, 2 benzodiazepines metabolized by glucuronide conjugation. Kinetics were determined from multiple plasma concentrations measured during the 48 hours after dosing. Mean kinetic variables for lorazepam in control and OC groups (n=15 in each group) were: volume of distribution (Vd), 1.33 and 1.45 1/kg; elimination t1/2, 13.1 and 12.2 hours; total clearance, 1.25 and 1.50 ml/minute/kg; free fraction in plasma, 10.3% and 10.3% unbound. For oxazepam, kinetic variables in the 2 groups (n=14 and 17) were: Vd, 1.05 and 1.19 1/kg; t1/2, 7.6 and 7.2 hours; total clearance, 1.60 and 2.03 ml/minute/kg); free fraction, 4.6% and 4.9% unbound. None of these differences were significant. Thus, metabolic clearance by glucuronidation of lorazepam and oxazepam is not significantly affected by OCs, in contrast with the highly significant reduction in clearance of the oxidized benzodiazepine diazepam. (author's modified)
[Breast feeding practice in the municipality of Paulinia, State of Sao Paulo, Brazil]
In 1977, a survey was carried out in the municipality of Paulinia, State of Sao Paulo, with the purpose of obtaining information about breastfeeding of children up to 2 years of age. The survey would provide baseline data for the evaluation of a breastfeeding promotion program which was to be carried out at a later time. The children's mean age at weaning was 3.3 months and 2.2 months when bottlefeeding was begun. At the end of the 1st month, 74% of the children were breastfed and 57% were fully breastfed. Children whose mothers were at least 28 years old were fully breastfed for a significantly longer period than children with younger mothers. Urban/rural residence and the sex of children had no influence on breastfeeding duration. (author's modified) (summary in ENG)
Nutrition and health practices among the rural women--a case study of Uttar Pradesh, India.
The present paper highlights the health and nutritional status of rural women in the western part of Uttar Pradesh. It is observed that the women as such are trapped in a vicious cycle of early marriage, frequent pregnancies, prolonged and intensive breastfeeding practices with improper nutritional support, and inadequate health care. The results indicate that the early age at marriage (about 14 years) among girls is continued because of traditional values, fear of sexual exploitation, and poverty. The paper also shows that 85% of the women have never practiced any family planning and as a consequence, they have too many pregnancies with short intervals between them (an average of 23-26 months). During pregnancy, they take no supplementary food and work until labor begins. On the average, a woman with a pregnancy in the 8th month must work for 14 hours/day. Malnutrition is quite common among pregnant and lactating women who generally breastfeed for more than 20 months. More than 85% of the deliveries are attended by untrained indigenous dais and generally no pre- or postnatal care is sought. Governmental health services are beyond their reach and they depend mainly on private doctors or home medicine during an illness. Women who fall sick more often than males generally hide their problems because of such reasons as protecting the husband from worry, saving money, shyness, and preventing any inconvenience in the household due to illness. (author's modified)
Generalization of the immigration and the stable population model.
Building upon an idea presented by Espenshade, Bouvier, and Arthur (1982) about the eventual stationarity of a population subjected to a net reproduction rate of less than 1 and a constant stream of immigration, this note reports the consequences upon the birth trajectory for all possible values of the net reproduction rate. It has been shown that when the net reproduction rate is equal to 1, the number of births increases linearly with time. As might be expected, the increase is exponential for values of net reproduction rate greater than 1. (author's)
Electrophysiological and psychological changes induced by steroid hormones in men and women.
The effects of hormonal changes during the menstrual cycle and of oral contraceptives (OCs) on the EEG, heart rate, and a number of performance tasks were investigated in 16 female subjects. Power spectral analysis in the EEG revealed significantly increased alpha frequencies and heart rates during the luteal phase of the menstrual cycle whereas the mean theta frequency and power decreased. A number of psychological test variables, such as reaction time to a tone, to a flickering light, and to a color tone sequence and the time to solve simple arithmetic problems was shorter at the periovulatory time. Another minimum was reached during the perimenstrual phase. The flicker-fusion-frequency was higher during these 2 periods. No such effects could be observed when the same subjects were treated with OCs. It is concluded that the phenomena observed during the luteal phase of the cycle may be the expression of a slight general arousal effect, possibly mediated by progesterone via the noradrenergic system. In a subsequent double-blind study, 30 male subjects were treated with a gestagenic compound (d-norgestrel, 2.5 mg/die), an estrogenic compound (estradiol valerate, 5 mg/die), an androgenic substance (Mesterolone, 100 mg/die), or with placebo. Only treatment with the progestational compound revealed significant changes in the EEG and the performance tests. These changes were qualitatively similar to those observed during the luteal phase of the female subjects. Under both conditions, i.e., luteal phase and d-norgestrel treatment, the body temperature was significantly increased. Hence, the question whether gestagens exert their effects directly on the central nervous system structures which modulate EEG appearance and behavior or indirectly via increased body temperature cannot be answered convincingly. (author's) (summaries in FRE, DUT, ITA, SPA)
Sera from 46 vasectomized men for 5 years and from 46 age-matched nonvasectomized men had previously been analyzed for circulating immune complexes (CICs) by 4 assays. 4 additional CIC assays have now been performed on these sera: 3 Raji cell enzyme-linked immunosorbent assays (ELISAs) using alkaline phosphatase-conjugated antihuman IgG, IgA, or C3 and the bull sperm ELISA. No significant differences in CIC levels were detected between the 2 groups using any of the assays. Results for 2 different sera obtained from 16 men 4 1/2 months apart correlated significantly for 6 of 7 CIC assays evaluated in this way. In the bull sperm and Raji cell ELISAS, utilizing anti-IgG in the detection layer, the vasectomized men with sperm agglutinating antibodies were found to have significantly higher CIC levels than those without sperm agglutinants. No association was found between the presence of sperm protamine antibody and levels of CICs. Since the vasectomized and control groups did not differ with respect to levels of CICs, immunoglobulins, or the complement C3 split product Cd3, all 92 samples were combined into 1 group for further analysis. Serum IgG levels significantly correlated with the CIC levels in 4 of 5 CIC assays involving binding of IgG; IgA levels correlated with CIC determinations in the Raji-IgA assay, while plasma C3d levels correlated with the Raji-C3, the Raji-IgA, and the Cl1-protein A binding assays. IgM levels did not correlate with activity in any assay. Finally, the degree of correlation between all 8 CIC assays was determined, and significant positive correlations between assays were found in 10 of 28 comparisons. (author's)
The epidemiology of endometrial cancer in young women.
A case-control study was conducted in Los Angeles County, California, of 127 endometrial cancer cases aged 45 years or less, in order to investigate the role of fertility, obesity, and exogenous estrogens in the development of the disease in young women. Use of sequential oral contraceptives (OCs) or estrogen replacement therapy (ERT) for >or= 2 years was strongly associated with increased risk of endometrial cancer. After excluding these cases since the OCs or ERT use were probably responsible for their disease, we were left with 110 case control pairs for further study. Among these remaining case control pairs, increasing parity was strongly associated with decreased risk (relative risk of 0.12 for women of parity 3 compared to nulliparous women, P<0.001). Current weight was associated with increased risk (relative risk of 17.7 for women weighing >or= 190 pounds compared to weighing <130 pounds, P<0.001). Combination OC use was associated with a decreased risk, which decreased with duration of combination OC use (relative risk of approximately 0.28 at 5 years of use, P<0.001), but the estimate of the protective effect was reduced and became statistically nonsignificant when allowance was made for weight and parity. The protective effect of combination OC use was only clearly evident in women who had less than 3 live births and weighed less than 170 pounds. These results provide further support for the unopposed estrogen hypothesis of the etiology of endometrial cancer. (author's modified)
Determinants of variations in breast milk protective factor concentrations of rural Gambian mothers.
The concentrations of 7 immunoproteins (IgA, IgG, IgM, the complement components C3 and C4, lactoferrin, and lysozyme) in the breastmilk of 152 rural west African women were measured as part of a semilongitudinal study to assess their importance in infant health. Each mother maintained a characteristic level of production of immunoproteins relative to other mothers, and the concentration of each immunoprotein within each woman was correlated positively with the others. Parity was the major determinant of ranking and mothers of parity 1 and 2 produced the highest concentrations of immunoproteins. Except for lysozyme, infants' intake of these protective factors decreased in early lactation, but infants ages 1-2 still received substantial amounts. The daily intakes by Gambian infants were similar to or higher than those of infants in Cambridge, England. A marked seasonal increase in infant morbidity was not accompanied by an increase in the concentration of protective factors in mothers' milk. (author's)
Technique of vasectomy [letter]
I would like to make several comments regarding the article in the February 1983 issue on vasectomy (Brownlee HJ, Tibbels CK: Vasectomy, J Fam Pract .16:379, 1983). The article in general is excellent. My personal technique is to manipulate and grasp the vas superior-lateral, and while holding it in position infiltrate on either side with xylocaine anesthesia using a 26- or 27-gauge needle, then use a small towel clip for immobilization of the vas. Making an incision over the vas between the jaws of the towel clamp allows ready accessibility. The vas is dissected free with blunt dissection and at least a 2 cm section is dissected free, each end is tied with plain chromic sutures, the towel clamp is then removed, and each vas end will retract. The wound is then closed with 1 or 2 plain chromic sutures, which dissolve in 3-4 days. The plain suture allows for sealing over the vas ends without residual fibroma and scrotal discomfort. The masturbation-produced ejaculate is examined after 3 weeks of condom use. The vas specimens are always sent to the pathologist for confirmation. This technique has resulted in a total operating time of 15-20 minutes with very little morbidity. I allow the patient full activity immediately with use of a scrotal support and 50 mg of meclofenamate (Meclomen) 4 times a day for 4 days. (full text)
Microsurgical tubal reanastomosis in a community hospital: report of a 3-year study.
Microsurgery for reestablishment of tubal continuity after previous tubal ligation has been performed by gynecologists with increasing frequency and improved rates of success over the past decade. Prior to the use of visual magnification and ophthalmic-type surgical instruments and suture material, the pregnancy rate was less than 20%. By using microsurgical techniques, this relatively low success rate has been doubled and even quadrupled in some institutions. Most reports concerning tubal reanastomosis have come out of several of the large teaching centers and university hospitals throughout North America and Europe. The following 3-year study is from a typical community hospital gynecological service. While the success rate, based on intrauterine pregnancy, is less than that reported by many of the large institutions, no patient was refused surgery because of a particular type of tubal ligation. The author was not selective concerning less desirable forms of tubal ligations which statistically have a poorer success rate than does a routine Pomeroy. A total of 32 patients underwent tubal reanastomosis using a microsurgical technique during this 3-year period. There have been 12 intrauterine pregnancies and 1 ectopic pregnancy to date, giving a 37.5% success rate. The recommended method of initial patient evaluation and microsurgical technique is described, and the current literature is reviewed. (author's)
6 men requesting male contraception received a daily oral dose of 20 mg medroxyprogesterone acetate (MPA) in combination with 50 or 100 mg percutaneous testosterone for 1 year. From the 3rd month, the sperm concentration was <1 million ml for all the men at 1 time or another during treatment, and usually <5x1 million/ml, with an average reduction of 95% with respect to pretreatment values. The sperm count returned to previous values 3-6 months after cessation of the treatment. While follicle stimulating hormone and luteinizing hormone secretion was inhibited throughout the treatment period, plasma testosterone levels were not reduced. Estradiol levels were unaffected while dihydrotestosterone was elevated. The secretory activity of the prostate and seminal vesicles was not appreciably affected; seminal carnitine concentration was reduced during the treatment with a subsequent return to pretreatment values. No pregnancies occurred during treatment. There was no impairment of libido in the subjects, nor any incidence of gynecomastia, or increase in average body weight. The only observed metabolic side effect was a moderate increase in glycemia. A synergistic action of MPA and testosterone is proposed to explain the inhibition of gonadotropin secretion. (author's modified)
Immunoglobulin in seminal fluid of fertile, infertile, vasectomy and vasectomy reversal patients.
We measured the concentrations of IgG, IgA, and IgM, in the seminal fluid of 16 fertile men, 77 men in infertile marriages, 21 men who had undergone vasectomy reversal, and 5 men who had undergone vasectomy only. The lower limits of sensitivity of the assay was 0.04 mg/dl. IgG (mean concentration 3.29 mg/dl, range 0.48-15.41 mg/dl) and Iga (mean concentration 1.11 mg/dl, range 0.05-19.11 mg/dl) were measurable in all specimens but IgM (range 0.04-0.76 mg/dl) was measurable in only 20%. Intrasubject variability of IgG and IgA concentrations expressed as the coefficients of variation of serial determinations ranged from 18-40% and 29-52%, respectively. Discrepancies between the presence or absence of measurable IgM in serial determinations were unusual. The mean concentrations of seminal fluid IgG and IgA in the fertile group were not significantly different from other patient groups. However, IgM was measurable in only 13% of specimens from the fertile patients but in 62% of specimens from the vasectomy reversal patients (P=0.03). This suggests disruption of the blood-genital tract barrier following vasectomy and continuing after vasectomy reversal. (author's)
Contraceptive-steroid potency and lipoprotein cholesterol [letter]
The interesting article by Wahl and her colleagues (April 14 issue) presents the results of plasma lipid and lipoprotein analyses in large groups of women and attempts to correlate these results with the potency of the contraceptive steroids that were being used. Although some interesting trends were noted, I have some difficulties in accepting the authors' conclusions. 1st of all, the "potency" of pharmaceuticals that, like estrogens and progestins, have multiple target organs and physiologic effects is a mine field in which one must tread carefully. There are very few human tests for the potency of sex hormones, and those that are available usually measure only the effect on 1 target organ. Animal tests are of only peripheral relevance because of large species differences in the pharmacokinetics and pharmacodynamics of synthetic steroids. Specifically, Wahl et al. suggest that ethinyl estradiol is 20% more potent than mestranol. In fact, there is good evidence that the 2 are approximately equipotent when administered by the oral route in women. Similarly, they suggest that norethindrone acetate and ethynodiol diacetate are 2 and 15 times as active, respectively, as norethindrone. In fact, both these progestins are rapidly deacetylated during intestinal absorption and 1st pass through the liver; the only active metabolite identified in plasma is norethindrone. In the postponement-of-menstruation test, I was unable to find any significant differences among norethindrone, norethindrone acetate, and ethynodiol diacetate. For norgestrel Wahl and colleagues selected a value of 30 times the potency of norethindrone. Since 1/2 norgestrel is an inert enantiomer, this would give the active isomer (levonorgestrel) a potency 60 times that of norethindrone. The postponement-of-menstruation test suggests a figure of only 17 times, which is in fair agreement with the lowest doses used for progestin-only contraception (30 mcg daily for levonorgestrel and 350 mcg daily for norethindrone). In addition, it is widely recognized that numerous physiologic, pharmacologic, and pathologic factors influence plasma lipids and lipoproteins. Wahl et al. attempted to control for these factors, but it is not clear that they were completely successful and that differences between groups were due entirely to types of contraceptive pills. There are, for example, lipid changes at different stages of the menstrual cycle. Were blood samples obtained from all women at the same stage of the menstrual cycle? Was the duration of steroid use the same? Were no other pharmaceuticals used? Were there seasonal changes in diet? Also, many oral-contraceptive prescribers try to fit individual women to a particular hormone balance, so that high-progestin or high-estrogen products tend to be given to women of different physiologic types. There could therefore be considerable preexisting intrinsic lipid differences among the women in the groups using different pills. Finally, I am struck by the rather antique range of contraceptives used by the study groups. In most countries there has been a large swing towards pills providing 30 or 35 mcg of estrogen daily, and the progestin content has also been considerably lowered in both fixed-dose and phasic formulations. Such products have little or no influence on cholesterol fractions in the majority of women, provided that the overall steroid dose is low and a balance is achieved between the conflicting actions of the estrogen and progestin complements. (full text)
Consumer demand and household production: the relationship between fertility and child mortality.
Forces which link biological and behavioral factors to infant mortality and fertility in the United States are examined. Estimates can be arrived at if all of the important types of behavior affecting infant survival, prices and income constraints facing households are diligently gathered. Using equations to determine the relationship between a family health endowment index in conjunction with a child's health, information about optimal prenatal and postnatal behavior can be estimated and observed. This estimate which is strongly a factor of parental and environmental health related factors attempts to characterize the biological effects of parents' behavior on birthweight, gestation and the rate of fetal growth. Another estimate presented is one which establishes a link between biological effects of birth order on infant mortality. In this analysis, factors such as medical care during pregnancy, mother's rate of smoking, mother's age, duration of breastfeeding, mother's race and child's sex were included. Household socioeconomic and health data were also estimated in order to understand state and county ability to provide adequate health facilities for pre and postnatal maternal care. In particular, results suggest that child mortality declines in developed countries, and that mother's seek prenatal medical care in early stages of their pregnancy when risk is anticipated. Further study of the differential pattern of black and white fertility behavior in regard to seeking medical care is warranted.
Measures of sampling error in POPLAB demographic surveys.
Measures of sampling errors indicate the difference between the estimate and the value being estimated. The International Program of Laboratories for Population Statistics (POPLAB) of the University of North Carolina has produced demographic surveys. These surveys contain sampling error designs that involve measures of: 1) standard error, 2) square root of the design effect, and 3) interclass correlation coefficient. In these surveys Bolivia, East Java, and Somalia households were selected on an urban/rural curve distribution comparing common elements such as age, marital and fertility distribution. Technical ratios and equations were then computed as a means of analyzing variances among the random samples. Detailed findings of the fertility surveys tabulated show generally small standard error relative to the size of estimates. This indicates the fine statistical precision of the demographic work. Terms such as deft (square root of the estimated design effect for the estimate) and roh (estimated interclass correlation coefficient for the estimate) are shown to have comparably large ratios.
Methods of projecting rural-to-urban migration, with reference to Southeast Asia.
Addresses 3 topics relating to the projection of internal migration as part of preparing regional and rural versus urban projections: 1) the role of migration projection in development planning (its relevance, projecting alternative futures--with an example from Indonesia, some goals for regional projections involving migration); 2) the possibilities and limitations of migration projection given present data and techniques (migration projections based on 1 and 2 censuses, sample survey estimates, recommendations for future censuses); and 3) innovative approaches for future research (use of an interregional migration matrix, separate projection of outmigration and the distribution of migrants to regions, separation of movers and stayers and consideration of return migrants, model age distribution for migrants, integrated models of population and economic development, reporting of error). The author concludes that there is a limit to improvements in accuracy obtained by improving techniques. Unless there is better understanding of the reasons for changes in migration streams, difficulties in predicting such changes will continue. Since migration can be influenced by policies intended and unintended, projection will always have to be based on assumptions about future policies. More research is needed on the effect of various policies and on other factors that affect rural and urban development and migration.
Population trends and the status of population policy in Africa.
There is every indication that Africa's population growth will remain well above the world average for the remainder of this decade and probably for the rest of this century. With the exception of the island states and parts of North Africa, fertility levels show little indication of change. This is in part a reflection of little desire for small families, as well as a consequence of limited or even restricted family planning services. Great diversity in attitudes regarding population policy prevails among African governments, ranging from extreme pronatal to committed antinatal. Even with antinatal policies, however, many African states have yet to attain any significant success in depressing their rates of growth. To date, Mauritius can be cited as the only state to have almost achieved the transition from high to low fertility. The consequence of these continuing trends is that Africa will see further increases in its youth dependency ratio. Pressures on infrastructural services will therefore increase, and the problems of generating employment will intensify. While demographic factors are by no means the only ones creating economic stress on the continent, they clearly are contributory. Unlike Asia or parts of Latin America, Africa's problem is less a matter of too many people but rather 1 of excessive growth in too short a time frame. A realistic and effective long-term population policy, therefore, is an immediate need. Several countries including Nigeria (with a pouplation of over 80 million) are experiencing a crude birth rate of 50 or more/1,000. At least 4 countries, including Kenya, are currently doubling their population in 20 years or less. With these current population trends, a demographic transition to low vital rates must assume passage through an even higher growth phase than is currently being experienced because the fall in birth rates tends to occur much later than the fall in death rates. Government population policies and the status of family planning activities are illustrated according to natal sentiments and attitudes. Trends in national vital rates and of population structures in Africa are illustrated. (author's modified)
Fertility decline in Indonesia: analysis and interpretation.
This study sets out the complexity of the circumstances in which Indonesia's significant decline in fertility (from 5.5 during 1967-70 to 4.7 for 1976-79) took place. The new political conditions which followed the changes of 1966-67 altered national policy, and economic development was accorded a central status. Subsequently, Indonesia embarked on its 1st period of rapid economic growth since the early 1950s; by the end of the 1970s some improvement in real income was apparent among a large section of the population. This opened Indonesian society to a profusion of imported consumer goods and to more exposure to western cultural influences. The government made a strong commitment to a policy goal of lower fertility, and a family planning program rapidly spread throughout the country. In addition, there was also a continuation of earlier trends of improving literacy and average education attainment, declining child mortality, and fewer women marrying at very young ages. The underlying socioeconomic and cultural factors that appear to have been bringing about the fertility decline can be loosely classified into those shifting the balance of economic benefits and costs of children and fertility regulation, those affecting social and administrative pressures bearing on fertility-related behavior, and those that alter people's internalized values concerning marriage, fertility, and family. Recent studies point to a rising child cost burden on families, especially related to educational expenses and to new consumer options. Modern contraception has become widely available through a village-based public distribution network and is virtually free. (In 1980, the contraceptive prevalence rate among married women aged 15-49 was 27%.)
Statistics in fertility research: values and limitations.
This report discusses the value and limitations of statistics in fertility research. The statistical approach is described, and its variations and different roles in research are discussed. General statistical tools, e.g. models and such data collection techniques as experimental and comparative studies, are examined. Briefly described are a number of specific statistical methods, including regression analysis, indexes, standardization, contingency tables, time series analysis and forecasting, hypothesis testing and graphic methods. A review of recent fertility literature found that statistical techniques are sometimes misused, and that unjustified inferences are made based on the data collected. Examples of this misuse and faulty inference include describing a variate of interest as having a causal effect or failing to make a critical evaluation of the data employed in the analysis. Suggestions for fertility researchers include: 1) More resources should be devoted to auditing data; 2) Reporting standards should be established for the results of statistical studies; 3) Measures of sampling uncertainty should always be provided; 4) Assumptions and conclusions should be critically evaluated; 5) More exploratory analyses, confirmatory studies, and randomized experiments should be done; 6) Basic data should be released for independent study; 7) Substantial use should be made of robust/resistant techniques; and 8) There should be validation of constructed models.
Mortality associated with fertility and fertility control: 1983.
New data is used to update estimates of mortality associated with fertility and fertility control published in 1979 by Christopher Tietze. Estimates and assumptions differ from Tietze's as follows: data on contraceptive effectivenss and on health risks and benefits through 1978 are used; estimates of maternal mortality are those deaths related to ectopic pregnancy and childbirth based on U.S. vital statistics from 1972 through 1978, inflated to account for well-documented underreporting; recently published and more precise age-specific estimates of 1st year failure rates experienced by women using each contraceptive method are employed; new estimates of mortality associated with oral contraceptives are used; estimates of legal abortion mortality are slightly lower; and the concept of cumulative mortality risk is used. Bases on the lowest contraceptive failure rates reported, levels of mortality associated with all major methods of fertility control are low in comparison with risk of death from childbirth and ectopic pregnancy when no method is used. Exceptions are risks associated with pill use after age 40 (or 35 for women who smoke). Except for the lowest risk methods (condom and abortion) and the highest (pill use by smokers), most strategies of fertility control result in a similar risk of mortality until the woman reaches 35 years of age, at which time risk from pill use rises more sharply than risk associated with other methods. If highest failure rates are employed, use of the pill by a nonsmoker or of IUD is safer than reliance on barrier methods or rhythm. It is noted, however, that few women make contraceptive choices solely on the basis of perceived risk of mortality.
First intercourse among young Americans.
In 1979 50% of women 15-19 and 70% of men 17-21 living in metropolitan areas of the U.S. reported they had ever had sexual intercourse. Average age of 1st sexual experience was 16.2 for women and 15.7 for men. Women's partners tended to be nearly 3 years older, men's less than 1 year older. Age at 1st coitus was generally younger among blacks. Over 6 in 10 women and less than 4 in 10 men were engaged to or had been going steady with their 1st partner; men were more than twice as likely to have had 1st intercourse with someone they had only recently met. 17% of women and 25% of men had planned the 1st intercourse. Contraception was used by 49% of women and 44% of men at 1st intercourse, those 18 or older being most likely to have used it. White women were more likely to have been protected but blacks were most likely to have used a prescribed method. Almost 3/4 of women who had planned their 1st intercourse were protected by contraception, the partner using a condom or withdrawal in 2/3 of the cases. 4 in 10 women who used a prescription method obtained it from a clinic, the rest from private doctors. Nonuse among women who had planned their 1st intercourse was explained by deliberate choice or ignorance of contraception; nonplanners were more likely to explain nonuse by not expecting to have sex. Nonplanners were also more likely not to have thought about practicing birth control. Among men, planners explained nonuse by choice or lack of availability, nonplanners by lack of availability or lack of knowledge. Overall, it is suggested that problems of teenage pregnancy would be greater than they are in the absence of programs to deal with them, although current efforts are insufficient to appreciably decrease premarital teenage pregnancy in the near future. (author's modified)
The cost of contraception is 1 factor that affects the choice of a birth control method. An analysis of the 1st year costs for the various methods, based on fees charged by private physicians and supplies purchased at drugstores, shows that the cost can be considerable and that there are large differences in cost between methods. Prescription contraceptives--the pill, IUD and diaphragm--are by far the most expensive of the reversible methods because they require medical supervision, but supplies alone are also more expensive. 1st year cost is highest for the pill--US$172, compared with US$160 for the diaphragm and US$131 for the IUD. The mean of US$154 for those methods is almost 4 times higher than the mean 1st year cost for condoms and foam (US$40) . Sterilization necessitates the largest initial expenditure; the cost of tubal ligation US$1180) is nearly 5 times that of vasectory (US$241). However, sterilization represents a 1-time cost, while the other methods involve recurring expenses that may add up to more than the cost of sterilization over time. The methods associated with the lowest failure rates--sterilization, the pill and the IUD--are among the most expensive. To offset the costs of contraception, 4.6 million American women obtained low cost care from subsidized family planning clinics in 1980. (author's modified)
The total fertility rate in Quebec, which has remained high throughout the 1940s and 1950s declined rapidly between 1960 and 1975 (from 3.8 children/woman to 1.8). Although data on contraceptive practice in Quebec is fragmentary, data from a number of sample surveys indicate a quiet revolution in reproductive behavior during the 1960s--part of a profound change in values and behavior that characterized the period. Using service statistics from the Regee de l'Assurance-Maladie du Quebec, the authors examine a further dramatic shift in contraceptive practice during the 1970s. While in 1971 only 2.5% of women surveyed said they or their husbands had been surgically sterilized, a follow-up survey in 1976 found that almost 1 in 3 women under age 40 who had been married at least 5 years was in a marriage where 1 partner was sterilized. By 1979 1/2 of Quebec women reaching age 40 had become surgically sterile (33% as a result of contraceptive sterilization and 17% as the result of hysterectomy), levels which will probably be surpassed by future generations. Findings are compared to the situation in other Canadian provinces and in the US.
Depo-Provera: the jury still out.
A public board of inquiry held hearings in January, 1983 on whether or not the Federal Food and Drug Administration (FDA) should reverse its 1978 decision not to approve of Depo-Provera for use as a contraceptive in the U.S. Depo-Provera, a product of the Upjohn Company, is the trade name for a preparation whose active ingredient is the synthetic progestin depot medroxyprogesterone acetate. It is injected at 3-month intervals to prevent ovulation. After 5 days of hearing, during which supporters asserted that it is at least as safe as other available forms of contraception, and opponents claimed that it might pose severe health risks to women, the controversy is far from settled. Depo is approved for use in more than 80 countries, and recently several international review bodies concluded that the benefits of its use outweigh the risks. It has a failure rate of 1/100/year. The author reports the various arguments for and against the drug, and also summarizes the findings of the various tests that have been conducted. After the hearing had been concluded, the board requested additional data and indicated that an outside panel of expert pathologists may be appointed to review the material. It was also suggested that the board may conduct additional public hearings.
This report for UNFPA (United Nations Fund for Population Activities) on Colombia's Maternal and Child Health and Population Dynamics (MCH/PD) program was prepared by an independent team of consultants which spent 3 weeks in Colombia in February 1980 reviewing documents, interviewing key personnel and observing program services. The report consists of 8 chapters. The 1st describes the terms of references of the evaluation mission. The 2nd chapter provides background information on Colombia and identifies some of the principal environmental factors that affect the program. Chapter 3 describes the organizational context within which the program operates. The chapter also includes a discussion of the UNFPA funding and monitoring mechanism and how that affects program planning and operations. Chapter 4 is a description of the program planning process; goals, strategies and objectives, and of the UNFPA and government inputs to the program between 1974-1978, the period under review. A large part of the report is devoted to describing and assessing each program activity. Chapter 5 consists of descriptions of management information; maternal care; infant, child and adolescent care; family planning; supervision; training; community education; and research and evalutation studies. Chapter 6 is an analysis of the program's impact on: maternal morbidity and mortality; infant morbidity and mortality; and fertility. Chapter 7 summarizes the Mission's conclusions and lists its recommendations. The final chapter deals with the Mission's position in relation to the 1980-1983 proposal. Appendices provide statistical data on medical activities, contraceptive distribution and use, content of training courses, target population, total expenditures, and norms for care, as well as organizational charts, individuals interviewed, and UNFPA assistance to other agencies in Colombia. (author's modified)
The Tonga 1973 children study: design, demographic aspect and disease prevalence.
In 1973, a population based study was conducted among Polynesian children (5-19) at Nuku'alofa (urban) and Foa Island (rural), Kingdom of Tonga, to verify an impression that cardiac disease among children was a major problem and that a variety of health problems would be more prevalent in the rural areas. The participation rate was 93.4% and 99.5% in Nuku'alofa and Foa respectively. Demographic data showed similar sex distribution but a younger Foa sample. The Nuku'alofa sample had significantly more subjects born outside their place of residence. This study demonstrated a total age standardized prevalence rate of 1.11% for cardiac disease due to congenital heart disease (0.66%), rheumatic heart disease (0.28%) and cardiomyopathy (0.17%). There was no urban-rural difference. The children in Nuku'alofa (24.16%) had more dental problems than Foa children (15.56%). Skin diseases were more prevalent among Foa children. It is suggested that the priority of studies of the Pacific natural experiments is the collection and analysis of data for health service planning based on questions of importance to the community. (author's modified)
A case study in the administration of the Expanded Programme of Immunization in Nigeria.
The World Health Organization (WHO) launched the Expanded Program of Immunization (EPI) in 1974 based on the belief that most countries already had some elements of national immunization activities which could be successfully expanded if the program became a national priority with a commitment from the government to provide managerial manpower and funds. The federal government of Nigeria quickly adopted the policy of WHO on EPI and urged the state governments to set up administrative arrangements for planning and implementation of EPI. The program started off in Oyo State of Nigeria after a pilot study conducted at Ikire in Irewole Local Government area in 1975. The stated objectives of the programs were: to provide immunization service to at least 85% of the target population e.g. children under 4 years; and to integrate immunization programs into routine activities of all static primary health centers in the state. This study focuses on administration of the immunization program in the Oranmiyan Local Government area of Oyo State, within the structure of the local government health system and the field health administration of the state government. This study shows that the stated objectives of the EPI are not likely to be achieved in the near future because of low coverage of the eligible population, due to inadequate community involvement in the planning and implementation of the program; 2) poor communication between different government departments; and 3) inadequate publicity. The effect of improvement in health status because of immunization programs, has been very difficult to demonstrate in Nigeria because a lack of accurate data on birth, morbidity, and mortality patterns of the population. Other socioeconomic and health factors of significance in the battle against infectious diseases include environmental sanitation, adequate and safe water supply, housing and nutrition. Nevertheless, immunization programs constitute one of the most economical and effective approaches to the prevention of communicable diseases and can produce dramatic effects in the battle to lower infant and childhood mortaltiy rates in the developing countries if they are well implemented.
Contraception for women with liver disease.
This review looks at the risks of pregnancy, discusses the influence of hormonal contraception on the normal and disordered liver, and briefly mentions some points to be considered with other methods of contraception. In women with auto-immune liver disease, complications related to pregnancy are common. The pregnancies of 37 women who had chronic active hepatitis (CAH) were studied. Pregnancy loss was high, with 4 terminations on medical grounds, 3 miscarriages and 4 perinatal deaths, 3 of which were in premature or low birth weight babies. The only congenital abnormality was 1 case of pyloric stenosis. Preeclamptic toxemia occurred in 10% of the pregnancies. The effects of chronic persistent hepatitis, cirrhosis, porphyria, hyperbilirubinemia, and Wilson's disease are also discussed. Combined oral contraceptives (COC) have been associated with jaundice, gall bladder diseases, and liver tumors. During acute viral hepatitis, patients are advised to stop using COC; however, after recovery, a delay in resuming COC, or even worse, unnecessary prohibition of COC, may lead to unwanted pregnancy., Where there is portal hypertension as a result of chronic active hepatitis, COC may lead to an unacceptable risk of thromboembolism. If COC were acceptable to a patient with mild CAH, the dose of corticosteroid might need adjustment as COC increases transport proteins and therefore makes a single dose of corticosteroids more bioactively available. Barrier and rhythm methods are unlikely to cause any problems for women with liver diseases. The Fitz-Hugh Curtis Syndrome (perihepatitis) has been reported in IUD users following pelvic inflammatory disease (PID). If this occurred in a woman with an already diseased liver, the effect could be disastrous. Sterilization would appear to be an ideal method, however, there are problems associated with it. The woman may not be fit for an anesthetic and laparoscopy can be difficult to perform on a woman with chronic liver disease.
This report records spontaneous abortion associated with Candida species infection in a patient with a plastic IUD. Although many women harbor Candida species in their vagina during pregnancy, involvement of the fetus is rare. Sporadic reports of intrauterine infection have occurred but more recent accounts have recorded fetal infection associated with an IUD in situ usually of the copper type. The present case documents fungal infection of the fetus with a plastic IUD in situ, a device more commonly associated with the presence of actinomyces. It is interesting to note that not only an IUD but also a cervical suture may be implicated in fetal Candida infection during pregnancy. Macroscopic findings considered to be pathognomonic of Candida species infection were not seen in the umbilical cord or placental membranes of this pregnancy, and, indeed the diagnosis was not established until there had been histological examination. The clinician should be aware of the possible association of fetal fungal infection in addition to the other recognized complications of pregnancy with an IUD in utero. Abortion is not an invariable consequence, as neonates suffering from skin rashes and/or pneumonia have been described recently.
Noragard versus Gravigard: a cost-effectiveness study.
An attempt is made to use the economists' technique of cost effectiveness analysis to determine whether the newly introduced intrauterine device, Novagard, is likely to work out cheaper in the long run than a widely used device, Gravigard, that costs less to purchase. While Novagard proves to be the less expensive option, considerable doubt is expressed as to whether a change from Gravigard to Novagard would actually enable family planning services to save money. The study incorporates the results of a survey that looked at the costs to women attending family planning clinics in terms of time lost, travel costs and discomfort. Nearly 20% of a sample of patients surveyed found the experience of IUD insertion either painful or nerve racking. The patients would likely welcome the use of an IUD such as Novagard that can remain in situ for 4 years. (author's modified)
Infant mortality in three parishes of western Jamaica.
The infant mortality rate is a sensitive index of health. However, in recent years, perhaps due to underregistration of deaths, the infant mortality rates for Jamaica, and particularly for certain parishes, have been so low as to make their accuracy questionable. This study sought to establish the infant mortality rates for the parishes of St. James, Hanover and Trelawny during 1980. Information on infant deaths in 1980 was sought from a variety of sources, as was information on live births in the same year. The infant mortality rate (1980) for the combined parishes of St. James, Hanover and Trelawny was estimated to be 27/1000 live births. It was estimated that only 31% of infant deaths in 1980 were registered. Health personnel were much more aware of infant deaths than were the Registrars of Births and Deaths, and hence, the Registrar General. Possible reasons for underregistration of infant deaths are suggested, but the topic requires further research. Attempts should be made to improve the registration of infant deaths. (author's modified)
The contraceptive prevalence survey project: content and status.
The United States Agency for International Development (USAID) selected Westinghouse Health Systems to carry out contraceptive surveys. The primary objectives of the Contraceptive Prevalence Surveys (CPS) are to determine periodically the levels of contraceptive use in the country; to examine the correlates of and differentials in these levels in order to assess the impact of various types of governmental and nongovernmental programs; to identify factors that will facilitate an increase in contraceptive use, particularly factors involved in program planning activities; and to institutionalize in each country the capability to design and implement studies of contraceptive prevalence, to be undertaken at regular intervals by an in-country agency. Each CPS generally collects data on the basic demographic background of the country concerned, knowledge of contraceptive methods, prior contraceptive experience and current method used, past fertility behavior and future fertility intentions, present utilization of various types of service delivery systems, perceived accessibility of contraceptives, and reasons for nonacceptance of contraception. In the CPS project, data collection and field operations have been strongly stressed. Efforts have recently been made to expand the extent and sophistication of CPS data analysis. For example, 2 countries are currently using a series of mathematical techniques called synthetic estimators to estimate subnational levels of contraceptive use by merging CPS and census data. Westinghouse, in cooperation with the University of Michigan, is currently working to develop community characteristics module for inclusion in future CPS projects.
Accelerated failure time models: an application to current status breast-feeding data from Pakistan.
A parametric method is presented for the analysis of current status data (e.g. data which indicate whether or not an event has occurred during a fixed observation period), based on accelerated failure time models and maximum likelihood estimation. The method has been applied to duration of breastfeeding. One of them, namely the Weibull distribution, seems to provide a well-fitting model. Furthermore, comparing this model with the semiparametric Cox regression model, the authors found that there is little loss of information and that at least the general results are very similar--if not equal--when using the parametric method. A considerable amount of memory space on the computer is saved this way which can be used for introducing more covariates. All analyses have been carried out from World Fertility Survey (WFS) breastfeeding data for Pakistan. (author's) (summaries in ENG, ITA, FRE)
Growth pattern of selected urban Chilean infants during exclusive breast-feeding.
This report describes the growth pattern of healthy, low middle and low socioeconomic class Chilean infants during exclusive breastfeeding. 242 infants who were on exclusive breastfeeding at day 30 postpartum entered the study. Of these, 59% were fully nursing at 6 months and grew at a normal rate without receiving either supplementary milk or nondairy food. Supplementary feedings were administered in 27% of the cases because of suspected primary inadequate milk output and in 14% of cases for other reasons such as pregnancy, illness, maternal work, or self prescription. Full nursing provided the highest rate of weight increase during the 1st 3 months of life and greater weight gain for boys than for girls up to the age of 6 months. Gastrointestinal pathology, malnourishment, or hospitalization were rare events in this population. It is concluded that maternal milk alone, if produced in sufficient amounts, can maintain normal growth up to the 6th month of life. The study supports the choice of exclusive breast feeding on demand plus child growth monitoring up to 6 months over routine prescription of supplements at earlier times particularly where supplement administration fails to meet individual requirements. (author's modified)
Perceptions about having children: are daughters different from their mothers?
108 daughters and their mothers rated the importance of 38 items concerned with the values and costs of having children. Daughters rated the items once for themselves and once as they thought their mother would. Subsequent factor analysis revealed 2 value dimensions--traditional values in having children and the value of childrearing and intimacy with children--and a general cost of children dimension. Correlations among the daughter's score on each factor, her mother's score, and her perception of her mother's score revealed a significant correlation between daughters' and mothers' scores on all factors. Comparisons between correlations indicate that daughters perceived their mothers' attitudes to be more like their own than they really were. Discriminant analyses were conducted for items on each factor. Daughters agreed somewhat less than their mothers with both traditional values and childrearing satisfactions but did not differ to a great extent on the cost factor. (author's modified)
Regional differences in family size: the case of the Atlantic provinces in Canada.
Data from the 1971 Public Use Sample Tapes based on the 1971 Census of Canada are analyzed to examine the relationship between regional background and fertility in the Atlantic region and the rest of Canada. 2 explanations are discussed and tested for their relevance in explaining the above average fertility in the eastern provinces. The results provide support for the characteristics assimilation proposition and the regional-cultural effect hypothesis. Standardization of social demographic differences (as a proxy for assimilation to the rest of Canada) results in a lowering of average family size among Atlantic females; however, the main effect of region is positive and stronger in magnitude. Possible sources of a regional cultural effect are discussed with reference to the social science literature concerning the Atlantic provinces. In a later section of the paper the association between the carry over influence of region on fertility among outmigrants from this area of Canada is investigated. The findings indicate the outmigrants constitute a select group who have below average fertility in relation to Atlantic nonmovers. Thus, the positive regional cultural effect is only of relevance to the indigenous nonmigrant population in the eastern region and has no carry over influence among persons who leave this locality. (author's modified)
Childhood disadvantage and the planning of pregnancy.
The relationship between the planning of pregnancy and subsequent childhood disadvantage in the areas of health, education and family conditions was studied prospectively to the age of 3 years in a birth cohort of New Zealand children. Unplanned children showed a systematic pattern of disadvantage in nearly all groups studied. However, multivariate analysis suggests that the apparent association between the planning of pregnancy and subsequent childhood disadvantage arose largely from a series of social and contextual factors associated with pregnancy planning practices. In particular, unplanned children tended to come from socially disadvantaged home backgrounds and these backgrounds were independently associated with an increased risk of childhood disadvantage. Further, a disproportionate number of unplanned children were exnuptial and the levels of disadvantage experienced by these children tends to reflect more their exnuptial status than the direct effects of failure to plan the pregnancy. It is concluded that when the effects of maternal social background and the nuptial status of the child are taken into account, the effects of planning of pregnancy on levels on childhood disadvantage for this birth cohort were almost negligible. (author's modified)
Familial roles and fertility: some labour policy aspects.
This paper, an International Labor Organization study, is concerned with the relationship between labor laws (such as minimum age for work) and their effect on fertility. With increasing industrialization, greater recognition of women's rights, and the provision of social security, there is a decrease in the number of children women have, a lessening of their dependency upon husbands, and a loosening of kinship ties. Economic development that takes women's and children's rights into account often serves to alter employment strategy with regard to training and employment opportunities. Demographers must take the change of family systems and roles into account in their forecasting of fertility levels.
Examines the extent to which resettlement in low-cost link housing schemes had affected residents' knowledge, attitude, and practice of family planning. The study attempts to show that there is a strong relationship between resettlement in low-cost link houses and family size, birth rates, and marriage patterns. Topics covered include knowledge of family planning, sources of information on family planning methods, attitudes towards family planning, attitudes toward induced abortion, and the practice of family planning and number of children. In Malaysia there is an increasing demand for urban shelter as so many people are moving to cities. The government has resorted to the construction of various low-cost housing schemes in the country for low-income groups. A house plays more than just a physical role of providing shelter. It also determines the structure and functions of the family it shelters. Thus, a house can influence the family's attitude toward procreation and ultimately the family's views and practice of family planning. A low-cost house may indirectly serve to limit the size of the family it shelters. Results show that the concept of family planning has become popular and women in low-cost housing schemes are not ignorant of family planning and, in fact, have positive attitudes toward it. The author recommends that more research be done in other low-cost housing schemes and permanent family planning clinics be set up in these areas for the residents.
Traditional methods of contraception of the Malays--an exploratory study.
Documents the traditional methods of contraception as practiced by the Malays. Investigates what these methods are, how they are used, and how effective they are in preventing pregnancy. The study also aims to find out the characteristics of the users in terms of age, income, occupational level, education, maternity, and fertility history. The place chosen for the study was Selayang, a suburb of Malaysia's capital city of Kuala Lumpur. A standardized, structured questionaire was used to collect data. 13 traditional contraceptive methods were discovered in the course of the study. Within the 13, there are variations as to the applications of the methods and differences in the ingredients. 5 methods were oral contraceptives, containing herbal mixtures. Other methods include the eating of raw fruits, flowers and shoots; applying a hot object to the abdomen externally; massage of the lower abdomen; taking other concoctions with some religious incantations; the withdrawal method; rhythm method; and various types of exercise. Findings show that there is no significant correlation between education and choice of traditional and clinical methods. Age has some significance in that younger women tend to use modern methods and older ones tend to use traditional methods. The author suggests that further research is needed to identify the ingredients in the traditional contraceptives which make them effective and thus develop a contraceptive similar to the traditional form, so as to be more acceptable to the Malaysian population.
Migration, fertility and social mobility in rural and urban communities.
Investigates the fertility behavior of migrants and natives of the Philippines by using social mobility characteristics and place of destination as control factors. 4 types of migrants compose the main groups of study. These include migrants to the city of Manila, migrants to 6 provincial poblaciones, migrants to 6 near-to-the poblacion barrios, and migrants to 6 far-from-the poblacion barrios. The author hypothesizes that migration status will vary with fertility behavior, socioeconomic characteristics, and place of destination. The study explores why migration could be a factor influencing low fertility. Findings show that while migrants on the whole have higher mean numbers of live births than natives, the differences are not statistically significant and the association between the variables is low. Migrant-native differences appear to be larger in urban areas, and fertility levels seem to be positively related to the areas' level of urbanization. Regardless of destination, there was not a significant relationship between migration status and fertility behavior, and little or no relationship between migration status and social mobility characteristics, or between migration status and family planning behavior. There were, however, statistically significant associations between fertility behavior and mobility characteristics such as education, occupation, and income. The author recommends that more Philippine studies be done involving primary qualitative data on social mobility characteristics like sociopsychological variables, in order to test the social mobility theory in explaining migrant-native fertility differentials.
Folk media and social development, Tanzania.
The term folk media refers to indigenous communication systems as illustrated in the use of music, songs, dance, poetry, proverbs, stories, and even rituals. This paper surveys some areas in which folk media have been used to achieve specific goals in Tanzania; the importance attached to such use as a means of communication cannot be over-emphasized. The author recommends further exploration of this mode of communication to influence social change, as well as the need to collect data on the results of communication campaigns employing folk media in order to document its effectiveness.
[Population and development policy in the People's Revolutionary Republic of Guinea. Provisional ed]
This report to a study commission on population and socioeconomic development in Guinea includes chapters on 1) current implicit population policy 2) explicit population policy, and 3) data needs for a study of the relationship between demographic variables and economic parameters. Some programs that express the government's implicit population policy are described, including such aspects as health and sex education, promotion of women and the family, special education for the handicapped and disadvantaged, and the objectives of the government education and training policy and advanced research activities. The creation of a family planning and human resources cell within the Ministry of Planning is described, and the provisions for collection of data on fertility and socioeconomic variables are outlined. Employment and labor force development are other concerns of the government. The explicit population policy of the government is pronatalist and is defended on the grounds that Guinea lacks manpower to exploit all of its resources, the country is not yet considered overpopulated, and there are enormous economic potential and employment possibilities, especially in agriculture. The present economic development policy of Guinea is based on the use of labor more than capital, and family planning is therefore not viewed as highly desirable. Data are needed on trends and levels of mortality and morbidity, on the structure and dynamics of the Guinean population, on the school age population and educational requirements, on the domestic rate of savings, and on the gross national product. A series of appendices provide further information on the government's educational programs and goals, female employment policy, public health policy, and the results of a study of the age structure of fertility.
[Health risks of intrauterine contraception (author's transl)]
Uterine perforation, intrauterine and ectopic pregnancy, pelvic infection, and fertility problems after removal of the IUD are among recognized or potential health risks of IUD use. The frequency of uterine perforation varies according to type of IUD, with estimates of cervical and uterine perforation respectively ranging from 0 in 4122 Saf-T-Coil insertions to 1.5 and .3/1000 insertions of the Copper T. Data on perforations and their treatment and sequelae are however incomplete and unsatisfactory. The structure of the IUD, the rigidity of the applicator, the size and position of the uterus and the time of insertion relative to delivery or abortion, and the physician's technique and experience are all related to the incidence of perforation. Reported pregnancy rates/100 woman years vary from 5.3 for the Lippes Loop A to 1.6 for the Copper 7 Gravigard among nulliparous users. Disparities result from inherent fecundity differences in the populations studied, the age-parity composition of the population, sociocultural factors related to timing and frequency of coitus, and methods of data analysis. Spontaneous abortion rates for intrauterine pregnancies with IUDs range from 23.5-52.9% depending on whether the device is in place, but rates do not differ greatly from those of diaphragm users if the IUD is removed, even during pregnancy. The IUD does not seem to increase the risk of congenital anomaly. Although evidence and opinion on the question are divided, the use of an IUD apparently does not by itself increase the risk of ectopic pregnancy. Later fertility does not seem to be affected: 80-90% of women discontinuing IUD use to become pregnant do so within 1 year. Pregnancy rates appear to be comparable to those of women discontinuing diaphragm use. Although evidence of a greater risk of pelvic inflammatory disease among IUD users has been observed, the extent of the added risk if any is unclear because of diagnostic and methodological problems. In comparison to other reversible methods of contraception, the rates of failure, and of mortality resulting from use of the IUD or indirectly from failure of the IUD, are low. Patients should however be carefully screened and informed of the risks and symptoms.
Just as some gynecological conditions contraindicate the use of mechanical methods of contraception, some pathological conditions influence the choice of contraception. Estrogens stimulate vasodilation, cellular multiplication of target tissue, endometrial proliferation, an myometrial hyperplasia, while progestogens diminish edema due to estrogens, discourage multiplication of target tissue, stimulate secretory differentiation of endometrial tissue, and inhibit myometrial contractility and hyperplasia. A sub-mucus fibroma contraindicates all hormonal contraceptives, which are frequently associated with necrobiosis. Interstitial and sub-serous fibromas also contraindicate use of combined pills, even those with progesterone dominant, although in these cases synthetic progestogens are sometimes highly beneficial. In cases of uterine polyps or endometrial hyperplasia, use of normal or minidose combined oral contraceptives (OCs)in contraindicated, but a normal dosed, discontinuous progestogen may be appropriate. A progestogen contraceptive may also be therapeutic in the case of endometriosis or endometrial hyperplasia. At present Danazol is recommended as a medical treatment for endometriosis; its antigonadotropin action makes it a contraceptive product without estrogenic, antiestrogenic, or truly progesterone effects. Careful surveillance is necessary during use. Antiandrogens such as Androcur and combined pills are advised in the case of hirsutism.
[Survey on nutrition and health]
5 chapters on aspects of nutrition and health in the area of the Integrated Health and Population Project of Petit-Goave, Haiti, are preceded by a brief introduction which presents details on the development of the project, geographical factors and population characteristics of the area, and sanitary conditions and services available. The 1st study, on the prevalence of ascaris, trichuris, and Necator americanus, indicated that over 80% of the population is infested and over 1/2 suffer mixed infections. The degree of anemia found in those infested with N. americanus was not always proportional to the degree of infestation. Almost 1/2 the population was infected with the worm, which was more sensitive to tetrachlorethylene than to any of the other formulations tested. An analysis of 3 methods of nutritional education in rural Haiti using the rate of mortality in children under 5 as an indicator suggests that all 3 methods are useful, but that nutritional education centers and recuperation centers are more effective than oral lessons with weight/age charts. A study of female puberty in rural Haiti explained the late median age of 15.5 years in terms of nutritional habits, chronic maladies such as bronchial asthma, and a distressed socioeconomic situation. A relationship between the age of puberty and the age of entry into unions of all types was also observed. An evaluation study of protein-calorie supplementation programs undertaken during a drought and a study of the relationship between the duration of lactation, postpartum amenorrhea, and birth intervals complete the work. The latter work found a median lactation duration of 20 months, which increased with age, as did the birth interval. The duration of postpartum amenorrhea ranged from 10-20 months depending on whether the child survived, and was also influenced by age.
[Burundi. The effects of demographic factors on social and economic development]
This analysis of the effects of demographic growth on socioeconomic development in Burundi was prepared to accompany the RAPID computer simulation. Burundi's population of 4 million is increasing at a rate of over 2.2%/year and already there are 285 persons/sq km of cultivable land. The wide range of development goals set forth in the 5-Year Plan for 1978-82 will be easier to achieve if the birth rate of 44/1000 can be reduced. With a mortality rate of 22/1000 and a life expectancy of 44 years in 1980, the growth rate shows potential for increase if new gains are made in mortality. A population redistribution whereby immigration to presently underpopulated areas and development of new urban areas is encouraged is being planned. Because of the age structure, with 43% of the population under 15, the population would continue to grow for at least 50 years even if fertility fell immediately to replacement level. If present fertility is maintained and life expectancy increases to 52 years in the year 2000, the population in 2025 would be over 16 million, but if the total fertility rate falls from 6.3 children/woman at present to 3 in 2000, the population in 2025 would be 8.1 million. If the present fertility rate is maintained, by 2010 the average family farm would decline from 1.4 hectares at present to .07 hectare; the shortfall in agricultural production would increase to 2.1 million tons; 500,000 additional hectares would be needed just to satisfy nutritional needs; the demand for forest products would almost triple; 138,000 new jobs would be needed but only 49,000 would be available; each 100 economically active persons would have 102 children to support; the number of primary school age children would increase to 1,860,000 although only 23% are enrolled at present; and the urban population would increase by a factor of 5. Each of the pressures would be reduced with a reduction in the population growth rate.
[Venereal diseases and fertility in rural Uganda]
A comparative study of the incidence of venereal disease was carried out in 2 districts of Uganda, Teso in eastern Uganda with a birth rate of 37/1000 and Ankole in western Uganda with a birth rate of 55/1000, in an examination of the relationship between venereal disease and infertility. 150 of the 270 men examined in Teso and 18 of the 166 in Ankole reported a history of urethral discharge; 70 in Teso and 5 in Ankole complained of difficulties in urination; 74 in Teso had thickening of the epididymis; and 49 in Teso and 1 in Ankole had a hydrocele. 343 women in Teso and 250 in Ankole were included, of whom 19 in Teso and 21 in Ankole were single. 32% of women in Teso and 9.6% in Ankole had been married more than once. 19.0% of wives in Teso and 2.2% in Ankole had never been pregnant. The average number of children/married woman was 2.9 in Teso and 5.2 in Ankole. 25% of the women in Teso and 8.9% in Ankole had lower abdominal pain at the time of examination; 6 women in Teso had Bartholin cysts, 14.6% in Teso and 1.2% in Ankole had vaginal inflammation; 90 women in Teso and 21 in Ankole had cervical inflammation or erosion; 18.4% in Teso and 2.4% in Ankole showed signs of gonorrhea in the smear or culture; 17.5% in Teso and none in Ankole had signs of salpingitis. Treponemal infection as demonstrated by serologic test was also more common in Teso. Although the majority of positive serologic results in Teso were probably due to an old, preexisting condition, the association of positive results with genital lesions in the men and abortions in the women in Teso suggests that syphilis is a factor. On the basis of the observations, it can be concluded that gonorrhea and to a certain extent syphilis explain the reduced fertility of Teso relative to Ankole.
Linking housing choice and residential mobility paradigms.
This discussion lays out 2 research streams--research by economists which has focused on housing choice and research by geographers and demographers which has emphasized the relocation process itself--and discusses attempts to bring these research streams together. The research stream which is focused on housing market choice arises out of a broad base of research in housing market economics. Despite the fact that much of the research on the housing choice problem has used information from population relocation data sets, the models themselves are essentially concerned with the static question of the choice of housing and allocation of households to houses and neighborhoods. The models incorporate implicit behavior, the behavior of choice, yet in every instance, the models are concerned with the outcomes of choice, of the actual allocations rather than the tradeoff aspects of leaving 1 location and choosing another. The concept of a dynamic tradeoff is key to the idea of linking the 2 research paradigms. The rich tradition of studies of population relocation within the city has as antecedents studies by Wolpert (1965), who identified the concept of stress induced residential relocations; Brown and Moore (1970) who developed a simple 2-step model of the decision to move and the decision to search, where increasing stress or dissatisfaction led to the decision to search; and specific studies of stress by Clark and Cadwallader (1973) and of dissatisfaction by Speare, Goldstein and Frey (1975). The disequilibrium approach and its variations were viewed as alternatives to the more traditional sociological and geographic models of residential mobility. The model proposed and tested by Onaka extends the concept of housing consumption disequilibrium to include dissatisfaction with individual attributes of housing, instead of a single index of housing services. 2 recent papers have proposed a joint mobility housing choice model. De Palma and Ben-Akiva (1981) developed a dynamic model of the spatial distribution of urban population based on individual choice and transaction costs. The paper postulates a decision hierarchy for an individual household which includes the decisions to search and to move and conditions the expected outcomes of these decisions on the availability of alternative units in the urban area. Van Lierop and Rima (1982) similarly proposed a 2-stage process of relocation behavior, where the probability of moving from the current dwelling is equal to the probability that the utility of moving minus the transition costs exceeds the utility of staying. A nested logit model of housing choice and residential mobility is presented. The model offers a complete specification of the housing choice residential mobility link.
3 recent studies about the relative effects of family planning and development are reviewed in an effort to point out their limitations and to augment them. A tentative theoretical framework is presented from which the problem of fertility reduction may be viewed. Also presented is an analysis of the "outliers" in 1 of the 3 studies. This analysis involves consideration of macrosocial and contextual aspects of different nations as a supplement to other analyses. Mauldin and Berelson (1978) and Tsui and Bogue (1978) used indicators of social setting and family planning effort to explain declines in, respectively, crude birthrate between 1965 and 1975, and total fertility rates between 1968 and 1975. The 2 studies used nearly identical sets of explanatory variables. With both studies using the same indicators, except for "labor force," it is not surprising that the results were the same. The results were previously obtained by Freedman and Berelson (1976), who also used the Lapham Mauldin index of planning effort along with similar indicators of social setting. Freedman and Berelson found that birthrate declines could be explained better by program effort (which independently explained 17% of the variance in crude birthrate (CBR) declines) than by social setting (which independently accounted for 7% of that variance), and that the 1972 birthrate itself was similarly explained (15% of the variance attributed to program effort alone, 5% to social setting alone). Mauldin and Berelson obtained nearly identical results. In the Tsui and Bogue study, the contribution of the 1968 level of fertility was the dominant influence on the 1975 total fertility rate. The standardized regression coefficient indicated that previous fertility explained 50-60% of subsequent fertility by direct relationship, a figure comparable to the social setting family planning interaction effects (44-58%) in the 2 other studies. Much of this discussion is devoted to an analysis of the "outliers" in the exploratory data analysis done by Sykes for Mauldin and Berelson (1978). The outliers in Sykes' exploratory data analysis were divided along 2 dimensions. The first involves the relationship between predicted and actual reductions in fertility. The 2nd dimension refers to the independent variables used to predict the fertility declines. This analysis involves analysis of contextual variables and an analysis of distributional variables. It is limited by missing data, but the analysis of Freedman and Berelson (1976), Mauldin and Berelson (1978), and Tsui and Bogue (1978) is plagued by missing variables: contextual variables; distributional variables; and unique national, regional, or local circumstances. These can only be adequately revealed by case studies and may be important influences on fertility behavior. Effects of family planning and social setting may be conditioned by contextual variables (e.g., island status as in Taiwan), or unique circumstances (e.g., coercion as in India), and distribution appears to have an effect of its own.
This 1st book of self-instructional modules, prepared for working journalists, particularly the ones assigned to development beats, and students of mass communication, is a manual for instructors who will direct/conduct the training program on implications on population growth on development. A sample course schedule for a seminar/workshop utilizing these materials is provided along with a pretest and a posttest on knowledge of population. For each of the 13 sessions included in this manual the objective of the session is outlined along with the materials required, the benefits of the session and a session overview. The following are the session topics: an overview on Asia; the Malthusian theory and related concepts; land and people; facts about population; population growth in Asia and implications of population growth; the social and cultural aspects of population growth; implications of population growth for community development, and development journalism and writing of population stories.
Focus in this book, the 4th in a series of learning modules designed to integrate the knowledge of causes and consequences of population into the training of journalists and students of mass communication, is on the application of facts about population in an analysis of population growth in Asia. The reading material included is from a source book developed by the Unesco Regional Office for Education in Asia. Topics covered are: demographic transition; age and sex structure of population; factors affecting population growth; mortality; levels and trends in fertility; factors affecting fertility; implications of mortality and fertility. Another section focuses on the population pattern in Asia, the age structure, urbanization, and varying population densities. A workbook section, in which the user makes population projections, is included. Exercises accompany the reading material.
The causes of male and female infertility.
This article examines male infertility and the problems of female infertility. A common cause of failure of a couple to have a pregnancy is failure of the man either to obtain an erection or to maintain it. Ideally, semen should be ejaculated right up against the cervix so that the spermatozoa have to traverse a relatively short distance into and through the mucus that is secreted by the cervix. Some men fail to have "intercourse on demand." They may be able to have intercourse at any time except the right time of the month for the partner. There can be good psychological reasons for this. The man may have an anatomical inability to deliver sperm into the right place. Although he may be able to insert his penis into the vagina, he may not be able to deliver the sperms correctly. If the opening at the tip of his penis is on the upper surface of the penis, as it is in men with epispadias, the semen will be ejaculated low down on the anterior wall of the vagina and will possibly leak back and never reach the cervix. In hypospadias, which is more common, the external orifice instead of being at the tip of the penis is somewhere on the under surface of the shaft. The semen again will not be ejaculated near the cervix and may leak out. The male may be unable to manufacture sperms. He may be unable to manufacture sperms because the testes are not in the right place, and a man may have perfectly good testes and make perfectly good sperms but be unable to transport the sperms to his penis. The testes may be perfectly normal when a boy is born but become functionally abnormal if mumps are acquired after the age of puberty. The causes of female infertility include: fused labia; stenosis of the vagina which may occur both congenitally and as an acquired condition; a too small uterus because of a congenital underdevelopment; blockage of the Fallopian tubes, usually caused by infection; failure to ovulate every month; and hormonal upsets. It is clear that upsets in the complex mechanisms of reproduction are involved both on the male and on the female side. Any 1 of them or any combination of these upsets can lead to infertility. Successful correction of these defects or upsets to result in pregnancy is achieved as much by obtaining a good balance between the action of all the hormones produced by the husband and wife as well as by achieving a good interaction between each partner's hormones on the anatomical organs involved in procreation.
The permanent emigration movement to the major emigrant-pulling countries (U.S.A.-Canada-Australia).
The introductory chapter to the study of the permanent emigration movement to the major emigrant pulling countries of the US, Canada, and Australia reviews the following: meaning and concept of permanent emigration; the emigration movement in the whole world and in Egypt; conditions to be fulfilled in an Egyptian emigrant; the procedures an Egyptian applying for permanent emigration should follow; and the problems and obstacles an Egyptian emigrant usually faces before and after arrival at the emigrants receiving country. The study's 1st chapter focuses on the quantitative development and qualitative categorization of the permanent Egyptian emigration movement. The chapter reflects the following findings: the majority of emigrants are males, and the majority of their companions are females; most of the Egyptian emigrants (95%) have gone to the US, Canada, and Australia; 73% of the Egyptian emigrants are Christians, and most of these have emigrated to Canada; a high proportion of the married Egyptian emigrants went to the US; the majority of Egyptian emigrants were in the 20-29 and 30-39 age groups; a large proportion of the Egyptian emigrants were those who previously worked in the government and public sector, and most of these emigrated to the US; and the majority of Egyptian emigrants were university graduates. The 2nd chapter deals with the motivation for leaving Egypt and emigrating abroad and the reasons why an Egyptian missionary refuses to return to his native land. The 2 chapters of the 2nd part of the study examine the positive and negative effects of permanent emigration movements. The following are among the identified positive effects: maintain the balance between population and available resources; absorb the excess of the labor force; increase the government income of precious foreign currency; improve commercial relations between the native country and the emigrant receiving country; and the emigrants may possibly form political groups that can direct the emigrant receiving country's policy to the good of their native country. The following are the identified negative effects: the government loses the benefits of the funds invested in the education of the emigrant; and the government loses the productive ability of the emigrant. Due to the fact that the total number of Egyptians who emigrated to the US, Canada, and Australia was so small during the 1962-75 period, it was found that the economic, demographic, and political results were quite insignificant.
Evaluation report of the World Fertility Survey.
A general report follows the "Executive Summary" of this evaluation of the World Fertility Survey (WFS). The general report covers the following: previous evaluations, terms of references, and composition and itinerary for the Evaluation Mission; background and objectives of WFS (origin of the program; objectives, priorities, and strategies); organization aspects of the WFS program (headquarters, country participation, operating procedures, survey organization, and coordination); inputs (scope of support to the program, procedures for provision of funds, headquarters costs, costs of country surveys, and complementary support to the program); methodological aspects of the program (sampling procedures; questionnaires, survey procedures, and basic documentation; data processing and archives; and production of the 1st country report); execution of national surveys (nature, character, and significance of WFS assistance; implementation of survey procedures); analysis (evaluative, illustrative, 2nd stage, and comparative analyses); building the national capability (contribution to survey taking capability, contribution to data processing capability, and contribution to analatical capability); dissemination of survey results (national meetings, limits of WFS participation in national dissemination activities, actual and potential audience for WFS survey results, and libraries in the WFS despository system); and use of WFS survey results. Conclusions are reported, recommendations are made, and country reports are included for the Dominican Republic, Mexico, Jordan, Kenya, Nepal, and the Philippines. The 1st objective of the WFS is to help countries acquire scientific information that will allow them to describe and interpret their populations' fertility, to identify meaningful differentials in patterns of fertility and fertility regulation, and to provide improved data in order to facilitate efforts in economic, social, and health planning. As of July 1980, a total of 36 less developed countries had completed fertility survey fieldwork, and of these 21 had published their First Country Report. The following were among the conclusions reached concerning this 1st objective: the sampling, training, field supervision, editing, and data processing standards set by the WFS for the national executing agencies were higher than those which characterized previous surveys; data processing was the major bottleneck in the participating countries during the surveys; and at all stages of the survey there was a conflict between the time constraints on completing the survey and getting the report out and the desire to rely as much as possible on local personnel. As far as utilization of WFS data, at this stage the Mission was able to evaluate only the short range use of the results.
Federal regulations that govern the allocation of Title 10 monies for family planning consistently have mandated that funded programs include counseling, diagnosis, and treatment services for infertility. The concept which is presented in this report is based on the experience and recommendations emanating from incorporating a program of comprehensive services for involuntariliy infertile couples into the framework of an existing family planning contraceptive program. The enabling proposal emphasized 4 basic premises, which are discussed in this report, and which were regarded as key to the program's success: couple care, i.e., seeing only couples and treating the male as an equal partner, contributing equally to the couple's ability to achieve conception and to become parents of a healthy child; continuity of care, i.e., having the same medical team and support staff follow the couple throughout their entire workup; custom care, i.e., tailoring the couple's workup to their individual and mutual needs as determined through the counseling and preliminary workup processes; and cost of care; i.e., ordering tests, laboratory work, and surgical procedures only when medically indicated and after routine, but frequently overlooked, basics have been explored and ruled out as causative factors. A 5th addition to the program, also reviewed, is convenience of care, i.e., scheduling patient visits to accommodate couples traveling upwards of 100 miles in all kinds of weather so as to accomplish as much as possible during each visit. Focus in the remainder of this report is on the evaluation of the male and the female, the infertility workup, program tiers and skill levels, administrative concerns, and program experience. The complete history, physical examination, and semen analysis are the basis for the workup of the male suspected of contributing to the problem of infertility. Evaluation of the female must include investigation into the ability to conceive as well as to safely deliver a healthy child. An infertility workup includes the usual tests for sexual abilities and fertility along with screening and therapy for numerous physical and mental contributing factors, e.g., finding and diagnosis and treatment for heart disease, diabetes, and major congenital abnormalities. Some of the steps, tests, and procedures which are integral to incorporating a self contained infertility service into an existing family planning program are described. The following administrative problems which arise from the peculiarities of an infertility service and which must be resolved according to each programs's structure, resources, and goals, are described: physical plant and equipment; staffing; insurance coverage; marketing and patient recruitment; laboratory, X-ray facilities, and hospital facilities; 3rd party reimbursement; public image; policy making; legal; telephone; forms; artificial insemination; and bookkeeping.
Sub-fertility and infertility in Africa.
In March 1973, two UN Economic Commission for Africa (UNECA) staff were assigned to work with the staff of the University of Ibadan, Nigeria in creating a study plan which was to be preceded by a workshop, the objective of which was to bring together scientists from various disciplines related to fertility and subfertility. The workshop goal was to examine the relevant factors known or suspected to exist, which could contribute to providing a clear and definable approach to the solution of the problems posed by subfertility and infertility in Africa. The workshop covered a wide range of topics, including venereology, natality, stillbirths, epidemiology of infertility, abortions, sociocultural habits of marriage and divorce, and psychological and genetic factors. It was hoped that the deliberations will raise the important issue, whether family planning activities in the African continent can continue to pursue only services related to family reduction to the exclusion of the problems of subfertility and infertility which have been recognized or felt to be present in a number of countries. In the 1st part of this workshop report the proceedings are summarized: statistical considerations (definition and measurement problems, geographic data, and census and survey information) economic, social, cultural, and psychological factors; medical and pathological factors (genital morphology, sperm count, specific infections, genetic diseases, and environmental and other factors); and policy and ideological implications. The 2nd part of the report, the appendix, includes the papers submitted to the workshop by participants which formed the basis of discussions. Studies on subfertility and infertility in Africa have differed widely in their methodological approach. Additionally, the nature and extent of the problem appears to vary widely from 1 area to another. In designing studies for any area, the following 3 conditions should be borne in mind: precise definition of the area and the measurement of the level and extent of infertility; causal factors; and remedial measures. Where information is already seemingly available, the study should be designed on a more intensive level with the objective of primarily defining the causal factors and remedial measures. In areas of high fertility where infertility occurs though relatively infrequently, it is necessary that an efficient mechanism be evolved which will allow an easy location of the subfertile group.
Childbirth: yesterday and today: the story of childbirth through the ages, to the present.
Historians have largely overlooked the story of the birth of human beings, ignoring the fact that in the act of creating life women assume a role that is replete with social, economic, and cultural significance. An attempt is made in this volume to make up the deficiency to some extent. The volume's 11 chapters review the following: childbirth among primitive people; some changes that occurred early in the history of civilization; the development of obstetrical knowledge; midwifery from prehistoric times to today; the history of child care; the mystery of birth; the status and role of the paternal parent; birth control and its development; and childbirth in modern times. Among the black tribes of Africa and the brown races of the islands of the South Seas and among the Indians and the tribes of polar inhabitants, the customs of childbirth continue as almost unbroken tradition. Unaffected by science and modern civilization, the women of those peoples continue to give birth just as their ancestors before them did. The superstitions and customs of the primitive manifest themselves in the beliefs and activities of many civilized people even today. Some changes occurred early in the history of civilization, but their advent was gradual and was constantly interrupted by lapses of ignorance and religious taboos. During the 15th and 16th centuries A.D., medicine hewed out new paths of obstetrical knowledge. Whatever progress was made in the field of obstetrics was the result primarily of the labors of Arab and Jewish doctors. The progress of the knowledge that eased the birth of humankind was due to the efforts of many persons following several directions of inquiry, observation, and study. Methods of child care have varied almost as much as the methods of bringing assistance to the woman in labor. Birth control may be regarded as a movement that developed, attained an ideological basis, and brought forth protagonists and antagonists in modern times, but population control is as old as humankind. It was variously as important to have many children as at other times it was deemed important to decrease human fertility. Even the primitive family, once the birth sequence was established, chose to increase or decrease its members in response to certain imperative needs. The problems of maternal mortality are considered in the context of the pregnant woman, the medical profession, and society in general. If maternal mortality and morbidity are to be reduced at all, a change must be made in the practice of obstetrics. Meddlesome obstetrics, which take the lives of many women, must be eliminated.
Primary maternal and neonatal health: a global concern--pediatric aspects.
Both mothers and children are at particularly high risk of morbidity and mortality. The child is vulnerable during certain stages of development; the mother is exposed to certain physical, physiological, and psychological stresses. The level of child mortality and morbidity is unacceptably high in 3rd world countries compared to that of the more developed nations. As details of child mortality are not uniformly available for all countries, it is necessary to use estimates of child mortality or to extrapolate from the statistics of a few developing countries with relatively reasonable registration systems. Despite data limitations, it can be inferred that the risk of infant mortality in such countries is 10-12 times as high as in more developed countries. It has been estimated that the infant mortality rate in many developing countries exceeds 100/1000 and may reach 200/1000 live births. The rate in more developed countries ranges from 8-15/1000. The neonatal component of infant mortality is more difficult to obtain. It can be estimated that it may reach 120/1000 live births in some less developed countries compared to 10/1000 live births in more developed countries. Regardless of the level of infant and child mortality, the probability of dying is at its highest about the time of birth and during the early neonatal period with a relative decline thereafter. Of importance is the impact of mortality on biological factors, family planning factors, social and environmental factors, and medical care factors. To understand the dynamics of interaction between these 4 categories of factors and child mortality, 5 points are made, based on the theory developed by the Egyptian scientist A.R. Omran in his "Theory of Epidemiologic Transition": 1) considerable decline has occurred in infant and child mortality in both the more and the less developed countries, but the rate of decline in the more developed countries has been more spectacular, 2) the fact that this reduction has been achieved at all should be an encouragement for the less developed countries, 3) the influence of these factors in reaching a plateau and infant fertility decline is slackening, 4) there was a differential decline in child mortality with mortality at 1-4 years declining first and foremost, and 5) child mortality levels have a crucial factor in determining how long a particular population is expected to live. A birth weight below 2500 gm is a primary contributing factor to perinatal mortality and morbidity. Apart from low birth weight, many other causes of neonatal mortality in developing countries are preventable. Proper maternal, antenatal, natal, and postnatal care effectively reduce death and morbidity from a variety of well known traumatic, metabolic, and infectious causes. Breastfeeding is the most effective measure for the prevention of malnutrition and for the protection against infection during infancy. Remedial programs to prevent neonatal mortality and morbidity are receiving little priority in many developing countries. The child health aspect of such a program is outlined.
Selected concepts of the health theme in family planning as recently reviewed are presented in brief terms. Each concept is illustrated by studies in both the more and the less developed countries. No attempt at comprehensive coverage of the literature is made. Attention is directed to parity and child mortality, parity and child health and development, sibling size and intelligence, parity and maternal health, parity and maternal morbidity, maternal age and child mortality, maternal age and child health and development, maternal age and maternal mortality, maternal age and maternal morbidity, and birth interval (child spacing) and child health. The overall conceptualization of the health theme in family planning is as follows: a child's chances of being born alive, surviving the 1st 5 years of life, enjoying goood health and adequate physical and intellectual development are reduced by poor pregnancy timing, i.e., being conceived at an early maternal age of less than 20 years or conversely at an advanced maternal age of 35+ years, a large sibship size of 3 or more, i.e., high parity in regard to the mother and high birth order in regard to the child, inadequate spacing between the child and his/her preceding or succeeding siblings, multiparity, poor prenatal and natal care for the mother and poor child care, and any combination of the above, particularly high parity at a young age or grand multiparity at any age. A mother's chance of surviving pregnancy and labor, of being free from obstetrical and gynecological complications, of enjoying good health and having normal and healthy children are reduced by the same factors affecting a child's health. The prescription of family planning will reduce substantially health risks to mothers and children. Consequently, family planning needs to become a part of routine medical care for responsible health professionals throughout the world. The provision of family planning services including effective information, education, and communication programs, is a basic responsibility of all governments and policy makers. This is the case regardless of the level of demographic pressures in the concerned countries.
Future prospects of family planning programs.
The experience of the National Family Planning Coordinating Board (Indonesia) has led to an understanding that family planning cannot be expected to arise spontaneously from socioeconomic development efforts. Members of individual families and communities need to view fertility reduction on their own terms and interests. Their appreciation of the value of a small family must develop through links to basic needs such as education, food, housing, and income. Modern aspirations must be created, and this must be approached with care. In the developing countries, it is necessary to identify from among the forms of modernization realized in developed countries which are useful to the effort of developing countries to improve the quality of life without negatively affecting cultural standards. The developing countries should be able to take advantage of the latest developments in science and technology and in so doing accelerate development processes. In particular, achievements in recent years have improved the efficiency and effectiveness of the management of family planning programs. Developments in contraceptive technology and reproductive biology constitute an important backbone of family planning. With any contraceptive method, the acceptance of the community remains very important. In countries where the delivery of contraceptives has reached the grassroot level, as is the case in Indonesia, management problems arise in maintaining continuation of use due to the logistics of oral contraceptives (OCs). The number of "current users" in Indonesia's program has reached a total of more than 7 million couples, most of whom use OC. The management of the program would have been easier if there were equally attractive contraceptive methods available that required less resupply. To deal with this problem a strategy was developed for the regular provision of OCs through distribution points acceptable to rural couples. The goal is to gradually shift the responsibility for the distribution of OCs and condoms from the program infrastructure to community institutions such as women's organizations, mothers' and acceptors' clubs. These village mechanisms are gaining an increasing degree of recognition due to their success in transforming development plans and messages into action. It is in the institutionalization phase that developing countries are trying to operationally integrate the family planning elements with those of other development programs. In addition to population education, approaches to deal with the youth of the country are being made. A motivation program is working to encourage the young generation to postpone their marriages.
Social benefits of family planning.
Some of the social benefits that families would derive from planning their families and spacing their children are reviewed. Studies that support the social benefits described are briefly cited. In less developed countries, infant and child mortality are much lower in small than in large families. In a survey of 11 Punjab villages over the 1955-58 period, 116 infants out of 1000 babies born to families with only 2 children died before their 1st birthday. The infant mortality rate ws 206/1000 in families in which the mother had given birth to 7 or more living children. For the same villages, 196 of 1000 children born between 3-4 years after a previous birth died before reaching age 2 years; the corresponding rate was 137 among children born after an interval of more than 4 years. The greater the number of children the greater is the likelihood of malnutrition among low income families. Since growth is related to nutrition it would be expected that the height and weight of children in small families would be greater on the average than in large families. Even in high income countries the children of poor families are taller and heavier at any given age when there are fewer children in the family. The number of children in the family is also associated with linguistic skills, intelligence, and educational performance. Both physical growth and the greater cultural nurturing associated with small families appear to affect intelligence. There is also some evidence that family size takes its toll on parents. Hare and Shaw who studied 55 British families observed that both physical and mental ill health in parents increased with family size. It was more marked among mothers than among fathers. General health would improve markedly if family planning measures were more widely available and more widely used to reduce early and late pregnancies, to place a reasonable limit on family size, and to keep a healthy interval between births. In regulating fertility through family planning, the families derive social benefits such as: maximization of nutritional resources; preserving the woman's health and lengthening her life expectancy; relieving the family's economic strain; allowing the woman the freedom to take advantage of education and employment opportunities and participate more actively in community life and to realization of ambitions and social, economic, and psychological needs.
Maternity care monitoring in twenty-two hospitals in West Java.
Maternity Care Monitoring (MCM) has been carried out in 12 teaching hospitals in Indonesia since 1979. Through this network, data have been collected, processed, and analyzed which could prove useful in determining strategies on maternal and child health (MCH) care. To obtain more representative data, the Coordinating Board of Indonesian Fertility Research (BKS PENFIN) proposed to the government to implement MCM in 22 hospitals. This proposal was accepted and necessary preparations were made which included designing of a register form for MCM as well as Child Care Monitoring (CCM), referral forms, and maternity death forms as well as the training of medical and paramedical personnel in completing the various forms used. For comparison the 22 hospitals in West Java were divided into 3 groups: Hasan Sadikin Hospital represented by 1336 patients; 7 hospitals in and around Bandung, consisting of hospitals covering a predominantly urban area, contributing 2500 cases; and 14 hospitals outside Bandung, scattered over West Java, contributing 433 cases. 20% of all pregnancies in the hospitals terminated by abortion, ectopic pregnancy, or hydatidiform mole. The prevalence of hydatidiform mole was of the same magnitude as ectopic pregnancy. A large number of women in the 25-29 age group were already grand multiparas and the mean parity in the 25-29 age group had already reached the number of 1.9-2.5. Most of the patients had had 5-6 years of education. Grand multiparous women and elderly patients were the most neglected groups with regard to prenatal care. The prevalence of anemia was very high (61%) in the hospitals outside Bandung. The prevalence of anemia was lower among those who had prenatal care. The same correlation was seen with birth weight except for groups who had no prenatal care. A sharp decline in prenatal mortality was also associated with prenatal care. Again 2 groups with no prenatal care had a relatively low perinatal mortality. 28.8-59.1% of mothers with 3 children still wanted additional children. Many patients including those indicating no desire for additional children were without contraceptive protection even after contact with the hospital. Only 8-15% wanting 4 or more additional children chose to adopt family planning. Hospitals in Bandung and surroundings provided 25-40% of the patients with sterilization or IUDs; hospitals outside Bandung provided these methods to only 20%. Male sterilization had a very low acceptance. As the small family concept is still not appreciated, health education efforts should be intensified to prepare future parents for their responsibilities.
The study purpose was to determine the longterm effects of neonatal hyperbilirubinemia treated with exchange transfusion on the child's neurologic, psychologic, motor, and psychiatric development. The hospital records of 2 private medical centers in Manila over the 1963-73 period were reviewed and all babies born during this period with nonphysiologic jaundice were listed. Those who could be traced to their residences were notified and asked to come for examination. Only 20 of those notified came for examination. 13 of the children underwent at least 1 exchange transfusion; 7 did not. The matched variables listed are those which can affect the bilirubin levels such as age of gestation (AOG), birth weight, condition at birth, manner of delivery, cause of the jaundice, and maternal age at birth. The mean age of the children at the time the research was initiated was matched because it could also affect the intelligence quotient (IQ) results. It was found that there were no significant differences, meaning that the exchanged and the nonexchanged population groups were comparable for the purposes of this research. The only significant difference between the exchanged and nonexchanged groups were the means of the highest bilirubin values attained during infancy. After a thorough physical examination and interview by a pediatrician, the children underwent a battery of psychological tests which included the Wechsler Intelligence Scale for Children--Revised (WISC-R), the Bender Gestalt Visual Motor Test (BGVM), and the Draw-a-Person Test (DAP). The mean IQ (FIQ) of the exchanged group was significantly higher than the mean IQ of the nonexchanged group. This suggests that the mentation of children subjected to high bilirubin levels are not so much affected as long as prompt management is instituted. Although the mean IQ of the verbal (VIQ) and performance (PIQ) of the exchanged group were higher than the nonexchanged group, the differences were found to be insignificant statistically. On the DAP and BGVM tests there was no statistical difference between the scores of the exchanged and nonexchanged groups. The mean scores of the performance IQ were almost similar, and there were no significant differences. The study reinforces the fact that prompt management of hyperbilirubinemia from whatever cause can still result in well adapted children with even high IQ. The longterm parameters of organic brain damage such as BGVM and DAP test, PQ scoring, EEG, audiometry and ophthalmologic examinations failed to demonstrate any harmful effects of hyperbilirubinemia in both exchanged and nonexchanged population groups.
Systematic maternal health care in Shanghai.
Maternal health care in China has been enriched and perinatal health care has gradually evolved in recent years in line with the family planning objectives of achieving a decrease in the birthrate. In Shanghai there are 9 maternity hospitals and 3 children's hospitals and a number of Obstetrics and Gynecology and Pediatric Departments in general hospitals at different levels led by the Maternal and Child Health (MCH) Division of the Shanghai Municipal Health Bureau with a total of 4794 obstetric and gynecologic beds and 2587 pediatric beds. The Shanghai First Maternity and Infant Health Institute and the Shanghai Children's Hospital are responsible for technical supervision in the field of maternal and child health care for the city of Shanghai. Changes implemented to achieve improvements in the MCH field are reviewed. Each district and county has its own MCH center in close cooperation with the clinical departments of the district or county hospitals. The center has responsibility for therapeutic and preventive procedures along with medical training and research studies in that area. At the primary level, there are 104 subdistrict hospitals in urban districts and 200 commune hospitals in the rural counties, with a MCH group in each of them. Each MCH group has 3-5 members who work as a team. All commune hospitals have obstetrical, gynecological, and pediatric clinics and in addition a hospital delivery service. The primary workers in the production brigade (barefoot doctors) who are under the direction of the MCH group are trained to provide antenatal and postpartum home visits, family planning consultation, distribution of contraceptives, simple medical treatment, preventive vaccinations, popularization of the knowledge of hygiene and care of women during menstruation, pregnancy, puerperium, and lactation. Because of their cooperative efforts, the maternal mortality rate decreased from 320/100,000 in 1949 to 10/100,000 in 1980. The perinatal death rate at the Shanghai First Hospital of Maternal and Child Health Care during 1961-77 was 12.8/1000. To promote the quality of maternal health work and maximization of the function of the primary organization, the MCH personnel of the hospital designed a maternity health card which was used in the urban districts beginning in 1978. Every pregnant woman is registered at the primary maternity health group where the midwife takes the history, performs a preliminary examination, and provides health directions for early pregnancy. After the registration, the card is given to the mother. The main findings and procedures performed in the hospital are recorded on the card. The maternity health care card strengthens the mutual cooperation between the 3 grade MCH network and promotes the quality of the work of the MCH group. By conducting systematic statistical analysis of the cards, knowledge is gained as to how the MCH work is progressing, quality levels and the results, enabling further improvement in the work.
Achievements in perinatal and maternal health: survival in Japan.
This discussion of achievements in perinatal and maternal health in Japan reviews the factors associated with perinatal and maternal mortality (parity and age, socioeconomic status, birth interval, antenatal care, medical facilities and environmental factors, and medical causes of perinatal and maternal deaths); and the strategies that reduced perinatal and maternal mortality in Japan (education, the provision of primary health care, proper antenatal care and identification of potential high risk mothers, the provision of emergency health services through an adequate referral network, and conducting a statistical survey). Perinatal and maternal mortality tends to be high in population groups in which the mother is younger than 20 or older than 35 years of age. Perinatal mortality is minimum in cases of multigravida 2 and 3, but increases thereafter. In Japan the increased risk of mother is significant after the 3rd birth. Perinatal and maternal mortality rates tend to be high among mothers from the socioeconomic classes with relatively low standards of living, limited education, and with little concern for her health. The shorter the birth interval, the higher is the perinatal mortality risk of the next child. The availability of high quality antenatal care is the factor most closely associated with the incidence of perinatal and maternal mortalities. A study of perinatal and maternal deaths to determine whether or not they were avoidable revealed that in many instances death could have been avoided if medical facilities and the social environment had been different. Antepartum hemorrhage, toxemia, cardiovascular and renal disease, and infections are the most frequent causes of deaths. Multidisciplinary health education needs to be provided beginning at the school level and extended to the communities. In this course, the physiology of human reproduction, human sexuality, family planning, and the health impact of nutrition and hygiene should be emphasized. Conducting a statistical survey on perinatal and maternal mortality can lead to a reduction in mortality by raising the consciousness of health personnel and laypersons. Compared to the decrease in perinatal mortality (30.1/1000 in 1965 to 13.0/1000 in 1978), the rate of decline of maternal mortality (8.8/10,000 live births in 1965 to 2.3 in 1977) in Japan has been rather slow.
Causes of perinatal deaths and prevention in the context of primary health care.
To realize the objective of the primary health care movement with regard to the problems of the newborn would require the application of technology that is appropriate for the given community. Variations between countries and even within a country are so great that there can be no universal set of instructions. It is important not to lose sight of the fact that advances, even the most basic in character discovered years ago and being used routinely even within institutions in the developing countries, have yet to reach millions of mothers and infants in many developing nations. The question that arises is how recent knowledge and technology can reach all the newborns in the least favored countries. This is the area in which the role of obstetricians and pediatricians is critical in realizing the goal of "health for all." The point is illustrated by an example from Ghana of work of physicians in an Obstetrics and Child Health Center. A training program was instituted in rural Danfa for traditional birth attendants (TBAs). The objective was to strengthen their areas of weakness and discourage harmful practices. These included the identification of women at risk, care of the cord, aseptic techniques, care of the newborn, family planning, and encouraging mothers to have their infants immunized. Midwives provided the training and supervision of the TBAs. Eventually a manual of the process was produced, and it has been adopted by the Minister of Health. By 1972, in a population of nearly 40,000, there were identified 263 TBAs and 26 assistants. The physician or medical expert has many roles to play in the effort to raise the level of neonatal care in the developing countries. Physicians can provide the inspiration, be the researcher, teacher, planner, and evaluator of the program. The initial step is for the physician to absorb the philosophy of the primary health care movement and be enthused about realizing the goal of "health for all" by the year 2000. The next step is to find out about the state of neonatal care at the primary health care level, in the home and in the community. Finally, the physician needs to experience the system and be able to apply scientific principles and to make improvements that can be sustained by the local attendants. The studies may be elaborate or simple depending on local circumstances, but they should lead to several decisions. These would include determination of which workers in the field to cooperate with and what support systems to build. Having determined which groups to train, the methods of training should be evolved.
Maternal mortality at Ife University Teaching Hospital complex.
The study objective was to examine the causes of maternal deaths at the 2 obstetrical units of the Ife University Teaching Hospital Complex in Ile-Ife, Nigeria in order to identify and suggest solutions for the key problems in the antenatal health care delivery system of the Teaching Hospitals Complex. All cases of maternal deaths (excluding deaths from abortion) at Ife State Hospital and Wesley Guild Hospital (Ilesha) were reviewed over the January 1979 to June 1980 period. Where the case notes were unavailable, the causes of death were obtained from the medical records department. During the review period, there was a total of 6710 births, 6308 of which were live births and 402 were stillbirths. During the same period, there were 66 maternal deaths (11.7/1000 live births); 19 (28.8%) were booked patients and 47 (71.2%) were unbooked patients. In the context of this study, the booked patients were those who registered at the antenatal clinic and had made at least 3 clinic visits prior to delivery. The unbooked patients had no antenatal care in any maternity center but were seen for the 1st time because of complications at or near term, or during labor. Most deaths occurred in mothers within the ages of 20-34. More deaths occurred among multigravida than among primigravida, whether booked or unbooked. Hemorrhage was the leading cause of maternal death and was responsible for 18 deaths (27.2%). Antepartum hemorrhage claimed 6 lives; postpartum hemorrhage claimed 12. Mortality from this cause was influenced by parity and by the amount of blood for transfusion. Sepsis was the next leading cause and occurred in 14 cases, 10 unbooked and 4 booked. Eclampsia was 3rd and occurred mostly among primigravida admitted as emergencies in labor. Factors which determined survival or death were parity, location of onset of convulsion (home or hospital), total number of convulsive episodes, and type of treatment offered. The 11 deaths from eclampsia occurred among primigravida. Obstructed labor was the 4th cause and occurred in 10 cases, 7 unbooked and 3 booked cases. Tetanus, the 5th cause, occurred in 5 cases, 3 unbooked and 2 booked cases. Infectious hepatitis was the most important single cause of maternal death. There were 3 deaths (4.76%) from this cause. Cardiac and pulmonary disease caused 3 deaths (4.1%) indicating these as rare causes of maternal deaths in this institution. Anemia caused 2 deaths (3%). It is the most common major antenatal complication in Nigeria.
Family planning strategies for the '80s.
There exists a substantial unmet need for family planning at this time, and the number of couples of reproductive age is expected to increase by 70% between 1980 and 2000. The family planning horizon is surveyed, reviewing how the sector has evolved and identifying directions for the future. Focus is on the orientation, experience, and accomplishments of the UN Fund for Population Activities (UNFPA) in its support for the various aspects of family planning in the different regions of the world. The acceptability of the family planning concept has increased markedly during the last 20 years. Of 158 countries responding to the UN "Fourth Inquiry Among Governments on Population and Development," 118 had adopted laws or policies favorable to family planning or supporting family planning either through the public or the private sector. 66 of the 132 developing countries had family planning programs. 35 had adopted programs for demographic purposes and 13 for health or humanitarian reasons. Approximately 92% of the population of the developing world live in countries which support family planning. Several changes have occurred in the administrative and delivery system dimensions of family planning. Single purpose, vertical programs have given way to more thorough integrations in the health network. Efforts have been made to include family planning components in various development initiatives. From a demographic perspective, there is considerable evidence that family planning programs have had a marked impact. Countries which have implemented effective programs have achieved substantial fertility declines even in the absence of advances in economic development. The health and human rights aspects of family planning have also been recognized over the past decade. In view of the health and demographic benefits as well as the human rights dimension, it is critical that family planning be within the reach of all couples desiring such services, yet this is hardly the case. UNFPA has emphasized the need for neutrality, flexibility, and innovation in its dealings with recipient countries. Rather than endorsing any particular approach to population problems, UNFPA has provided assistance to those aspects that a requesting country deemed important and which were within the bounds of its mandate. During the course of its 12-year existence, UNFPA has followed two major principles in extending assistance for population activities: every nation has the sovereign right to determine its own population policy; and each individual couple has the right to determine its family size. UNFPA, which has supported the conventional and the innovative, has extended assistance in family planning at the global, national, and local level.
The International Conference on Primary Health Care held in Alma-Ata (USSR) provided a forum for all those concerned with the crucial problem of maternal and neonatal health. The importance of maternal and child health (MCH) within the approach of primary health care cannot be overemphasized. The basic principles underlying the overall strategies and policies for primary health care are fundamental to the concepts of maternal and child health care: the intrasector approach; the need for total coverage; the participation of individual families and communities; and maximum use of existing resources. The emphasis of MCH care within primary health care must be to support community and family self-reliance. The World Health Organization (WHO) works in close collaboration with the other UN bodies and supports activities to promote more efficient and effective contraceptive methods for the integration of maternal and child health care in all aspects of health development programs, increased community participation in maternal and child health/family planning activities, better approaches to multidisciplinary and multisectoral program development, and the inclusion of traditional practitioners in health delivery systems. Training continues to be a major part of the maternal and child health program, as part of WHO's support to national efforts in strengthening national institutions and self-reliance in health personnel development. The program of teacher training in comprehensive maternal and child health includes activities which are tailored to the specific needs of national programs. Local adaptation of the WHO "growth chart" to measure child growth and development is also promoted. The results of the WHO collaborative study on breastfeeding, carried out in 9 countries, are used for the promotion of appropriate infant feeding. The new focus of the nutrition activities is the improvement of nutrition and health through action at the community level and as far as is feasible with local resources. Research in maternal and child health/family planning is consistent with the primary health care approach. Another activity focus is the development of appropriate technology and practical guidelines relating to the management of the complications of pregnancy and childbirth and of specific, prevalent diseases of childhood. WHO is collaborating with 94 countries which are expanding their immunization programs in order to reduce significantly the incidence of the common infectious diseases of childhood. Technical cooperation with and among countries is promoted.
Training and supervision of traditional birth attendants at the primary health care center level.
The principle operating behind the traditional birth attendant/mother health worker (TBA/MHW) program is to guide the community in mobilizing and utilizing its own resources in order to care for itself. The goal is to make this program an integral part of community activities and to minimize dependence on outside support. When possible, the replication of new technical skills and knowledge should take place within the community from 1 TBA/MHW teaching another. In the planning and implementation of training programs for TBAs and MHWs, the principle of functional literacy and adult education would come into play. The training should be aimed at mastering specific tasks that TBAs are expected to perform. The training program's general purpose is to develop training programs to teach the technical knowledge and skills that will put into effect the expected roles and responsibilities of the TBAs and MHWs in the delivery of essential health service components of primary health care. The specific objectives are: training community selected TBAs and mother leaders as primary health care workers; providing the appropriate basic knowledge of essential health service components of primary health care; developing the appropriate skills of the trainees to enable them to implement their roles and responsibilities; and inculcating an awareness for needed positive change in attitude towards attainment of health. TBAs and MHWs should be selected by the community from among their own people. Although they are accountable to the community, they should be trained and supervised by a technical member of the local health service system. The training content should be relevant to the job functions and needs of the community and should be limited to the minimum information required to perform these tasks and the rationale for doing so. Training methodology at the primary health care center level is nondirective, dialogical, and experiential. The TBA/MHW themselves will decide where and when to hold their weekly meetings of 2-3 hours duration per week for 15 months (a total of 180 hours). The training period is staggered, depending upon the TBA/MHW's convenience and availability of time. Monitoring of the training course will be the responsibility of the trainer and other health staff. Measures undertaken to evaluate training effectiveness and trainees' achievements are listed. The overall effectiveness can be measured by impact or achievement of work objectives.
Utilization of mothers for some aspects of primary health care in Philippine barangays (villages).
The ultimate goal of the Mother Health Worker project, located less than 100 km northwest of Manila, is to improve the general level of health and children in the adjacent villages of Barrio San Roque and Barrio Santo Nino by developing a low cost and self-reliant health care system which has the following objectives: tap and mobilize the indigenous personnel resources in the 2 communities who will function as the backbone of the health care system with selected mothers acting as 1st contact care providers at a ratio of 1 mother health worker (MHW) for every 10-15 households; create a 2-way referral system from the home and/or school to the barangay health center (operated by the rural midwife) to the rural health unit (operated by the rural health physician); and assist the community members in the identification and priority of community health problems and in finding ways to solve these problems. The project's basic strategy is to train selected community interested mothers as MHWs who will promote simple but essential health services in the 2 communities under the supervision of the project midwife and occasionally by the rural health unit midwife. The 3 phases of the project are: regional and community preparation, scheduled for the 1st 3 months; in service training of mothers as MHWs; and operation of a village drug store. Of the 39 mothers trained, there are now 37 MHWs continuing. The following are ongoing activities of the MHWs: immunizations; maternal and child care during and after deliveries; family planning education; treatment of common illnesses in the community; and deworming and nutrition activities. The MHWs have effectively served as campaigners for immunization, nutrition, and family planning activities and were readily accepted by the community to provide simple and immediate management of common children's ailments. They can be relied upon to participate actively in the continuous and permanent health care delivery in remote rural localities and make use of available indigenous materials. A reversible referral network was established complimented by a village pharmacy, which can dispense herbal and synthetic medications.
The nonspermicide honeycup method of contraception.
Data are presented which suggest that the standard technique of diaphragm fitting is erroneous, that the use of spermicide with the diaphragm is unnecessary and causes irritations and inconveniences to the user and her partner, and that the combination of these problems results in the diaphragm being used erratically and is the primary cause of diaphragm failures. The author developed a method that utilizes a continually embraced size 60 honied diaphragm. Spermicide has not been required with this usage, which the author has termed the nonspermicide honeycup method (NSHC). According to the spermicide fitted diaphragm (SFD) method, each woman must be fitted for a diaphragm by a set technique. Furthermore, it is stated that the diaphragm fit may be influenced by weight change, childbirth, abortion, sexual excitement, or even tension during fitting. This has resulted in a wide range of diaphragm sizes from 50-105 mm rim diameters. Due to this complexity, diaphragms must be fitted by highly trained professional practitioners, and the law requires that they be dispensed by physician prescription. The main question raised by NSHC, "to fit or not to fit," can only be answered by comparisons of diaphragm failure rates (DFRs) in controlled studies. If readers fail to look behind reported DFRs to their data bases, they may interpret diaphragm studies incorrectly. Another problem for the reader in the interpretation of diaphragm data is that variables that influence fertility may vary so much between study populations that they cause significant differences in DFRs which may be misinterpreted as being due to a diaphragm variable. Beyond questions of follow-up and controls, critical readers must consider the question of causes of diaphragm failures. From 1974-79 the author prescribed size 60 Koroflex diaphragms for all patients who requested diaphragm contraception. They were instructed carefully as to how to place their diaphragms correctly and continual diaphragm vaginal placement was strongly advised. The importance of spermicide was downplayed. Chart review of these patients in 1979 gave a total of 11 woman years exposure with 10 pregnancies reported. Follow-up was poor, but the results were considered remarkable in that 2 cardinal rules of SFD were broken: always fitting a diaphragm and always emphasizing the primary importance of spermicide. The NSHC hypothesis makes 3 predictions: women who have been instructed in the correct placement and continual use of a size 60 Koroflex diaphragm will have no higher failure rates than those instructed and fitted with SFD; the majority of diaphragm failures will be shown to be associated with nonuse of the diaphragm on 1 or more occasions during the menstrual cycle of fertilization; and analyzes of diaphragm failures among a diaphragm fitted population will show a lower than expected proportion of diaphragm failures among users with sizes 60 and 65 diaphragms.
Smallpox as an etiologic factor in male infertility.
An attempt was made to assess the role of smallpox infection as an etiologic factor in infertility in men. The study is based on the analysis of 800 patients who had registered with the Family Welfare Bureau in Bombay, India during the past 19 years for investigation and treatment of infertility. A thorough history was taken and a physical examination was performed on each patient. In every case a routine semen analysis was repeatedly performed 2 or 3 times, at an interval of 15-30 days, to assess the magnitude of spontaneous variations occurring in the semen. In all cases of azoospermia and in cases of severe oligospermia, where the sperm count was less than 10 million/cu cm, a testicular biopsy was performed. In 895 cases there was history and evidence of prior smallpox infection. These cases (designated the smallpox series) were analyzed according to the sperm counts and according to the lesions observed in the testicular biopsies. For the control series, another group of 895 serially registered infertile patients who had not had smallpox was analyzed in an identical way. Testicular biopsies were performed in 358 azoospermic cases belonging to each series. In analyzing the cases according to the sperm levels, the mean sperm count prior to therapy was considered to be the representative count in each patient. The incidence of smallpox in the present series of infertile men was 11.18%. The incidence of severe oligospermia and moderate oligospermia was practically the same in both series. The incidence of azoospermia was 42.57% in the smallpox series and only 17.87% in the control series. The incidence of normospermia was only 30.17% in the smallpox series and as much as 52.52% in the control series. The incidence of obstructive azoospermia was as high as 79.36% in the smallpox series. It was 46.23% in the control series. In patients with nonobstructive azoospermia, testicular lesions such as partial or complete arrest of spermatogensis at various levels, germinal cell aplasia, severe tubular atrophy, and hyalinization of the tubules were encountered with comparable frequency in both series. The study supports the frequent clinical impression that the incidence of obstructive azoospermia is very high in patients who have had smallpox. 4 of 5 such cases have obstructive lesions. The site of obstruction is usually at the lower end of the epididymis, and the testes seem to escape the brunt of the disease.
Preliminary findings for the Asian Family Planning Program Determinants Project are presented in tables and cover the following: decades of change; program efficiency over program lifetime; acceptance and contraceptive use; program efficiency; elasticities; and the overall path model. Over the past 30 years Asia has experienced deep economic, social, and political changes. During the past 2 decades there has been a widespread acceptance of fertility limitation policies and development of family planning programs. Both domestic and international inputs into programs have grown rapidly. This has been associated with increased use of modern contraceptives and the fertility decline. Costs in both staff and dollars of recruiting acceptors have risen in the Asian programs, yet costs of achieving contraceptive users have remained roughly constant. In effect, current program costs produce both immediate and longer term returns, which would allow discounting current costs. The overall regional mean provides a standard for assessing individual countries. Some have shown substantial increases in efficiency, and others have shown declining efficiency. From current program acceptors, current and future contraceptive use can be calculated for each program year for which required acceptor data are available. This allows the assessment of both program and nonprogram sources of contraceptive use. Program efficiency can be assessed by using either staff, costs, or facilities as denominators in output to input ratios; producing measures of staff efficiency, cost efficiency, and facility efficiency. Each measures a different dimension of efficiency and is produced by different sets of determinants. Both staff efficiency and cost efficiency are positively related to contraceptive use. More efficient programs have larger impacts in producing contraceptive use than do less efficiency programs. Thus, program efficiency is a valid measure of performance. The logic of double-logged regression permits assessment of the relative impact of different environmental conditions and program inputs on contraceptive acceptance and use. The overall path model, including political, ecological, and socioeconomic conditions, and program inputs and outputs, explains about 87% of the variance of Asian fertility over the past 20 years.
The natural family planning teacher.
This manual on natural family planning (NFP) covers human reproduction and family planning, teacher training methodology of NFP, and organization--follow-up and evaluation. NFP principles are based on scientific methods of detecting the fertile periods in women. The 3 NFP methods are the ovulation mucus method, the sympto-thermal method, and the temperature method. In the ovulation method the woman learns to recognize the changing cervical mucus pattern and to identify the fertile and infertile phases of the menstrual cycle. The ovulation or mucus method is based upon the detection and observation of estrogenic mucus whose histochemical and macromolecular structure has been studied in great detail. Of all the ovulation symptoms the mucus symptom is the most important. The sympto-thermal method combines both the postovulatory temperature rise, changing cervical mucus, and other ovulation signs and symptoms to identify the cyclic fertile period of individual women. In this method the following signs and symptoms of ovulation are used to pinpoint ovulation and confirm that it has occurred: cervical mucus; abdominal pain; breast; fullness of the vagina or a feeling of laxity; mood changes, either euphoric or depression. By carefully recording her temperature under basal conditions, the woman is able to identify the postovulatory temperature rise (thermal shift) and thereby recognize the beginning of the postovulatory infertile period. The temperature rise is due to progesterone produced under the disintegration of the ovum by the corpus luteum. It is essential that knowledge on NFP be imparted individually in order to ensure acceptance of the method, view it seriously, resolve to learn all its aspects, and use it successfully. When instructing a woman (couple), the need for family planning should be presented in its total context to support proper family values. Thus, the instructor should know how to speak in simple terms about love, sex, and marriage. The instruction should emphasize the point that NFP fosters deeper union between husband and wife and a loving concern for each other. Before the teacher can start teaching the subject proper it is necessary to give the couple initiating instructions in a graded pattern. Suggested topics for initiating instructions include marriage, its aims and objective, and positive family values.
Male contraceptive in stomach salve.
A salve to be rubbed on the stomach to deliver testosterone and estradiol into the bloodstream to stimulate the brain to halt production of gonadotropins for contraceptive purposes is being prepared for clinical testing on human beings. The salve would inhibit sperm production without affecting libido or other secondary sex characteristics. Although this method of sperm suppression has been under investigation for a long time, an acceptable method of delivery that avoids the large doses required in an oral contraceptive has been hard to find. For the past 12 years the method has been used on rats, rabbits, and rhesus monkeys via subcutaneous implanting without contraceptive failure or apparent health hazards. The implants would be too large to be practical for human use, but the hormones in the salve permeate the skin readily. Under the influence of the salve, the brain, which cannot distinguish between hormones in the salve and those produced by the testes, slows production of gonadotropins, indirectly inhibiting the growth of the 500 million or so sperm produced daily. Difficulties of controlling dosage with salve may mean that the salve is impractical for worldwide use.
National sterilization: policy, program, practice.
An extensive national family planning program was launched in Bangladesh in 1965 to provide family planning services with a view toward containing incessant population growth. Grassroot level motivators, coordinated and supervised by progressive and higher level tiers at Thana and district level, were placed to implement the program. Temporary and conventional contraceptive methods were emphasized, but sterilization, particularly vasectomy, services were introduced. Provision of sterilization services on an extensive scale heralded the beginning of the availability of free and safe sterilization services. This was the case even at the rural level. In the wake of the independence of Bangladesh, family planning was emphasized with greater earnestness. The government mobilized efforts toward a proper implementation of programs, and it recognized encumbrances in matters of logistics, personnel training, and so forth. The plan demanded the achievement of targets set for each contraceptive method, including sterilization. The government of Bangladesh has given adequate importance to the problem of population growth during the 2nd five-year plan (1980-85). It is proposed that the total fertility rate be brought down from the prevailing 5.85 to 4.1/woman by 1985. It is expected to bring down the growth rate from 2.65% to 1.7% by 1985 through deliberate and voluntary means. The 2nd five-year plan has as its goal raising the current contraceptive acceptor rate from the prevailing 12.66% to 38%, of which 43% will be voluntary sterilization. Due to the present popularity of voluntary sterilization, it can be safely said that an unmet demand exists for this service. By the mid 1970s, the phenominal rise of tubal ligation was clearly established and vasectomy declined. Tubal ligation has continued to maintain its upward swing. The favorable response to voluntary sterilization necessitated the provision of increased service centers and trained physicians. At the present time the government is able to provide such services up to the Thana level. There are plans to establish a family planning center at the union level. In 1974 the Bangladesh Association for Voluntary Sterilization (BAVS) was formed. Its philosophy is to promote voluntary sterilization, to make information about the procedure available, to create awareness among physicians about the importance of voluntary sterilization, and to train health personnel. Since its inception, BAVS has maintained a steep rise in services. The minimum medical standards identified by BAVS are outlined.
Vascular headaches and oral contraceptives.
A study was conducted among 2 groups of patients with increasing vascular headache unrelieved by antimigrainous medications. From patients referred for neurological complaints between 1964-80, 1800 who were taking oral contraceptives (OCs) complained of increasing severity and numbers of vascular headaches. An additional 200 taking estrogens to prevent hot flashes had similar complaints. Patients who were headache free with no family history of vascular headaches, or patients who had clearcut tension or muscle contraction headaches without a vascular component or a family history of vascular headaches were selected as controls. Initially, 80 patients in groups of 10 were given varying strengths of the combined and sequential pills for a 6-month period. 40 of these patients were headache free before taking the pill and remained free of vascular headache. Those with muscle contraction headache (40) did not experience an increase in headache, nor the onset of vascular headache by taking the pill. 2 failures revealed significant vascular headache with their early menses, but none in the 2 years before the control study. A further 40 controls were chosen from women who had had tubal ligation and who wanted to take OC to reduce bothersome menstrual flow. Half of them were headache free, and the other half had muscle contraction headaches. Each group remained free of vascular headache while taking the pill. Of the 1800 patients seen for evaluation of their headache, 1350 were unwilling to stop using OC. Both the brand and the strength of the pill were changed, but only 63 were able to continue to take a new pill without continuing to experience an increase in their headaches. Headache control was attempted through the use of various medications. Most patients continued to experience headache, but 147 continued to take the pill, and by changing their migraine medication, succeeded in controlling their headache. In the 450 patients who were willing to stop taking OC, the majority returned to their prepill headache state in 1 cycle, but 89 took 2 or 3 cycles before the return was complete. Of these patients, 171 have since had a tubal ligation. These patients consented to try the pill again in order to reduce menstrual flow. 160 experienced an increase in their vascular headaches on taking the pill and a return to their prepill status with its cessation. 11 patients showed no change. Of the patients with headache, 162 experienced severe vascular headache for the 1st time. There was a striking increase (over 50%) in the incidence of prodromal features. There was usually a delay of a few weeks to a few months before the headaches became uncontrollable. In 200 additional patients taking estrogens orally or by injection for menopausal symtpoms, aggravation of vascular headache was similar. A case history is included.
Recent population changes in Japan and their spatial implications.
Using demographic data derived from the 3 most recent censuses (1970, 1975, and 1980), an attempt is made to monitor the spatial trends exhibited in Japan during the 1970s by 3 vital and interrelated expressions of the national advance, i.e., population growth, urbanization and regional development. Some attempt is also made to underpin the analysis with appropriate reference both to regional development theory and to certain concepts pertinent to the evolution of urban systems. In the 1950-70 period the population of Japan increased from 84 to 105 million. The demographic expansion stemmed in large part from a substantial curtailment of infant mortality, from a significant reduction in the death rate, and from a concomitant increase in life expectancy. During the decade covered by this investigation, the national population total showed a further increase to 117 million, this despite a continuous birthrate decline and an apparent easing back in the fall in the death rate. There is now widely expressed concern about Japan's population structure. For much of the 1950-70 period, the real Gross National Product (GNP) grew at a rate in excess of 10% per annum and this was attendant on important shifts in the sectorial balance of the economy. There were further sectorial shifts during the 1970s, involving continuing expansion of the tertiary sector seemingly at the expense of the primary sector. The secondary sector's share of the labor force remained the same as in 1970, but there was a small slip to 36% in its contribution to GDP. Urbanization is closely related to the 2 preceding aspects of change in that the demographic and economic growth have burgeoned the spread of urbanization. In sum, Japan was in the throes of a fundamental transformation during the 1950-70 period. The spatial framework used in this and subsequent parts of the analysis is provided by the scheme of 47 prefectures. In 1970, 16 of the prefectures showed mean population densities equal or greater than the national average of 281/sq km. What is important about the occurrence of above average densities is their confinement to the southern coastlands of Honshu and to northern Kyusu. The summary of population trends presented in a figure indicates the gradual consolidation of the core, or axial belt, during the 1950-70 period. During the 1970s the process of urbanization made some impact on the more remote areas of Japan, and this peripheral urbanization might be viewed as the 1st modest step in the desired closing of the gap between core and periphery. The increasing loss of population from the inner areas of Tokyo, Osaka, and other leading cities cannot be interpreted as heralding the imminent demise of these cities. There has been no diminution of their general standing as employment centers. The character of decentralization thus far has been essentially selective, primarily involving the displacement of residence. It has been short distanced and destined for the suburban margins rather than overspilling the limits of the axial belt. Despite the maintenance of the core cities, it appears that little progress has been made toward realizing the goal of a more equitable distribution of growth throughout Japan.
FPA of Western Australia project 'Network.'
Australia's volunteer project, Network, operates under the following assumptions: many young people are sexually active as is indicated by the unwanted pregnancies in these age groups; adolescents are in need of information relevant to both their sexual activity and their sexuality and the opportunity to share their views on the reasons for their sexual activity, their needs, fears and conflicts arising form this in an open manner; young people with minimal training can be more effective in talking about sexuality with their own peers in contrast to other formal and conventional methods of sex education; and young adolescents need a more nondemanding atmosphere so that they could decide their level of participation. Toward this end, Network's objectives were aimed at providing a group of trained young volunteers who were prepared to work with groups of young people and an opportunity for these young people to have free access to information concerning contraception and a place and people with whom they could discuss openly matters relevant to them as developing individuals. A group of 10 volunteers was selected in November 1976. They were primarily tertiary eduation students from the field of medicine, social workers, and a YWCA trainee counselor. The 1st stage was to train the group to acquire knowledge in contraceptive technology, their own sexuality and to become comfortable in discussing sexuality and relationships, and group dynamics and group manangement. The Association's staff were to provide the information and to train the volunteers in contraceptive technology. The areas concerned with group work and understanding of one's own sexuality were primarily conducted by 1 of the social workers. In January 1977 the Network began to function on the Family planning Association's (FPA) premises. For the November 1976 to November 1977 period, support from the FPA Council was minimal but the staff was very helpful and assisted in a variety of ways. In June 1978, Network had to be disbanded not because of questioned worth but for other reasons. The FPA based Network suffered from group friction and was limited to the confines of the FPA youth clientele, but after its separation from the FPA, Network faced new problems. There was a need for a paid coordinator as volunteers were already fully committed. Because of lack of funds Network could not get a center of its own. The alternative was to work with and move to other groups. The latter course of action was unsuccessful.
What do we know about future population growth?
The eventual accuracy of population projections depends on many variables, and for this reason the demographer must remain wary of placing too much faith in the results. Projections are simply scenarios of what a population's size might be and its age-sex composition could look like under a given set of conditions. Before a demographer proceeds with a projection, it is necessary to answer a few questions: what will the future course of the birthrate be; what will the future trend of life expectancy be; and how will migration affect a country or area's future. Nearly all that can be ascertained about the future size of any population depends on how well foresight can approximate answers to these questions. Of course, the pattern of future birthrates and death rates is unknown. Consequently, the attempt is to make educated guesses, which demographers prefer to term assumptions. Focus is directed to how this process might work when trying to make an assumption on future birthrates, a crucial component of any projection. For example, suppose one wants to project the future birthrate of a country with high fertility and an essentially agrarian economy, the classic preindustrial condition. In practical terms, the issue revolves around the question of when a country with high or moderately high fertility will reach replacement level, i.e., an average of about 2 children per couple. A demographer must assume something about future birthrates in order to make projections, but debates continue on just what effects further social and economic development will have on fertility in different countries. Other factors further complicate the assumption process. There is no certainty that all countries' life expectancies will gradually increase along with health conditions. Migration streams often react to economic conditions or political pressures without warning. And, projections rarely try to incorporate large scale disasters into their assumptions. Mortality caused by calamities such as floods and wars and epidemics find no place in projections due to their unpredictable nature. To illustrate the point, the example of Africa is used, as projected by the UN Population Division. It shows the effect of different assumptions on the pace of fertility decline. UN projections assume, based on Africa's social and economic development, that the continent's fertility will drop to replacement level anywhere from 2030-2070. If it does, the question is what then. What year between 2030-2070 Africa reaches replacement level fertility is of enormous importance as far as its eventual population is concerned, illustrating that projections simply serve as powerful analytical tools and not as forecasts of future population.
Phases of population-land relationships in south-eastern Nigeria.
The land in the southeastern region of Nigeria remains a scarce resource on which various adjustments in agricultural practices, settlement structures, and land tenure have been made to accomodate the needs of increasing numbers of people. These adjustments seem to occur in phases and are altered as pressure on the available resources mounts. 3 phases can be identified with regard to responses to population land imbalance in southeastern Nigeria. Phase 1, which probably lasted from the origin of settlements in the region to the time of European contacts in the early 15th century, was the period when the population land relationship was in equilibrium. It was characterized by low population density and slow and limited technical progress. This was prior to the introduction of cash crops and new farming techniques into the region's farming system. The society was virtually self-sufficient. The relationship between the population and the resources of the environment became established within the boundaries of limited localities. Any effects of population pressure during this 1st phase were mitigated by high mortality rate and other losses, particularly through the slave trade. Despite the losses, the isolation provided by the forest environment of southeastern Nigeria was a major factor in the population build up which introduced phase 2 of the relationships. The equilibrium of the traditional agricultural society was dislocated as the growing population increased pressure on the available resources. Greater European contacts from the late 15th century onwards had several consequences. The economy was monetarized, new cash and food crops were introduced, and there was a desire to mobilize existing resources within the context of the broader interregional economy. Speculative crops were developed to increase food resources. In phase 3, which spans from the early decades of this century to the present day, extra local factors are being introduced into the system as a result of wider exposures to the outside world. This phase coincides with the period of active British colonial activities in Nigeria, political independence in 1960, and vigorous post independence political and economic activities. Throughout Nigeria migrants from southeastern Nigeria are engaged in various income yielding activities. Those still remaining on their land look for additional sources of income simply because earning from agriculture are too small to support them. The strategy of multiple job holding is a mechanism by which those who are still living in the rural areas of southeastern Nigeria maintain a reasonable standard of living.
The Association of Voluntary Sterilization (AVS) conducted a survey in 1981 of freestanding clinics and outpatient hospital facilities to determine the cost of sterilization. Of the 888,000 sterilizations performed in the US in 1981, approximately 5% (31,000 female sterilizations and 15,000 vasectomies) were done in freestanding clinics or outpatient hospital facilities. This is a small proportion of the total, but among this small universe of providers costs were generally much lower than those for in-hospital procedures or for services from private practitioners. Some providers reported using a sliding scale of fees based on an individual's annual income. Such costs are not analyzed here because the data provide no information on the most frequently used points on sliding scales. Only costs in facilities that had a fixed fee for services are presented. The data reflect charges for male and female sterilizations in all 4 regions of the US. 252 facilities were surveyed. 77 reported providing female sterilization only, 115 offered vasectomy only, and 60 provided both male and female sterilization services. Of the 137 facilities serving women, 41 reported fixed fees, 23 used a sliding scale of fees, and 73 did not respond to the question on cost. Of the 175 providers of vasectomy, 55 reported fixed fees, 47 used a sliding scale, and 73 failed to respond to the question. Among 41 providers in clinics and outpatient hospital facilities, the average cost of a female sterilization was $492, far below the $1180 recently estimated for the private sector. The median cost, $450, was less than the mean. 63 responses fell within $100 of the median, i.e., between $350-$550. The lowest charges were in the South. By geographic region, median charges were $500 in the Northeast, $450 in the North Central region, $377 in the South, and $419 in the West. Among the 55 providers of vasectomy (42 freestanding clinics and 13 outpatient facilities), the average cost of vasectomy was $201, lower than the recent estimate of $241 among private practitioners. The median was less at $195. Vasectomy fees were more uniform than those for female sterilization. The 4 regions differed little. In sum, outpatient sterilization procedures, particularly for women, represent great savings, in some cases more than 50%. Given that the cost for vasectomy is much lower than for female sterilization, it is still possible to realize savings of as much as 17% in outpatient facilities.
Early termination of breastfeeding among Philippine urban poor.
The research objective was to identify factors that caused mothers to terminate breastfeeding prematurely, i.e., before the infant reached his or her 1st birthday. Nursing for at least 1 year was a minimum goal of health authorities in the area of this research. The study was conducted in 2 urban poor areas and in 2 fringe squatter settlements of Cebu City, a metropolitan area of 500,000 people in the central Philippines. The data were collected by 2 women field workers. The 130 participants, who were within 3 months of delivery, pre- or postpartum were recruited in 1979. They were visited in their homes once a month by the worker who weighed the mother and the baby, inquired about their diets, and recorded breastfeeding experiences and plans. Special attention was given to any problems the mothers were having that might interfere with continued nursing. Other than encouraging mothers to use the local health center, workers did not intervene to support breastfeeding. The mothers were followed for at least the crucial 1st 6 months. Many were followed for a year or more. Of those who agreed to participate prior to delivery, and who composed 1/3 of the total group, some 95% initiated breastfeeding. Of the 3 who did not, 2 tried to nurse but gave up when the newborn showed persistent diarrhea. Between 10-20% of babies were on a mixed diet of breast and bottle feeding, some beginning as early as the 1st month when mothers returned to part-time work. Other mothers, feeling that the babies were not getting enough to eat, added bottles regularly. This pattern did not necessarily lead to the early termination of breastfeeding. With the exception of 2 instances when mothers decided that their babies were big enough to get along without breast milk, the mothers were forced by circumstances as they perceived them to wean the child. Almost all the terminations were abrupt, with the mother continuing to have an adequate supply of milk. The insufficient milk situation reported by 9 mothers is an exception. In most cases, stopping was a crisis, because the mothers felt that to continue would endanger the child while to stop would sacrifice the benefits of breastfeeding. The major reasons for early termination are discussed: diarrhea, insufficient milk, returning to work, mother sick or pregnant, infant refuses the breast or is not growing, and milk is salty or not good.
Evaluation of the Turkish Fertility Survey 1978.
The objective of this report is to evaluate the quality of data obtained by the Turkish Fertility Survey (TFS). The goal is to understand the extent to which the estimates of the demographic measures and variables obtained through the survey are both accurate and reliable. The sample was a nationally representative equal probability sample of noninstitutional households. Of the 4769 eligible women identified in the households, 4431 were interviewed. Focus is on the respondent errors and biases which may occur by misreporting of ages and durations, displacement, and omission of vital events. The information on age reporting, nuptiality, fertility, and infant mortality come from both the household schedule and the individual questionnaire. Overall, the demographic data of the TFS appear to be of reasonably high quality, producing levels and trends in fertility, nuptiality, and infant and child mortality that are free from significant biases due to omission and misreporting of ages and dates. The most prevalent error found was that caused by digit preference. That error does not have a substantial effect on grouped data, except for women 45 years of age and older, who were excluded from individual interview as a result. In age reporting, the amount of digit preference varies substantially with education, type of area, and development of region of residence. It has improved substantially over the 1975 census. A large increase in age at marriage has occurred in the last 15 years and particularly in the last 5 years. Comparisons of reconstructed distributions of the TFS with those of earlier censuses point to omission of nonlegal unions in the census. There is some evidence for digit preference in dates of marriage from distribution of marital duration. A marked decline in fertility has occurred in Turkey, particularly in the last 5 years. Comparisons with other estimates and internal comparisons produce no evidence that challenges this trend nor the current levels of fertility. Comparisons of the household age distribution with a 1% sample of the 1980 census did produce an indication of possible omission of children under age 10, which could possibly influence the reporting of births in the birth history. Yet, there are indications of substantial recent changes in nuptiality and a rather high proportion of current contraceptive users. The single year estimates of past levels of mortality seem affected by misreporting, omissions, and for small numbers until at least the year 1958. Yet, estimates for 5-year calendar periods show that remarkable declines have occurred in the mortality of infants and other children both in rural and urban areas.
Effects of early parenthood on the cognitive development of children.
In an effort to clarify the relationship between the parent's age and the child's intellectual development, the data from the HES Cycle 2 were examined. The HES Cycle 2 was conducted by the National Center for Health Statistics from 1963-65. A nationwide probability sample of noninstitutionalized children 6-11 years of age was selected and examined. For a sample of 7119 children, data were collected through interviews with parents, physical examinations, psychological tests, school reports of behavior and performance, and birth certificates. For children living with 1 or both natural parents, current age of the parent(s) present in the household at the time of the survey as reported in the parental interview were used to calculate the age of the parent(s) at the time of the child's birth. 3 indices of intellectual development previously constructed from the HES data by Dupuy and Gruvaeus to clarify the effects of socioeconomic status on intellectual achievement were used as dependent variables: the index of Intellectual Development (ID); the index of Sociointellectual Status (SIS); and the index of Differential Intellectual Development (DID). The ID index is comparable to the Full Scale Wechsler Intelligence Scale for Children (WISC) Intelligence Quotient (IQ) score. Although the analysis of the relationship between parental age at child's birth and 3 indices of cognitive development showed a relatively consistent pattern of lower scores in the children of mothers or fathers who were under age 20 as compared to those whose mothers or fathers were no longer teenagers, the absolute magnitude of the differences in scores among age groups was less than 1 standard deviation. In the ID scores, where socioeconomic factors were not eliminated, the difference between the highest and lowest mean scores for maternal and paternal age groups was about 9 points for the total group (excluding the under 14 age group), less than 8 for white and other races (excluding the under 14 age group), and less than 5 for blacks. When the influence of education and income were removed in the DID scores, the differences became less marked. In several of the analyses, the trends were not consistent, i.e., children of younger teenagers did not always score lower than children of older mothers. This finding suggests that factors other than parental age may be of greater importance. The analyses, as well as the other studies reviewed, make it clear that sociodemographic variables contribute more to a child's cognitive development than either maternal or paternal age at the child's birth.
Vaginal pH effects caused by OCs and various copper and inert IUDs.
The effects of oral contraceptives (OCs) and various copper and inert IUDs on human vaginal pH were evaluated. A thorough history and examination were performed on the 331 women selected for the study. Participants were divided into 3 groups: 110 control cases of normally menstruating women (34 at early follicular, 44, at late follicular, 22 at early luteal phases); 83 women using combined oral contraceptives (COCs, 41 women were Primovlar users and 42 women were using Anovlar 1, 23 at early follicular, 18 at late follicular, 22 at early luteal phase and 20 at late luteal phase); and 138 IUD users (71 Lippes loop and 57 copper IUD users, i.e., Cu T, Cu7, and ML Cu250). With the patient in the lithotomy position, the labia majoras were widely separated. The electrode of the pH meter gently touched the lower portion of the vagina for determination of pH at this level. The speculum was opened, locked in situ, and the electrode determined the pH of the middle third of the vagina. The speculum was further introduced and the electrode touched the anterior and posterior fornices for their pH determination. Comparisons were made of the pH of middle third of the vagina of women using Anovlar 1, women using Primovlar, and the control cases. In Anovlar 1 users, there was a statistically significant drop in the mean vaginal pH at the early follicular phase. In other phases, the mean pH was increased significantly except in the early luteal phase. In Primovlar users a drop in the mean pH value during the early luteal phase was found. An increase in the mean vaginal pH was found in the remaining phases. The increase was statistically significant only in late luteal and follicular phases. In copper IUD users an increase of the mean vaginal pH at all phases of the menstrual cycle was found. This increase was significant in all phases except early luteal phase. In Lippes loop users, a significant increase in the vagina pH at all phases was found as compared to control cases, but this increase was insignificant in the early follicular phase. A larger increase was found in Lippes loop users as compared to Cu IUD users.
Drug interactions with oral contraceptives.
The pharmacological interactions of oral contraceptives (OCs) with other drugs is an important concern for family planning programs. Careful research into several potential interactions with OCs has found few problems of clinical significance. Those interactions which have been researched and which do have program implications are summarized. This list should not be regarded as complete, for some drug interactions remain to be discovered. Some drugs have been deliberately omitted because there is too little evidence regarding their effects on OC users. Cautions regarding drug interactions should be a part of the contraceptive labeling. Rifampicin, a powerful antibiotic which is used to treat leprosy, along with the drug isoniazid, forms a treatment for tuberculosis. At least 17 pregnancies occurring in women taking rifampicin while on OCs have been reported in the literature. A high incidence of breakthrough bleeding is also common. Rifampicin has been found to accelerate the metabolism of OC steroids, thereby reducing their protective effectiveness. Low-dose pills are particularly likely to be ineffective when taken with rifampicin. Ampicillin is a penicillin used in the treatment of a wide range of infections and marketed under many brand names. The reports of 3 pregnancies during ampicillin use in OC users prompted several investigations of possible interactions. Experiments in animals found that contraceptive hormonal levels were decreased when ampicillin was administered, but it is unclear whether this is clinically important. At least 4 studies have concluded that it is unlikely that ampicillin decreases the pill's effectiveness. By 1978 a total of 9 pregnancies had been reported in the literature in women taking OCs and anticonvulsants concurrently. The interaction may work both ways--the OC reducing the anticonvulsant's effectiveness and vice versa. 1 study has shown that longterm contraceptive use may increase the effect of diazepam, a tranquilizer and muscle relaxant. Providers should be made aware of this potential interaction. 1 study has shown increased metabolic clearance of acetaminophen, the most commonly used nonaspirin pain reliever, in pill users, implying that its effectiveness is reduced and that the dosage needs to be higher than normal in OC users. For the individual health provider and for the woman taking OCs who requires 1 of these drugs, the interactions may be quite important.
Recent trends in fertility in less developed countries.
The significance of recent trends in the fertility of less developed countries (LDCs) is best seen by examining the sequence of their birthrates, death rates, and rates of increase during the past century or more and the projected rates for a similar period in the future. A figure shows the approximate course of these rates in the less developed world as a whole from 1850-1980, and as projected to 2100. The rise in the annual rate of increase between 1850 and around 1960 to a peak of about 2.5% is a unique episode in the history of these countries. The sustained population increase since 1850 and the very rapid recent growth have no precedent. The source of this acceleration is a mortality decline, gradual until about 1930 and very rapid after World War 2, while the birthrate remained high. As can be judged from the rather extensive evidence, parity related limitation of childbearing was absent in most populations before there was a modern, sustained reduction in birthrates. Such a reduction began in more developed countries in the late 19th or early 20th century and has begun in many LDCs in the past 2 or 3 decades. 2 mechanisms kept the overall rate of childbearing moderately high instead of very high in the preindustrial population in which parity related fertility limitation was apparently absent: marriage customs that prevented a large fraction of potentially fertile women from living in fruitful sexual unions and the prolongation of intervals between births by various practices or conditions that were unrelated to parity. A historical reversal of the acceleration in the rate of increase of the population of LDCs has occurred, a reversal brought about by a major decline in the birthrate, which since the mid 1960s has been more rapid than the continuing decline in the death rate. The reduction in fertility in some countries has been more than 50%. There is an important element of momentum in population growth that will cause a continued increase in numbers in LDCs long after couples merely reproduce themselves. The future number of parents will be considerably larger than the current number in these populations because of past growth. It is the large numbers now under age 20, born when fertility was still high, who will be replacing themselves early in the next century. The large decline in the overall LDC birthrate is composed of a very large decline in a few populations, a modest decline in others, and no change, or even some increase, in the remainder. The absence thus far of a decline in the birthrate in most of the poorest countries in the world, with a total population of about 800 million, is reason for continued concern.
This report, based on recent studies of family budgets, agricultural development plans, health status and planning, and nutritional status in the Dominican Republic, examines the causes and correlates of widespread malnutrition in the country and the likely evolution of food and nutrition through the year 2000 if no changes are made. Among the sociodemographic aspects of the food and nutrition problem is the rate of population growth, which increased in the Dominican Republic to its maximum in 1965 and dropped to 2.6% in 1980. At the same time, the urban component increased to 52% of the population in 1981 from 24% in 1950. Extreme class differentiation in the rural sector, with 70% of the population receiving 45% of the income, is another factor. Agricultural production is growing at one of the lowest rates in Latin America, and much of the crop is still exported, to the detriment of domestic consumption. 14 nutrition surveys between 1962-80 showed rates of malnutrition in children under 6 varying from 30.4% to 75.4%. Per capita food consumption in 1980 was 519.0 kg/year, less than the 579.0 kg/year of 1964. Food consumption is negatively affected by the lack of an overall government policy to confront malnutrition, the dependence of food consumption on employment and income distribution, the health problems of the population which prevent full biological assimilation of food, and inappropriate food beliefs and prejudices. A comparison of the balance between projected food production for the internal market and projected food requirements to meet the nutritional needs of the population through 2000 shows deficits in the majority of foodstuffs. For cereals, only rice and maize production will exceed demand, while wheat is not domestically produced. Large deficits of tubers and roots, legumes, bananas, oils, and milk are expected. By the year 2000, the country may however be able to satisfy 88% of its overall food needs, but there may be no improvement in nutritional status if the access of the poorest population to food does not improve.
African women, industrialization and another development. A global perspective.
Historically, the women of Africa have been differentially integrated into the world economic system, serving primarily as a labor reserve and a mainstay for the subsistence and reproductive sectors. If and when necessary, female proletarianization can come into effect. African women, by virtue of their strategic role in traditional food systems, have acquired certain skills compatible with labor intensive food processing industries. Consequently, in some countries they have been involved in the handling, processing, and packing of food. In many 3rd world nations regulations protecting minimum wage levels do not exist and collective bargaining activities are not strongly in force. Economic hardship and the desperate need to survive can lead some groups to accept even lower wages. Consequently, although the employment of women at lower wages violates the principle of equal pay for equal work, agroindustries with monopolies can deliberately and with impunity hire women at lower wages than men. In general, when women are hired in industries the nature of their employment is precarious, frequently being of a casual and seasonal nature and in greatest demand during peak periods. In an effort to understand the implications of industrialization for African women a global perspective is necessary, for at present the incorporation of the African women in direct industrialization is minimal. Racism has played an important role in the exploitation of the African continent, and no serious study of class and gender inequality in Africa can overlook that important fact. Numerous studies have shown how industry perpetuates the sexual division of labor. Even in the industrialized nations, women often have held the least paid and most precarious jobs in industry. Women's vulnerability is further worsened by several factors, the most obvious being their reproductive capabilities. In addition to being more vulnerable to industrial hazards, their employment can be truncated by pregnancy. Alternative development begins with analysis, and this process has already begun under the intellectual leadership of 3rd world scholars from the industrialized countries. Alternative development must question assumptions upon which many of the earlier analyses and solutions have been based. An alternative model must seriously question the emphasis by international agencies and governments on female labor force participation as an indicator of improvement in women's status and economic position. The emphasis must be on the quality rather than the quantity of female participation, for women can participate in the labor force as exploited wage laborers. An alternative strategy needs to also emphasize parity. Looking inward, development plans should emphasize internal economic development rather than external trade. An alternative development will have to proceed on several fronts simultaneously each well planned, executed, and anticipating the next stage of development.
Women as food producers and suppliers in the twentieth century. The case of Zambia.
It is argued in this discussion that women's ability to produce and supply food has been deteriorating over time. Although this may have begun in precolonial times, particularly with the advent of merchant capital, 20th century economic and political developments have accelerated the process. This situation applies to peasant production as a whole, but discussion is limited to food production and supply. The discussion attempts to understand and discuss the position of women as food producers and suppliers within the framework of the social relations of production, distribution, and surplus appropriation. Land and labor issues have affected women's food production capabilities adversely, and their ability to supply food has been deteriorating. In those countries where their husbands are wage laborers, women have both fed themselves and their children and have supplemented their husbands' wages through food gifts and by maintaining them during their stay at home before the cycle begins again. Despite the fact that they could not adequately do so, men were obligated to start partially maintaining their families "back home" through cash remittances, but cash came at irregular intervals, or it was insufficient, mainly because of small wages. Some women have tried to increase their food supply capacities by going into seasonal wage labor, but often the wages are too low and the prices of food too high for this strategy to work. The time spent in wage labor could be better spent in their own production, provided the factors of production are favorable to them. The intensification of cash crop production has drawn land and labor away from food crops resulting in local food shortages. This process was realized earlier in West Africa when the colonial government started to import rice from China. Gradually, this became an acceptable food crop, but attempts to grow it in sufficient quantities have benefited only men. With the growing urban population rice became a viable marketable crop, to the disadvantage of sufficient food supplies for the producers themselves. The case of Zambia is presented, and it is concluded that the situation of women producers and of food production worsened at a pace responding to the nature of capitalist appropriation of land and labor and the intensification of cash crop production. Thus the phenomenon became more marked after 1945 when colonial states intensified cash crop production. The situation persisted after formal independence. Another Development must tackle the problem areas of land, labor, the sexual division of labor, the state, and men.
Knowledge and practice in family planning of Thai women.
Family planning knowledge and practice in Thailand were examined, particularly contraceptive practices. The source of the data was the 2 rounds of the National Longitudinal Study of Social, Economic, and Demographic Change. The 1st round was conducted in 1969 for rural and 1970 for urban areas; the 2nd rounds were conducted in 1972 in rural and in 1973 in urban areas. The other data source was the Survey of Fertility in Thailand 1975 (SOFT). Both familiarity with contraceptive methods and salinecy of contraception increased substantially in the 5-6 years between the surveys. At the time of the 1st round of the Longitudinal Survey, about 3 out of 4 urban women were able to mention a contraceptive method without prompting while just under half of the rural women could. Most of the remaining women claimed that they recognized at least 1 method when a list of methods was read to them, but again this was less the case for rural women. By 1975, 92% of urban and 86% of rural women could mention a method without prompting, and almost all women indicated a familiarity with birth control when those who recognized a method from a list were included. By 1975 the method most familiar to both rural and urban women was oral contraception (OC). It was the most salient method as indicated by the much higher percentage of women who mentioned OC without a reminder than mentioned any other method. Contraceptive usage increased rapidly during the period under observation. The proportion of all women who ever used contraception increased from under 1/5 to over 1/2 in the 5-6 years covered by the surveys. Current use increased during the same time from under 15% to over 1/3 of all women. The increase was most marked in rural areas where the number of current users increased from just over 1 in 10 women to more than 1 in 3 women. By 1975, almost one half of all rural women reported having ever used some contraceptive method. With the exception of the youngest group of married women, there was remarkably little variation among the different age groups of women in terms of the proportion who had ever used or were currently using contraception as of 1975. By 1975, OC was the most commonly used method for both rural and urban women. Increased OC use over the period under observation accounted for more of the total increase in contraceptive use than all other methods combined. In each of the surveys, female sterilization accounted for a substantial proportion of the contraception practiced in urban areas. IUD use also increased over the period under observation, particularly among rural women.
Vasectomy: clinical aspects and reversibility.
Sterilization, which was originated in Thailand 35 years ago, was initially performed in Bangkok and in the large up-country towns only. Sterilization acceptors were the minority group of well educated families. Population in Thailand increased rapidly following World War 2, and the demand in sterilization has risen respectively. In 1950 the government decentralized the National Health Program, and both vasectomy and tubal ligation were accepted by the Thai. After the government announced their population policy in 1971, vasectomy was included in the plan and has become popular. During 1967-72 there were only 2588 vasectomy acceptors. After the government launched an intensive program, the numbers were augmented. In 1977 there were 15,000 vasectomy acceptors, and 107,000 tubal ligation acceptors--a ratio of 1:7. At Ramathibodi Hospital in Bangkok there were 536 vasectomy acceptors. In 1967-69 the National Family Planning Division was established and activities were motivated through health centers, i.e., hospitals, provincial health centers, hygiene centers, mother and child care centers, and so forth. The government set up a Mobile Vasectomy Unit in 1975 with the goal of performing vasectomy in the remote areas of the country. The National Family Planning Division, established in 1977, has encouraged private clinics throughout Thailand to perform sterilizations. The aim of vasectomy surgery is to block the passage of spermatozoa through the vas deferens. The standard technic of vasectomy consists of division of the vas at the level of upper scrotum and removal of 1 cm portion of the vas. Both ends of vas are tied with No. 3-0 black silk thread. Currently, there are more than 20 methods of vasectomy. The result of vasectomy can be divided into 4 categories: complication, changes from the obstruction of sperm passage, autoantibody, and result in physical and mental condition. The effects of vasectomy on postvasectomized Thai men were studied in 1976 and 1978. The studies involved 185 men who had a vasectomy performed at Ramathibodi Hospital. The postvasectomized man usually feels scrotal ache or discomfort for a few days. The testicular size will not change. Approximately 50% of vasectomized men showed sperm antibodies in their serum after 6 months to 1 year, which gradually diminished at 1 1/2-2 years. The studies did not reveal any significant changes in psychosexual behavior. With the standard method of vasovasostomy the rate of pregnancy of 30% is acceptable by many. Microsurgery is introduced into this field as there is a high rate of pregnancy requirement after vasectomy reversal.
The mechanism of spontaneous recanalization of human vasectomized ductus deferens.
Many cases of spontaneous ductus deferens recanalizations have been recorded in the last few years, since vasectomy became an effective and safe male contraceptive method. The exact mechanism of spontaneous recanalization is unknown. The patient, a 46-year old man, declared that his wife became pregnant 3 years following his vasectomy. Examination of the patient revealed a nodule that was 1 cm in length on the left ductus deferens 2 cm from the superior pole of the left testis. In the right ductus deferens a lesser nodule was seen--0.4 cm long 2 cm from the superior pole of the right testis. A spermiogram showed a sperm count of 39 million/ml with 70% motility at the 1st hour and normal forms. Following surgical exploration, a bilateral vasectomy with recession of 3 cm long segments, just at the sites of former vasoligations, was performed. The right and left segments were fixed in Bouin's fluid for 24 hours and embedded in paraffin wax. A dense fibrous scar tissue filled the space of 4 mm between the distal and proximal stumps. The lumen of the proximal cut end was slightly dilated and had a blind end. The lining epithelium was pseudostratified and columnar and involved some spermatozoal debris and other cells. The lumen of the distal stumps lined by some epithelia was irregular. Many tortuous blind-ended tubules lined by ciliated cubic epithelium that arose from this cut end invaded the scar tissue. The lamina propria and muscular wall were morphologically normal and ended in sudden constriction at the rim of scar tissue. A dense fibrous scar tissue filled the space of 2 mm between the distal and proximal cut ends and covered the ductus deferens on both sides. The extension was 8 mm long. The distal and proximal stumps were connected by a tortuous canal lined by pseudostratified low columnar epithelium. Close to the scar tissue, the muscular walls of distal and proximal stumps ended abruptly, and only a tortuous epithelial canal passed through the scar tissue. In sum, the longitudinal and serial histologic sections of spontaneously recanalized ductus deferens and those of the contralateral ductus deferens displayed many tortuous epithelial tubules growing from the mucosal epithelium of distal stumps intruding into the fibrous scar tissue toward proximal stumps. 1 of the growing gland-like tubules might perform the spontaneous recanalization.
The Dakar Declaration on Another Development with Women.
The following consensus regarding the current problems and alternatives was reached at the Seminar "Another Development with Women," held in Dakar, Senegal during June 1982. The crises of capitalism and of existing socialist models of social progress have deepened over the last 10 years, increasing the threat of nuclear war and of the imposition of narrow national interests by force of arms. Additionally, these crises have contributed to the expansion of poverty in the 3rd world and to the growth of unemployment and social unrest in the industrial countries. Although increasing political tensions and economic inequalities affect the total population, women are particularly acutely affected, and women are no longer willing to play a passive role in defining development priorities and actions. Despite efforts to realize a more equal partnership for 3rd world countries in the world trade and financial system, international terms of exchange continue to affect negatively the living standards and health conditions of the large majority of the population in developing countries. An example of how the position of women as traditional producers and providers of food has been undermined in many regions of the world is cited. Women's customary rights to land have been suppressed. National governments' policies of maintaining cheap food prices for urban dwellers lead to low prices for the crops women cultivate. Finally, women cultivators rarely reap the benefits of modernized production since agricultural extension services, technological inputs, and technical assistance are directed primarily towards men. Giving women land ownership is a 1st step toward structural transformation. This must be supported by adequate training and a fair pricing system. It is believed that the most fundamental and underlying principle of Another Development should be that of structural transformation, a concept which challenges the economic, political, and cultural forms of domination which are found at the international, national, and household levels. At the international level, Another Development should replace the forms of dependent development and unequal terms of exchange with that of mutually beneficiary and negotiated interdependence. Nationally, models of development must be based on the principle of self-reliance, the development of internal and regional markets, the creation of endogenous patterns of consumption and production, and the building of genuinely democratic institutions and practices. At the local and household level, Another Development whould reject existing structures that create or reinforce a sexual division of labor that is oppressive, primarily to women and children, but also any other structures which constitute major constraints on self-reliant development.
Another development with Women.
The objective of this discussion of "Another Development with Women" is to add some thoughts to the scientific approach, which combines survey techniques and computer style data analysis (measurability, detachment, and objectivity). Its purpose is to tilt the balance of the development process a bit further towards women, and it proposes to introduce another element into the discussion on development with women--that of experiential knowledge (knowledge based on collective experience). Women researchers have a double consciousness, similar to that of the black or other discriminated minority, an awareness of the motives and strategies of the oppressor as well as the inner view of the oppressed. To find some answers to the question why the development debate is sometimes obscure, sometimes sterile, and usually frustrating, and to understand why the goals of development remain distant oases, it is necessary to turn attention to the actual contribution women are making to development. Fundamentally, most of women's activities seem to fall outside the definition of "gainful employment." The activities are labeled "nonmarket" or "nonmonetized" activities. It is the differential between work and creativity that fundamentally affects women and erodes their economic and social status. Another unperceived dimension to women's work, which further conceals their efforts and prevents them from surfacing, is the fact that until recently socioeconomic series and indicators were not desegregated by sex. Consequently, the available data on key economic and social questions could not answer the fundamental questions of where are women working, in what numbers, in which activities, and at what wage levels. During the last 2 years some global data for an international information base on women has become available, and the new data will make it possible to follow much more closely, and on a comparative basis for a much larger number of countries, new developments concerning women's employment, working conditions, and their contributions to society. To gain some insights into the processes of development, 4 different economic and social indicators are examined: agriculture, industry, health, and education. Also examined are women's main roles in food production, industrial work, health provision, and education. It is clear that in any theory of power and its distribution, women bear the brunt of inequality in terms of income and rewards, assets, and resources. Another Development will have to find ways by which the unexplored creative energies of women are released.
Mahani Moshin, trained in nursing and midwifery and a pioneer of family planning in South Yemen and currently Deputy Director of Maternal and Child Health and Family Planning for the entire country, states her doubts that a developing country like Democratic Yemen can realize the Alma Ata goal of Health for All by the year 2000. She relates that there are numerous problems to overcome, social and cultural as well as health problems. The administrative problems of a territory like South Yemen would be considerable to the richest countries but Democratic Yemen is the poorest Arab nation. Faced with an infant mortality rate of over 150/1000 and high rates of mortality and ill health from largely preventable diseases, the government is embarking on an ambitious program to bring primary health care and eventually family planning to the bulk of the population living outside the capital. In Aden, where housing, nurseries, and kindergartens are all in short supply, many women want only 2 or 3 children. Family planning has been freely available for some years, and every form of fertility regulation is available, including vasectomy. The situation is different for the country as a whole. The average number of children per woman is 7, and there has been little demand for family planning outside the towns, possibly because women are only now beginning to learn about it. It is government policy to make family planning available gradually in the rural areas, primarily for birth spacing. 60 miles from Aden, at Musaymir in Lahej Governorate, is the setting for the trial introduction of 1 aspect of South Yemen's primary health care program. Lahej is 1 of 2 governorates which have begun to train health guides--volunteer health workers chosen by their communities who receive 3 months' training in hygiene and sanitation, nutrition, and basic health care. The health problems vary, but in this district the main ones are malnutrition, malaria, trachoma, and 2 forms of bilharzia. The 1st batch of health guides in Musaymir were trained in 1981, and 2 years later only 8 had dropped out. 1 health guide, Imad Saled Ahmed, tells about his work as a health guide in 2 villages whose main problems are sanitation and nutrition. The strategy of Dr. Ahmed Abdul Latin, Director of Primary Health Care at the Ministry of Health in Adenk is to provide a 1st contact point with the population. About 270 rural health units, which are essentially little more than first aid posts, will be upgraded into primary health care units with more emphasis on preventive medicine. In addition to providing the 1st point of contact, nurse midwives will supervise the health guides and the traditional birth attendants.
The 3 helicopters of the Flying Doctor Service are 1 way in which the government of Malaysia tries to provide health services to the more remote areas of the country. This service can only reach 248 villages and only briefly. In many instances there is time only to resupply the people with medicines and to evacuate urgent cases. At each stop the team of 4 (a doctor, a hospital assistant, and 2 nurses) saw about 60 patients. The primary task was to isolate the serious cases and to carry out the immunization program, but there were recurrent complaints: coughs, sore eyes, fever, colds, and measles. The most common remedies provided were cough mixture, worm tablets, Panadol, vitamins, and tinned milk. The only help for birth spacing was the distribution of 2 packets of oral contraceptives (OCs). Overnight stops for more careful investigation and health education have, for the time being, been discontinued as part of the national economy drive which cut US$2.18 from Sarawak, Malaysia's health budget in 1982. Village health teams from existing clinics normally travel out to surrounding areas on similar missions, but these too have been curtailed, and other mobile teams are involved in specific health programs dealing with mosquito and fly borne diseases, tuberculosis, leprosy, communicable diseases, and other rural health improvements. 1 result of the work has been to lower the infant mortality rate in Sarawak from 29/1000 in 1975 to a reported 19.5/1000 in 1979. The health statistics show clearly how far the remote rural areas are lagging when it comes to the general health of the population as measured, for instance, by malnutrition. The State plans to build 7 basic rural health clinics every year to serve an extra 15,000-20,000, but with a population increase of 30,000 each year that will not meet the growing need or the unmet need. The current plan is to appoint village health workers in a phased program to reach remote settlements and villages who now rely on mobile units and the Flying Doctor service. In 1979 a new approach was tried. 13 mainly illiterate Iban "medicine men" were given 2 weeks' training at a local dispensary. A review of the scheme showed that it had some benefits with an improved attitude toward maternal and child health. A 2nd pilot scheme was launched in 1982 among a Malay community near Sambir with focus on nutrition. In February 1983 a new approach to training trainers for the village health promoter program was launched. Health staff learned how to select promoters, how to plan a training course for them, and how to help them learn.
A demographic study in an area of low fertility in North-East Tanganyika.
In East Africa the existence of areas of relatively low fertility is well established, and 1 such area is in northeast Tanganyika in Pangani district. This study of the demographic structure of selected villages was undertaken in an effort to quantify the prevailing opinion regarding the apparent infertility in the area and to elucidate some of the responsible factors. A subsidiary investigation was undertaken to obtain more detailed information on marriage stability, fertility, and mortality. Details were obtained of their 503 present and previous marriages from 271 married men resident in Madanga and the adjacent villages of Barabarani and Jaira, a sample representing about 90% of all married men in these villages. There was an appreciable number of unmarried persons in all age groups, but an excess of unmarried individuals occurred in adult males primarily in the younger age groups (except in Mwera, where it continued into the 50s), in adult females mainly in the older age groups. The large number of unmarried adults, while indicating a certain hesitancy on the part of men to marry (every girl is married as soon as she is of marriageable age) is attributable especially to the instability of marriage. In Mwera, for example, all unmarried adult women and 111 out of 224 unmarried adult men had been married once or more. The Madanga area marriage sample suggested that of all marriages more than half were terminated by divorce within the 1st 5 years. Of the remainder, about half ended in divorce before reaching the 10th year, and only about half the remainder survived beyond the 15th year. These figures shed some light on the fertility prevailing in the area. The fertility ratios were low. The highest, in Madanga, was double that of Mwera but still failed to reach the figure observed in the low fertility populations such as in Denmark (41.4) and Holland (49.5). This was in part attributable to the high proportion of infertile marriages. In the Madanga marriage sample these represented over 50% of all unions and occurred especially in those which were of shorter duration. Productivity in the fertile marriages was not low. The average number of live births (6.24) for continuously married parous women at the end of their reproductive years was quite high and so was the average number (3.07) of live births per fertile marriage regardless of duration. In Mikinguni the proportion of married adults (75%) was higher than in the 3 main villages both for males and females. The fertility ratio was also much higher. The Pangani urban sample presented a marked contrast. There was an appreciable number of unmarried adults, and the overall incidence of unmarried adults both male and female was high. The fertility ratio (24.2) was again low.
Consider the cervical factor in reproduction.
The postcoital test has an important role in early evaluation of the infertile couple. It provides information on the quality of sperm and the ability of cervical mucus to sustain sperm progression. A satisfactory result indicates sperm and mucus are compatible, yet does not rule out other incompatability. Cervical mucus obtained too early or too late in the cycle, from anovulatory or hypoestrogenic women or from women with chronic cervicitis, invariably gives invariably gives abnormal postcoital findings. Definite conclusions can be drawn only when it is certain the test has been performed immediately before or during ovulation. Often, it is necessary to repeat the test several times in the same cycle, until a shift in the basal body temperature (BBT) documents that ovulation has occurred. A World Health Organization (WHO) consulting team suggested in 1976 that a postcoital test should be classified as normal if more than 7 motile sperm per high power field are seen under the microscope and as abnormal if no sperm or only immobilized sperm are seen after a meticulous search of the whole slide. Detecting moving sperm in any part of the slide overrides all abnormal areas and makes the result acceptable. Thick, tenacious, sticky, scanty, or absent mucus during the fertile days of the menstrual cycle accounts for about 1/3 of all cases of cervical factor infertility. Thick and cellular mucus, if it is abundant, may respond to oral antibiotics, particularly if mycoplasmal or chlamydial organisms are isolated. More often, dehydration produces mucus of low volume and quality. The prognosis is poor if the volume does not increase after estrogen administration. Decreased sperm motility is responsible for the greatest number of abnormal postcoital results. Protein content can be studied to confirm abnormalities of mucus quality. An appropriately performed AIH-PC provides a differential diagnosis of the factors that may be responsible for abnormal postcoital tests. Usually when postcoital tests are abnormal the results of the postinsemination test are also abnormal. Attention is directed to anatomic abnormalities, coital impairment, short mucus secretory phase, cervical mucus hostility, and sperm abnormalities. Different types of inseminations can be tried. It is always worthwhile to see if splitting the ejaculate improves the quality of the sperm dramatically. Split ejaculate insemination is indicated if either part is completely normal.
The World Health Organization's (WHO) aim is to achieve a level of health that will allow all the world's citizens to lead a socially and economically productive life by the year 2000. Peter D. O'Neill's book, "Health Crisis 2000," is based on WHO's European regional strategy for attaining "health for all" by the year 2000. Its goal is to enable a large audience to participate in a dialogue on the real issues. An analysis of trends in health and disease, made over the past 3 years by representatives of the medical profession, has produced ominous signs that current health policies have set a dangerous course. If "health for all" is to be realized by the year 2000, it will be necessary to implement a new strategy with 3 inseparable themes, i.e., health as a way of life, the prevention of ill health, and community care for all. While the book analyzes the 1st stage of work which the WHO European Region has drawn up for itself, it interprets the official strategy document and offers ample detail to draw ministers, parliamentarians, industrialists, and the media into the debate. Fakhruddin Iqbal reports that a recent study suggests that the Bangladesh family planning program neglected to consider age old social and cultural values. The study identifies 2 distinct cultural values that present obstacles to the program: the traditional preferences for age old treatment as opposed to modern medical practices and the persistent tradition of relegating women to the lowest rung of mass education; and the traditional family size perceptions of the people. Andrew Hamilton writes that the Jamaica Family Planning Association has employed 7 people to spread knowledge of family life education and family planning among youth. These 18-23 year old youth associates are part of a major national drive to keep Jamaica's population below 3 million by the year 2000. About traditional midwives Jan Steele writes that they deliver between 60-80% of babies in the developing world each year and provide support and care in environments commonly shunned by the medical profession. The IPS reports that according to the 1980 census the population of Brazil is 120 million. If the current demographic trends continue, the population will double by 2014. With the present unemployment level, there will be 41.5 million people underemployed and 15 million unemployed in 2014. Meena Panday writes that Nepal cannot seem to get its population program going. The Population Council reports that no evidence exists as yet that use of the copper bearing or nonmedicated IUD increases the risk of ectopic pregnancy.
Both the principles and objectives of the Bucharest Plan continue to be totally valid. Substantial preparations for the International Conference on Population were based on the premise that the principles and objectives of the World Plan of Action adopted at Bucharest should remain untouched. The central concept of the Plan of Action is that the primary cause of population problems is underdevelopment and that demography, taken out of its economic and social context, is of little value. The Conference will be an assembly of government representatives, and it was decided by the Population Commission that the discussion by government representatives would be more valuable if prepared for on the scientific level. The Secretariat selected several points from the Plan of Action for the provisional agenda of this meeting, for discussion at New Delhi and follow-up at Mexico. They were: the influence of modernization on fertility and the family; the interrelationship between changes in family formation and changes in fertility; options in decisions on family size; the life cycle of women and their function in society and in family; demographic goals and political options; and policy implications and technical cooperation. The meeting dealt not only with fertility of populations and birth control but also with the family and the relationship between the evolution of the family and that of fertility. It was agreed that regardless of the structure what was most striking was that the family is holding its own despite the phenomenal questioning of the political and social structures that profoundly affect the traditional framework. The meeting dealt with the upheavals in family life caused by the reduction in mortality and the fertility decline in the 3rd world. 8 factors or groups of factors were identified as being able to affect fertility through the modernization process. The most controversial issue was that some governments wanted to promote small families to change the traditional framework without accompanying economic and social measures. Factors that bring about structural changes in society which in turn can speed up the decline in fertility were discussed at great length, such as improved education, raising the marriage age, postponing the birth of the 1st child, reducing the feeling of insecurity, establishing effective birth control programs, and the role of the community. An issue that was not adequately dealt with was the status of women. It was recommended that activiites should be encouraged which enable women to get out of the house. The group discussed ways of evaluating the influence of family planning programs on fertility.
Modernization affects fertility.
Several possible approaches exist for analyzing the relationship between modernization and fertility. The various aspects of modernization tend to be closely related to each other, making it difficult to assess the distinctive effects. Rather than organizing this discussion in terms of selected intervening variables which are reasonably independent of each other, the intervening variables were selected on the basis of 2 criteria: each variable has been reported to have either a positive or negative impact on fertility, directly or indirectly; and each variable has been reported to be affected by the process of modernization in either a positive or negative direction. The 8 intervening variables or sets of variables chosen for analysis can be grouped as follows: demand for children--labor value of children, children's value as old age support and risk insurance, economic costs of children, and infant and child mortality; supply of children--age at marriage and proportion never married, postpartum sexual abstinence and widowhood/widowerhood, and infecundity due to breastfeeding, malnutrition and disease; and fertility regulation--physical, psychic, and monetary costs. Extensive research on the value and costs of children during the past 2 decades indicates that economic dimensions are more important than others in explaining the shift from a desire for a large number of children (e.g., 6-8) to a desire for a small family (2-3 children). Changes in the following 3 economic variables are found to be relevant to this shift: labor value of children to their parents, children's value as old age support and risk insurance to their parents, and economic costs of children to their parents. The reduction of mortality, particularly infant and child mortality, is a social goal that is worthwhile for its own sake. It should also be considered as a means of reducing fertility and population growth rates in less developed countries. The findings suggest that if fertility decline is the issue, a policy of mortality reduction is a promising approach. The impact of modernization on fertility through all demand variables in consistently negative. By contrast, the impact of modernization on fertility through the selected supply variables, with the exception of age at marriage and proportion never married, is consistently positive. If the demand for children is less than the supply, couples may want to regulate their fertility . Whether or not they actually will depends on actual and perceived costs of fertility regulation. Family planning programs have contributed substantially to the decline of fertility in many less developed countries by reducing the physical, psychic, and monetary costs of fertility regulation to individual couples.
A product of dual import: intravaginal infection control and conception control.
The Reproductive Biology Research Foundation in St. Louis, Missouri evaluated the dual role of the commercial product, Progonasyl, as an intravaginal chemical contraceptive and an agent for intravaginal infection control. The contraceptive effectiveness of Progonasyl has been tested by previously reported technics. The bacteriostatic, trichomonacidal, and fungacidal qualities of the medicament have been determined under clinically controlled conditions. Results established Progonasyl as both an excellent intravaginal contraceptive and as a most effective weapon for controlling intravaginal infection. The technic of evaluating an intravaginal chemical contraceptive consists of exposing 30 female study subjects to artificial coition after the placement of a measured amount of the particular product under investigation. These reasarch subjects carry artificial coition to orgasmic phase response levels. With orgasm, a seminal specimen of established fertility is injected intravaginally. In sequence, 6 samples of intravaginal content are removed at intervals of 1-5 seconds, 15 seconds, 30 seconds, 1 minute, 2 minutes, and finally, 5 minutes after the insemination. The material returned is evaluated microscopically immediately after aspiration. Thus far no commercial product tested has returned a perfect score by providing complete protection for all 30 of the study subjects involved in the program of intravaginal contraceptive evaluation. Delfen Cream scored the highest number of total points of any intravaginal chemical contraceptive product evaluated. The suggested contraceptive dosage for Progonasyl was 4 1/2 cc of the product. This material was injected intravaginally in liquid form. 9 points were lost by Progonasyl during the 1st insemination sessions with the 30 subjects in 9 microscopic evaluations of intravaginal content; active, unencumbered spermatozoa were observed moving freely within their particular test area of the vaginal barrel at the time of the experimental sampling. The long maintained protective qualities of this individual contraceptive product were best exemplified during the 3rd insemination sessions which were conducted from 5-8 hours after the initial experimental period. Regarding infection, in most cases the presenting symptoms of acute vaginitis were controlled by the 1st intravaginal application of Progonasyl. In only 2 instances did symptoms persist after the 2nd treatment session. A specific complaint of intravaginal or labial warmth, stinging, or burning was recorded from 17 of the 100 women who underwent treatment.
The importance of family considerations in mobility decisions of rural to urban migrants in India was investigated by analyzing evidence on urban rural ties. The empirical basis was a survey of migrant heads of households in Delhi conducted from October 1975 to April 1976. Only 14% of the migrants in the sample were accompanied by family members when they moved to Delhi, and at the time of the survey 44% of the sample were living on their own as nonfamilial households. 82% of the migrants reported having family members living in the area. In 1/3 of these cases the rural household contained the wife of the migrant. Over 3/4 of the sample visited their origin regularly, and 2/3 were sending money. Migration decisions are discussed in the context of the mutlicentered family, and urban rural family links are classified into several distinct types, and the importance of visits and remittances to origin for each of these types are investigated. An econometric analysis of conjugal separation is presented, and the determinants of remittances are investigated. The salient methodological innovations are a 7-part typology of urban rural familial links and the use of logit analysis in the identification of the important determinants of conjugal separation. Nearly 4/5 of the migrants visited their place of origin. The proportion reporting visits was higher for migrants who had family members at place of origin, but as many as 60% of the migrants not having family links maintained contact with rural residents through visits. If migrants recognized mutual kinship rights and obligations dictated by the social system, they maintained close functional ties with their kin. Only 56% of unmarried migrants living as nonfamilial units reported visits to origin compared to 92% of those living with their nuclear unit. For migrants who reported presence of family members at origin, there was no significant difference between landowners and nonlandowners in the proportion who reported visits. Married migrants who had left their wives in the rural area were more likely to visit origin during the agricultural busy periods. A majority of the migrants maintained economic links with the rural area, and in early all these cases financial flows were from the urban to the rural area. Remittances tended to be related positively to urban earnings and needs of the rural household and negatively to obligations in the urban household. There was no evidence of ties weakening over time, but migrants who planned to settle in the city remitted less. To an extent conjugal separation was temporary and reflected husbands and wives making the journey at different times. Migrants were also inhibited from bringing their wives to the city if they owned land at origin or had migrated to obtain cash for specific needs. A part of the explanation also lies in varying regional cultural and environmental characteristics.
Fertility of polygamous marriages.
An attempt was made to study fertility differentials between wives of monogamous and polygamous husbands within a homogeneous group which is known not to practice any kind of family planning. The population concerned are the Beduin of the Negeb (Southern Israel) who were enumerated in 1946 and among whom certain further inquiries were undertaken. Polygamy is infrequent among these Beduin; over 90% of the marriages are monogamous. The study covered 240 polygamous families who form the basic material of this discussion. The reasons and motivations for polygamy among the Beduin are not well documented. The material helps to reveal some of the methodological problems involved in analyzing such data. The problems are primarily due to 2 types of factors: the lack of developmental stability of the concepts, i.e., every polygamous family must pass through a monogamous stage before it can become polygamous and, by the death of either of the wives (or by divorce), a polygamous family may at any time return to the state of monogamy; and the lack of information on the actual incentive to and reasons for polygamy. The latter factor makes it difficult to judge how polygamous families are selected and whether, specifically, they tend to include a high proportion of sexually more vigorous men, or of sterile women. A general conclusion may be drawn from the available data. Women living in polygamous marriages have fewer children than wives of monogamous husbands. This is due in part to the lower average duration of married life for subsequent wives of polygamous husbands and in part, in the case of the Beduin women, to a lower fertility of women who share their husband with other women. It is suggested that this is the effect of the lower frequency of sexual intercourse which may effect both 1st and 2nd wives of polygamous husbands, but most likely affects the 1st wife more than the 2nd husband. The fertility of women living in polygamous marriage is far higher than half that observed in monogamous marriages of the same social and cultural milieu. The total number of children born in a polygamous family (by all wives together) exceeds the total number of children born to monogamous families. This is most likely the primary demographic reasons for polygamy, i.e., to ensure a greater number of offspring to a man. Consequently, polygamy is encountered most commonly among hunters or in pastoral societies, like that of the Beduin.
Under-age girls and contraception: the parent's right to be informed.
Victoria Gillick, the plaintiff, a mother of 10 children, of which 5 were adolescent females under age 16, sought declarations in the High Court that a National Health Service (NHS) notice (HN80 46) issued in December 1980, which concerned family planning services for youth, was providing unlawful advice. The action followed correspondence between Gillick and her local area health authority. Gillick sought assurance "that in no circumstances whatsoever will any of my daughters be given contraceptive or abortion treatment whilst they are under 16 in any of the family planning clinics under your control, without my prior knowledge, and irrefutable evidence of my consent." She also requested assurance that she would be automatically contacted in the interests of the safety and welfare of her children. The West Norfolk and Wisbech AHA replied explaining that Gillick's wishes would be made known to the local clinics, but refused to provide a categorical assurance in the terms sought by the mother. The request raised the issue of the confidential relationship of doctor and patient, and the final decision had to be the doctor's clinical judgment. Accordingly the plaintiff sought declarations against the AHA and the DHSS. The basis of the plaintiff's arguments was the following: the "guidance" advises doctors either to commit offenses as principals of causing or encouraging unlawful sexual intercourse (USI) with females under age 16; and the "guidance" authorizes doctors to give advice and treatment to children under age 16 without their parents' consent. In a reserved judgment Mr. Justice Woolf said that Gillick was fully entitled to proceed by writ and seek a declaration that the DHSS's advice was unlawful, but he accepted the defendants' submissions as well founded: that unless the plaintiff could show that the result of following the DHSS's advice was the commission of a criminal offense by a doctor or unlawful conduct by a doctor, the plaintiff was not entitled to the declarations she sought. The case raises some important social issues. It provides some guidance, but many personal situations remain open to question. What emerges is the following: doctors should note that their conduct may amount to being an accessory before the fact if they are so foolish or "misguided" as to encourage an underage female adolescent to have intercourse and give her assistance to achieving that end; the judge stressed that the case where a doctor would be prepared to offer advice about contraceptive methods without parental consent would be "most unusual" or exceptional; with regard to the age at which a female can consent to treatment and/or, for example, vaginal examination, it was not argued before Mr. Justice Woolf that, since the age of consent was raised to 16 as recently as 1885, for 600 years the common law accepted that the age of consent to sexual intercourse was 12, and thus it was submitted this would include examination and treatment for that purpose by a doctor.
Epidemiologic aspects of infertility.
This discussion of the epidemiologic aspects of infertility defines terms and reviews indices for estimating infertility rates, estimates of infertility in Africa and other countries, primary versus secondary infertility, the epidemiologic strategy for defining the nature and magnitude of infertility, and the etiology of infertility (schistosomiasis, filariasis, and thyroid disease and goiter). The high levels of infertility in certain areas of Africa continue to be an enigma to research and a priority problem to providers of health care. 2 well recognized processes may contribute in some areas to part of the problem: the consequences of postpartum and postabortal sepsis, affecting the woman; and the consequences of sexually transmitted diseases, affecting either the man or the woman. Neither of these 2 phenomena appears capable of totally explaining the problem as seen in many African countries. There are many countries and regions within and outside Africa where high levels of sexually transmitted diseases are found or where inadequate obstetric care is common, yet infertility is not of the magnitude to affect 40, 30, or even 20% of couples in these areas. In contrast to the impression derived from clinical data, the impression from the various demographic indices from several developing countries suggests that secondary infertility is as frequent as, if not more frequent than, primary infertility. A World Health Organization (WHO) Task Force on Infertility has developed and undertaken preliminary testing of a simplified questionnaire to be used in the categorization of both the level and the nature of the problem perceived as infertility in different communities. As recommended by the experts, married or cohabiting couples in which the woman is aged 20-29 years should be used as the indicator group as to whether a problem of infertility exists in a community. The application of this system in Nigeria has shown it to be useful in estimating the levels of primary infertility and secondary infertility, but there appears to be a tendency toward underreporting of pregnancy wastage and child loss. Rather than arising from a single cause, as with many health problems encountered in Africa, the problem of infertility may be the result of multiple factors. There is evidence that a variety of pathogens localize in the vessels and tissues of the genital tract. Under such circumstances, microbial organisms not usually given to local pathologic changes may in fact be more prone to produce local, chronic infection in tissue invaded by other parasites of otherwise low virulence, thus possibly leading to infertility in either the man or the woman. This hypothesis calls for further investigation.
[Live-birth rates specific for age of mother by live-birth order--1966-1981 (author's transl)]
Birthrates by mother's age group and by live birth order between 1965 and 1981 were studied using vital statistics obtained from Ministry of Health as well as census and population projection results obtained from Bureau of Statistics. Although total fertility rate was fairly stable between 1968 and 19773, settling around 2.13-2.14, it drastically declined between 1974 and 1977, and it continued to decline gradually to reach as low as 1.74 in 1981. Birth rates by birth order showed the same tendency as total fertility rate in cases of the 1st and 2nd births. As for the 3rd and 4th births, birthrates reached their peak in 1973 and dropped abruptly afterwards. After 1975 birthrates, regardless of birth order, declined. This was especially true of the 5th birth and beyond, which dropped drastically by 70%. Exception to the trend described above was 1966, which was "hinoeuma," a "wrong year" for giving births in Japan. Since 1965 the average ratio of birthrate by birth order to total fertility rate was 45% for the 1st birth, 40% for the 2nd birth and 15% for the third and beyond. The average maternal age changed slightly from 27.70 in 1965 to 27.78 in 1970, 27.48 in 1975 and 27.84 in 1981. While the average maternal age at 1st birth has been increasing since 1974, the maternal age at 2nd and 3rd births has been increasing since 1978. In 1981 peak ages of mother in birthrates by birth order were 25 for the 1st birth and 27 for the second. Birthrates prior to those peak ages are declining noticeably, which resulted in raising the average age of mother at childbirth.
[Recent trends in fertility and reproductivity by prefectures (author's transl)]
Recent trends in fertility and reproductivity of the Japanese female population were investigated. Gross reproduction rate and net reproduction rate by prefecture calculated from the 1980 census were compared with those of 1975. Simplified methods of calculation were used. Total fertility rate dropped by 9.8% during the five years. It was 1.750 nationwide; the lowest, 1.437 of Tokyo; the highest, 2.378 of Okinawa. Those prefectures with higher rates in 1975 declined more drastically than those with lower rates. Correlation between regional characteristics of population and fertility/reproductivity in connection with urbanization was not so significant any longer. Gross reproduction rate also dropped nationwide by 9.8% during the same 5-year period. The lowest was 0.6999 of Tokyo; the highest, 1.148 of Okinawa which declined by 17.6% nevertheless between 1975 and 1980. On the whole regional difference is diminishing. Net reproduction rate was 0.837 compared to 0.922 in 1975 nationwide, with Tokyo's 0.691 as the lowest and Okinawa's 1.119 as the highest and the only one above 1. The regions with higher rates in 1975 tended to decline more drastically. Regional differences are narrowing.
[The uterine factor as a cause of sterility]
The case records of 96 patients examined in the infertility clinic of a La Paz, Bolivia, hospital between August 1977-December 1979 were examined to estimate the importance of uterine factors in infertility. The most important tests for determining uterine involvement were hysterosalpingography, endometrial biopsy, culture or innoculation of the menstrual blood, and history and clinical examination. Of the 77 endometrial biopsies, 25 showed secretory endometriums and 15 showed proliferative endometriums, 9 each showed endometrial hyperplasia, tuberculosis, and luteal insufficiency, 8 showed estrogenic insufficiency, 2 showed decidua, 1 showed gestational endometrium, and 1 showed chronic endometritis. It was concluded that the 9 patients with tuberculosis and 1 with chronic endometritis, or 12.6% of those undergoing biopsies, were infertile because of an organic uterine cause. Hysterosalpingography demonstrated that each of them also suffered from bilateral tubal obstruction. The remainder of the biopsies except those of the 25 secretory endometriums were functionally abnormal. Only 1 of 9 cultures of menstrual blood was positive. 56 hysterosalpingographs were normal. Of the remainder, 6 showed uterine hypoplasia, 4 showed tuberculosis, and the rest showed other anomalies. 16 of the 17 also demonstrated bilateral tubal obstruction. In 23 of the 96 cases uterine pathology was present; it was found to be the 4th most common cause of infertility. However, in 95.7% of cases some other factor was also responsible.
Blood levels of levonorgestrel in women following vaginal placement of contraceptive pills.
6 healthy women aged 25-38 years, attending a family planning clinic in the Dominican Republic, participated in an experiment to determine blood levels of levonorgestrel (1Ng) resulting from daily vaginal placement of contraceptive pills containing .5 mg dl-norgestrel and .05 mg ethinyl estradiol and to evaluate the effect on ovulation. Subjects were observed for 3 cycles. Blood samples were taken on days 14, 18, 23 and 27 following the 1st day of menses on a pretreatment cycle. In 1 cycle the pill was taken daily for 21 days by the oral route, and in another it was placed in the vagina on the same schedule. Blood samples were taken frequently during the 1st 24 hours and subsequently on days 5, 8, 12, 15, 18, and 21 of experimental cycles. Plasma levels of 1Ng reached a peak of 3-4 ng/ml 1-4 hours after oral administation of dl-norgestrel and fell slowly thereafter to a level slightly over 1 ng at 24 hours after ingestion. Plasma concentrations of 1Ng rose at a slower rate and reached a lower peak value after vaginal placement. After 4 hours the 2 curves were approximately parallel. The mean 1Ng plasma concentration 24 hours after vaginal insertion was less than 1/2 the value after oral administration. The differences in plasma levels were statistically significant for each of the times studied. Differences were most pronounced in the 1st 2 weeks. In each pretreatment cycle, progesterone levels reached a peak above 4 ng/ml, indicating ovulation. All but 1 treatment cycle by either route had progesterone values suggesting anovulation; the exception was a vaginal administration cycle. 4 of the 6 women maintained low estradiol levels, mostly between 20-40 pg/ml, during treatment cycles by either route. The lower plasma levels of 1Ng after vaginal insertion of pills may reflect inefficient absorption of steroids within the vagina, or a difference in metabolic degradation when the drug is administered parenterally via the vaginal blood supply. It was still possible to suppress ovulation in 5 of the 6 vaginal cycles without attempting to adjust the dose.
[Recent trends in fertility and mortality in Third World countries]
The 1960s marked a turning point in the history of world population growth as the annual rate of increase, which reached 2%, ceased its ascent. Fertility rates have declined sufficiently rapidly to produce lessened growth rates when compared to mortality among 3/4 of the world's population. The maximum growth rate of developing countries occurred about 1960-65, with a value of 2.4% produced by birthrates of about 40/1000 and mortality rates of about 16/1000. The growth rate is now under 2.1%, due to declines of birthrates to 32/1000 and mortality rates to 11/1000. The recent demographic development of 40 developing countries with populations of over 10 million in 1982 is examined in greater detail including 13 African countries, 8 Latin American countries, 4 East Asian countries, and 15 South and West Asian countries. In 1975-80, the total fertility rate was under 4.7 children/woman, while in 1950 it exceeded 6. A regional comparison for these years indicates that fertility in Africa has scarcely changed in 25 years, while the lowest rates, under 4 children/woman, were found in 3 Latin American and 4 East Asian countries in 1975-80. Reasons for the fertility decline in different countries have included higher marriage age, increased use of contraception in situations where the effect exceeded that of lessened durations of lactation, smaller ideal family sizes, and general socioeconomic progress. Among all developing countries, life expectancy at birth has increased from 42 to 55 years since 1950, but the differences between countries remain great, with almost all African countries, and most South and West Asian countries having life expectancies under 50. Infant mortality rates declined significantly in most of Latin America, but remain very high in Africa and South Asia. Improvements in mortality apparently do not correlate as well with economic development per se as with improved maternal and infant health care, improved water supply, and improved nutrition. A graphic representation of the declines in fertility and mortality in the 40 countries indicates that they are closely related.
[Population reproduction rates for all Japan: 1981 (author's transl)]
Standardized and crude vital rates, reproduction rates for female, and intrinsic vital rates for 1981 were calculated and compared with those for the years 1925 to 1981. For the year 1981, not only the final results but the important rates and numbers which appeared in the process of calculation were also published: population and age specific fertility and mortality rates. According to the 1981 standardized vital rates, birthrate is 12.55% which is 0.21 lower than 12.76% of 1980. Birthrate has been drastically declining since 1974 and the same is true of the crude birthrate. Standardized death rate is 3.48% which is 0.14 lower than 3.62% of 1980. The same tendency is observed in crude death rates. Natural increase rate also decreased because the decline in the birthrate was greater than the decline in the death rate. In terms of reproduction rates, total fertility rate is 1.74; gross reproduction rate, 0.85; net reproduction rate, 0.83. Net reproduction rate dropped below 1 in 1974 and shows speedy decline. Total fertility rate was below 2 in 1975, and it has steadily been declining. Total fertility rate for 1981 marked the lowest with the exception of 1966, the year of "hinoeuma" which was a wrong year for having babies in Japan.
[Demographic pressure, "informal sector" and technological choices in Third World countries]
Trisectorial models of economic functioning have been proposed to replace the dualistic models that proved incapable of illuminating postwar employment trends in developing countries. The new models propose 3 sectors: the subsistence sector, where average productivity corresponds to the subsistence minimum and which is thus incapable of generating a surplus for savings; the intermediate sector, weakly capitalistic, characterized by the absence of a permanent salaried work force or codified labor relations, in which precariousness of employment and the exploitation of specific social relations allow a low wage rate, with a concommitant mode of regulation that largely escapes state control; and the intensely capitalistic sector, with a salaried work force, codified labor relations, existence of administered prices, various state subventions and protections and a monopolistic type of regulation. The 3 sectors are described in greater detail and represented graphically, along with a critique of the limitations of most studies employing a trisectorial perspective. A study of the impact of demographic pressure at different levels of technology embedded in specific sociohistoric systems follows. The final section contains an analysis of 3 types of effects which may mediate the role of demographic pressure in the choice of technologies: effects of demographic pressure on structures of production and consumption, on segments of the labor force, and on involutive and evolutive processes. It is argued that the links between demographic pressure, technologic choices, and the productive sector can only be analyzed in specific social systems.
[World demographic perspectives]
This article discusses methodologies for arriving at population projections and predictions and their limitations, and presents short-term predictions for 1980-2000, longterm projections for 2000-2025, and very longterm projections for 2025-2100, which are highly speculative. The UN population projections for 210 countries and territories are provided by age and sex and by rural or urban status. The UN projections are prepared in 3 phases: 1) analysis of the quality of the basic data in different regions; 2) development of hypotheses concerning the evolution of fertility, mortality, and migration; and 3) separate projection of each component of growth. 4 variants, the medium, high, low, and constant fertility versions are usually prepared, of which the medium projection is considered most likely and that of constant fertility is included only for comparisons. The world crude reproduction rate fell from 2.41 in 1950 to 1.96 in 1975-80, and is expected to fall to 1.34 during 2000-2010 and to almost unity in the mid 21st century. Only Africa and Latin America are expected to have crude reproduction rates above replacement level in 2025. According to the medium projection, the world population will each 6.2 billion in 2000 and 10.4 billion in 2075, when it will be nearly stationary. Future growth in already developed countries will be minimal, but Third World countries, which had a population of 1.7 billion in 1950 and 3.3 billion in 1980, will have nearly 5 billion by 2000 and will stabilize at about 9.1 billion, representing 87% of total world population. About 40% will live in South Asia. The population in 2075 will be 1.2 billion in Latin America, 2.2 billion in Africa, and 1.7 billion in East Asia. The age structure of the future population will undergo considerable aging and the trend toward urbanization will accelerate.
A painful swollen arm in a young woman.
Primary thrombosis of the deep veins of the upper arms accounts for less than 2% of total cases of deep venous thrombosis, and fewer than 10 reported cases of venous thromboembolism in association with oral contraceptive (OC) use have involved the upper extremity. This article describes the case of a 20-year old woman with recurrent arm swelling and pain who had been in good health until developing a small area of redness in her right arm and fever to 99.8 degrees Fahrenheit 6 weeks previously. The condition had been diagnosed as spider bite, for which no medication was given, and cellulitis with axillary lymphadenopathy, for which oral antibiotics were prescribed. Gradual improvement in pain and swelling occurred, but the arm did not return to normal size or consistency. Hospitalization and treatment with 9 days of intravenous Cefamandole provided some resolution. The patient had taken OCs for 2 1/2 years to regulate menses and was a cigarette smoker. She was discharged on oral Tetracycline but was referred for further evaluation because of persistent symptoms. The physical examination was normal except for an increased right upper extremity circumference, increased turgor of upper arm tissues, and some tenderness along the axillary vein and in the axilla itself. A venogram showed complete obstruction of the axillary and subclavian veins on the right with remarkable collateral circulation. The superior vena cava was patent. Treatment with intravenous Heparin followed by oral Warfarin produced no improvement in clinical condition. Primary upper extremity thrombosis is generally a disease of young men. In this case OCs may have served as a thrombogenic risk factor.
The Guyana experience in broadcasting provides a model for a study of transition from free enterprise to socialism in a developing country. This study attempts to evaluate the impact on broadcasting in Guyana of almost revolutionary political, economic, and social changes in the society. It also tries to project the future of broadcasting in Guyana based upon an analysis of the past and present. Rather than importing a model for broadcasting from external sources, a system was evolved with the changes in the society. The present system of broadcasting comprises 2 radio stations (Radio Demerara and GBS) both of which are totally financed by advertising and are in competititon with each other for listeners and revenue. There is no broadcast policy laid down to govern either station so, formally, they can do as they like in terms of program and commercial content. In practice, the Minister of Information is responsible for broadcasting and can give directions to the Government Corporation--GBS. Under Radio Demerara's licensing agreement the Minister can in theory order that certain material either be broadcast or not be broadcast. Since the Minister has the power to revoke the license under which Radio Demerara operates, it is conceivable that the Minister can give directions to the station with which it would comply for fear of losing its license. In 1976 the management of the Guyana Broadcasting Service devised its own set of guidelines for the operation of the station. These guidelines are generally adhered to by the media practitioners within the station. The preamble to the guidelines, setting out policy for station operations, recognizes that Guyana is a society in transition and that broadcasting has an essential role to play in the following: developing an understanding among the widest cross section of society of the changes in the country's political, economic, and social patterns; creating awareness among the largest cross section of people of developmental objectives; assisting in changing people's tastes and attitudes in keeping with the country's ability to satisfy those tastes and attitudes; and attempting to weld the country together from both a racial and class viewpoint. Radio Demerara's policy has been guided by its shareholders' demands that it make a profit. It has programmed inexpensive and popular programs, but over the years it has moved in the direction of more locally produced programs to protect its license to broadcast. To some extent the structure of ownership and financing of broadcasting and even guarantees of independence under the law are insufficient safeguards against possible government manipulation. Specifically, in Guyana where the government controls 80% of the economy, the government is all powerful, and guarantees of independence "under the law" are simply trappings. The short-term broadcasting structure will most likely be a government owned public corporation operating a radio and television station.