The European Community was established in 1951 to reconcile France and Germany after World War II and to make possible the eventual federation of Europe. By 1986, there were 12 member countries: France, Italy, Belgium, the Federal Republic of Germany, Luxembourg, the Netherlands, Denmark, Ireland, the United Kingdom, Greece, Spain, and Portugal. Principal areas of concern are internal and external trade, agriculture, monetary coordination, fisheries, common industrial and commercial policies, assistance, science and research, and common social and regional policies. The European Community has a budget of US$34.035 billion/year, funded by customs duties and 1.4% of each member's value-added tax. The treaties establishing the European Community call for members to form a common market, a common customs tariff, and common agricultural, transport, economic, and nuclear policies. Major European Community institutions include the Commission, Council of Ministers, European Parliament, Court of Justice, and Economic and Social Committee. The Community is the world's largest trading unit, accounting for 15% of world trade. The 2 main goals of the Community's industrial policy are to create an open internal market and to promote technological innovation in order to improve international competitiveness. The European Community aims to contribute to the economic and social development of Third World countries as well.
The population of the Federal Republic of Germany (FRG) was an estimated 61 million (including West Berlin) in 1986 and is in the process of declining gradually as a result of low birth rates. The infant mortality rate is 11/1000, while life expectancy is 73.4 years for women and 67.2 years for men. Of the work force of 27.6 million, 5.4% are engaged in agriculture, 41.6% work in industry and commerce, 10% are employed by the government, and 42.7% are in the service sector. The gross national product was US$898.8 billion in 1986, with an annual growth rate of 2.6% and a per capita income of $10,680. The government is parliamentary and based on a democratic constitution emphasizing protection of individual liberty and divided power in a federal structure. Political life since the establishment of the FRG in 1949 has been characterized by remarkable stability and orderly succession. The FRG ranks among the most important economic powers in the world. The economy is largely export oriented, with 25-30% of the gross national product shipped abroad each year. Competition and free enterprise are fostered, but the state participates in the ownership and management of major sections of the economy, including public services. A major concern at present is the country's ability to adapt to new markets and to develop sophisticated technologies.
The population of Yemen stood at 2.02 million in 1984, with an annual growth rate of 2.9%. The infant mortality rate is 137/1000; life expectancy is 46 years. The literacy rate is 32%. The work force of 410,000 is distributed as follows: agriculture and fisheries, 43.8%; industry and commerce, 28%; and services, 28%. In 1984, the gross national product in Yemen was US$1130 million, with an average real growth rate of 7.4% in 1973-83. In 1978, the 3 political parties were amalgamated into the Yemen Socialist Party, which became the only legal party. Until 1982, economic policy was focused on infrastructure development and agricultural self-sufficiency; since that time, there have been efforts to discover and produce oil. Most of the people of Yemen are subsistence farmers or nomadic herders.
The population of Luxembourg stood at 366,000 in 1986, with an annual growth rate of under 1%. The infant mortality rate is 11.7/1000. Life expectancy is 70 years for men and 76.7 years for women. There is 100% literacy. Luxembourg's gross domestic product in 1986 was US$5.1 billion, with an annual growth rate of 2.5% and a per capita income of $13,900. Of the labor force of 161,000, 5% are engaged in agriculture, 35% are employed in industry and commerce, 49% work in services, and 11% are employed by the government. Luxembourg has a parliamentary form of government with a constitutional monarchy. The 3 major parties are the Christian Social Party, the Socialist Party, and the Democratic (Liberal) Party. Luxembourg is a highly industrialized, export-intensive country. The iron and steel sector is the most important single sector of the economy; steel accounts for 36% of all exports, 10% of the gross domestic product, and 9% of the work force. The recent relative decline of the steel sector has been offset by the development of Luxembourg as a financial center. In 1987, the government estimates that unemployment will remain below 1.8%, inflation will increase slightly to 2%, and the gross domestic product's growth will increase to 2.8%.
Coping with economic crisis: policy development in China and India.
This paper explores health policy options in response to economic crises in developing countries. It is based on the premise that policy is best pursued within a broad understanding of the determinants of health within populations. To provide an empirical base for analysis, the health status and health care systems of China and India are compared. A conceptual framework on the determinants of the health status of populations is then developed, incorporating both the performance of health care systems and nonmedical factors which influence health. Using the China and India experiences, the paper reviews the strengths and weaknesses of traditional tools used in the analysis of health policy. Significant policy change, it is argued, is best implemented through structural change of several health care system components simultaneously. Health policy analysis, it is further argued must consider the broader political economy of the society. Moreover, there remain many perfectly understood sociocultural aspects of behavior which enable some families to produce good health despite economic constraints. The paper concludes that economic crisis presents an opportunity for structural review of a society's health systems. Health policy options in response to economic crisis cannot be confined to the health care sector. Rather, health policy should be viewed as only 1 very important element in a package of socioeconomic policy options. Critical to policy choices are reliable information on the condition of the poor and high political priority to minimize the adverse impact of economic crisis on the health, nutrition, and social welfare of disadvantaged groups. (author's)
Integrating PHC services: evidence from Narangwal, India.
Integration of family planning services within primary health care is a concern which continues to be debated. The current advocacy for introducing selective and vertically organized health care interventions is the latest in a series of swings in the balance between integrated and vertical approaches. This paper reviews the findings from Narangwal in North India, where a research project introduced combined health, nutrition, and population interventions into different sets of villages. Significant reductions occurred in morbidity and mortality in children, their growth improved, and family planning use increased, all at a combined cost of about $US 2.00 per capita (1971 prices). Integrated or combined services generally performed at least as well as more selective approaches and because of their integrated nature, were often more efficient. The major advantage of integrated services was that they provided multiple benefits, an important consideration in areas with many competing causes of morbidity and mortality. Although it was not demonstrated conclusively that either women's and children's health services or family planning services improved the utilization of the other, the results tend to lend support to the value of integrating these services. It was concluded that Narangwal demonstrated the potential of an incremental approach to integration, based on a process of learning by experience and supported by a continuous feedback of information from both formal and informal assessments. (author's modified)
Popular participation in health in Nicaragua.
The Nicaraguan revolution has given priority to health, and promotes community participation in order to improve health. In prerevolutionary Nicaragua, public health programs were plagued by misplaced emphasis, paternalistic attitudes, and lack of follow-through. Working with community organizations and volunteers, postrevolutionary efforts have addressed major public health concerns such as vaccination, sanitation, nutrition, and breastfeeding. Beyond simply using community volunteers to execute health campaigns, the Ministry of Health has developed a structure for community participation in planning, budgetary decisions, and supervision. This system both builds on and helps to create community leadership and grass roots organizations. By giving these community groups a role in planning and administration, the health system maintains the flexibility essential if health services are to be brought to Nicaragua's geographically and demographically diverse population. The contra war has taken a heavy toll on community volunteers and health campaigns. Despite limited resources and the dangers of war, the Nicaraguans have developed a system whereby the local communities and the Ministry of Health work together to improve the country's health status. (author's)
The authors selected epidemiologic, clinical, serologic, and microbiologic findings and their interrelationships among 57 women with acute pelvic inflammatory disease (PID). Cervical cultures positive for Neisseria gonorrheae alone and for both N. gonorrheae and Chlamydia trachomatis were associated with young age, nulliparity, and use of birth control pills. Positive serologic findings for C. trachomatis and/or N. gonorrheae from the cervix and predicted the presence of a pelvic mass. High levels of antibody to Mycoplasma hominis were associated with increasing age and parity, and predicted a low concentration of C-reactive protein (CRP), a long hospital stay, and a high convalescent phase erythrocyte sedimentation rate (ESR). Women with recurrent PID had higher titers of antibody to C. trachomatis than those with primary PID. The use of an IUD predicted high CRP, high acute-phase ESR, long hospital stay, and was frequently associated with positive serologic tests for M. hominis. These results demonstrate that the clinical picture of PID depends not only on the microorganisms involved but also on many epidemiologic factors such as age, contraceptive method, and parity. (author's)
[Christian education programs concerned with family planning in Peru]
3 lay programs offering family planning and other services in conformity with the teachings of the Catholic Church were started in squatter settlements and other low income neighborhoods of Peru between April 1967-May 1970. A pilot program begun in April 1967 in 1 parish added 7 sites before being absorbed in June 1978 into a larger program. The need to make spouses aware of responsible parenthood and to aid them in regulating their family size in accordance with Church teachings led the bishops of Lima to authorize creation of centers for Christian education in each parish. 14 centers were created by June 1970. A program providing for national coverage, beginning with parishes closest to Lima, was begun in May 1970. Educational, medical, and welfare services were offered. The goals of the program were to study the current reality of families, impart the education needed to promote responsible parenthood, consolidate or legalize marital unions, and prepare motivated and trained couples to work in responsible parenthood programs in their communities. The educational programs were based on a 22-week course for couples led by a trained "leader couple". The topics covered included relations between spouses, parents, and children; sex education and sexual hygiene; and the meaning of a family open to community life. The medical program was developed to provide the medical attention required by couples to enable them to fulfill their parental responsibilities, and to teach them to regulate their family size in conformity with Catholic teachings. Complete training in the periodic continence method was provided, and oral contraceptives were offered for up to 2 years postpartum. From April 1967 to June 1970, 4028 women received 36,612 cycles of pills. The medical program provided gynecological services, treatment of infertility, cancer detection through Pap smears, and birth spacing. 325 couples accepted the rhythm method. Between April 1967-June 1970, the average age of women accepting pills declined from 28.5 years to 27.0 years and the average number of living children declined from 4.7 to 4.1. 18.6% of the women left the program for unknown reasons and 15.8% were dropped when their last child reached 2 years of age. 1.8% of users became pregnant because of errors in pill taking. 1.5% terminated pill use because of side effects. 55% of the women were lactating when they entered the program.
[Barrier methods; spermicides; coitus interruptus]
The condom obviously causes no increase in morbidity or mortality. On the contrary, through an important decrease in infection from those classical sexual diseases (syphilis, gonorrhea) and sexually transmitted diseases (infection resulting from intercourse, mycosis, trichomoniasis, chlamydia, and AIDS), the danger of infection from the partner is greatly reduced or even prevented (safe sex). In addition, the danger of salpingitis can also be reduced. The vaginal pessary does not pose a health risk and causes neither morbidity nor mortality. This method is not employed by a wide number of individuals although it presents a very favorable alternative for female contraception. Local spermicides (ointments, tablets, etc.) cause no increase in morbidity or mortality. Local side effects such as allergies are very rare. Most of the substances which destroy semen, especially nonoxynol, have a clearly protective, anti-infection effect. Therefore, they lessen the possibility of transmission of infection through coitus. There are no increased dangers for the child (e.g., deformity) if pregnancy occurs while using this form of contraception. Coitus interruptus is still a common method used among all groups in the population. There is no increase in morbidity or mortality. With regard to risk, sexual and psychological damage occur on occasion, but not too commonly; if the female can still have an orgasm, no disadvantage to the woman is likely to occur. (author's modified) (summaries in GER, FRE, ENG)
[Contraception by long-acting steroids]
Few injectable contraceptives are presently available on the market, with the exception of medroxyprogesterone acetate (Depo-Provera). Norethisterone enanthate (Noristerat) is used in Germany and levonorgestrel in silastic subdermal implants (Norplant) in Scandinavia. Compared with oral contraceptives (OCs), these preparations offer the advantages of simple administration and lack of estrogenic side effects. However, menstrual irregularities and amenorrhea after prolonged use are common, and the return to fertility following discontinuation is often delayed. Clinical trials totaling more than 11 million woman years suggest that these products are safe insofar as liver and cardiovascular function, blood coagulation, lipid metabolism, teratogenicity, and cancer risk are concerned. The mortality rate is at or near 0 and is therefore considerably lower than for oral or intrauterine contraception. Despite these favorable aspects, the acceptability of these methods is rather limited. Especially in Europe, these long-acting steroids are used mainly by women who have completed their families, by those unable to take OCs regularly, and by those who suffer estrogen intolerance. (author's modified) (summaries in GER, FRE, ENG)
Removal of intra-uterine contraceptive devices with non-visible threads [letter]
A not infrequent problem arises when the threads of IUDs are cut short because of complaints from the patient's husband or when the threads retract into the cervix or uterus through uterine action. Once it has been confirmed that the IUD is intrauterine the next problem is the method of removal. Dilatation and curettage (D and C) has the disadvantages of expense (+or= R350) and requires anesthesia, hysteroscopy requires special training, and use of metal hooks and clamps is moderately painful and involves sterilization of the equipment. Sherwood Medical has produced a plastic endometrial biopsy curette (Endo-Pap) with 3 notches on each side, which is narrow and flexible and passes easily and painlessly through the cervix. It was considered that the Endo-Pap could be used to retrieve the threads of IUDs, and this was attempted in 12 cases in which no threads were visible at the ectocervix or present in the endocervix. In 7 cases the threads were retrieved easily and with minimal discomfort using between 1 and 3 insertions. In 2 of the remaining 5 cases the IUD was subsequently retrieved with a metal hook, and the remaining 3 patients required a D and C--in 1 case the IUD was partially embedded in the uterine wall. In my opinion the simplicity and efficacy of this method make the Endo-Pap the 1st choice for removing IUDs with nonvisible threads. A slightly thicker curette with longer notches and less flexibility would probably give even better results. The Endo-Pap curettes were supplied by Pharmaceutical Enterprises (Pty) Ltd, Howard Studios, Howard Drive, Pinelands 7405. (full text)
The effects of gossypol on membrane functions of the human erythrocyte were studied. Gossypol (10 mcM) had no effect on spontaneous hemolysis, osmotic fragility, cell volume, cholinesterase activity, hexose transport, ouabain-sensitive inorganic cation transport, ouabain-insensitive inorganic cation transport, and nucleoside transport. Conversely, the same amount of gossypol inhibited inorganic anion transport by approximately 90% for 3 different substrates (phosphate, sulfate, and chloride). Inhibition of inorganic anion transport was characterized using sulfate as the substrate and had the following features--potency, rapidity (onset occurring in 1 minute), potently blocked by physiological concentrations of albumin and plasma with 50% blocking achieved at 0.03% albumin, occurred by a noncompetitive kinetic mechanism, independent of medium Ca++, Mg++, or pH. Gossypol was bound to human erythrocytes and cell membranes isolated from erythrocytes. 4,4'-Diisothiocyanostilbene-2,2'-disulfonic acid is a potent inhibitor of anion transport and can be covalently bound to band 3. Covalently bound 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid-displaceable binding had the following characteristics: it was saturable at approximately 10 mcM gossypol, it exhibited 1/2-maximal binding at approximately 3 mcM gossypol, there were approximately 10 <6> sites/cell, corresponding to the number of band 3 monomers/cell, it comprised approximately 10% of the bound gossypol at an initial extracellular gossypol concentration of 10 mcM, it affected the conformation of approximately 30% of the membrane proteins corresponding to the fraction of band 3 in the erythrocyte membrane. The results demonstrated that gossypol, at low concentrations, is a specific, membrane-active agent. (author's)
[Diocesan plan to establish a natural family planning services program]
The Diocesan Plan for Establishing a Program of Natural Family Planning (NFP) services calls for a staff consisting of an administrator for the service program, an advisory committee to help develop evaluate the program, a diocesan association of groups providing NFP services, and the existing NFP service centers within the diocese. It is anticipated that establishment of a diocesan NFP program will require 5 years. The administrator should be committed to NFP and should accept the teachings of the Catholic Church on responsible parenthood and conjugal intimacy. The advisory committee, if needed, should consist of no more than 12 representatives of professional service disciplines and directors of existing NFP services. Some dioceses already have structures such as family life committees that could serve as advisors. Systematic efforts must be made to assure that priests and other religious persons have up-to-date knowledge of medical, programmatic, and educational aspects of NFP and of the integration of periodic abstinence by married couples in the context of human sexuality. NFP service providers within a diocese may be independent entities, or they may be part of a family life program, parish, Catholic social service organization, hospital, health center, or of a Catholic university. Catholic institutions of higher education are the appropriate places for regional, community, or diocesan training programs for NFP instructors and supervisors. Existing NFP institutions and programs should be carefully evaluated at the outset of the diocesan program. Public relations and motivational campaigns as well as training programs for individuals should be established. Larger existing NFP programs can undertake more diverse activities such as programs for specific nationalities or subcultures. The principal programmatic areas for NFP programs include NFP education, quality control, consultation and referral, and a plan for diffusion. Person-to-person teaching methods have been shown to be highly effective in teaching and motivating potential NFP acceptors. Follow-up should be an integral component. The couple should be encouraged to learn both the cervical mucus and symptothermal methods in order to choose the method most appropriate for their circumstances. Quality control measures such as periodic review of graphs and review of graphs for cases of unplanned pregnancy should be undertaken.
In Africa, as in all areas where childbearing is considered both a duty and a joy, the occurrence of sterility is particularly unfortunate. Hysterosalpingography (HSG) is the most common of the many techniques now available for study of female infertility. Before performing HSG, the physician should examine the male's external genitalia to rule out anomalies. The woman should undergo a complete gynecological examination to rule out malformations and infections. HSG should if possible be preceded by tranquilizing and antispasmodic medications. If there is possibility of pelvic infection, HSG should be done under antibiotic cover. The antispasmodic allows errors and hasty conclusions to be avoided in cases in which the tube only appears to be blocked. The radiopaque material for HSG may be either a hydrosoluble or oil-based product; each has advantages and disadvantages and as yet neither has been shown to be clearly superior. The radiopaque material can be changed if use of 1 product does not give clear images. A good HSG reading requires more than 2 or 3 films. To avoid excessive radiation exposure, the surrounding organs should be closely covered and the duration of the examination should be reduced to a minimum. A preliminary radiologic examination before administration of the radiopaque material can assure absence of matter in the pelvis that would render the films illegible, and can reveal calcified ganglions indicating a history of tuberculosis that would preclude HSG without antibiotic cover. Of 168 examinations performed over a 20-month period in a clinic in Dahomey, 22 showed bilateral tubal obstruction, 14 showed unilateral obstruction, and 25 showed unilateral or bilateral hydrosalpinx. 31 showed uterine alterations, including 5 cases of adhesions and 26 cases of polyps, fibroma, hyperplastic metritis, or inflammatory lesions, only 6 of which preserved normal tubal motility. There were 11 cases of peritoneal adhesions, 5 of tubal endometriosis, 3 of postmyomectomy sterility, and 1 apparently malignant intrauterine tumor. Results were considered normal in 45 cases. Almost half of the women sought treatment for secondary rather than primary infertility. Postabortal and postpartum infections were a prime etiological factor.
The authors carried out a retrospective study of 162 cases of male infertility explored in a hospital unit in Lyon, France. Assays of 1 -alpha-1,4-glucosidase (epididymal function marker) backed up by clinical findings were used to select 3 types of epididymal malfunction. 1) There was complete obliteration of the epididymal duct, resulting in azoospermia. This diagnosis was based on both testicular biopsy findings, demonstrating unimpaired spermatogenesis and on the dramatically reduced level of assayed activity (< 40 mIU/ejaculation), as well as on clinical findings. 2) There was anamalous epididymal function combined with moderate oligoasthenozoospermia or normospermia. In these cases, low levels of assayed activity do not parallel fairly high sperm counts (between 20-30 million spermatozoal/ml). 3) There were those cases which were difficult to interpret and which involved severe oligoasthenozoospermia (< 5 million/ml) and reduced level of epididymal marker, suggesting partial blockage of the epididymis due to a focus of infection. Varicoceles were found more frequently among the European population, whereas a history of genital infection was more frequent among the North African population. However, when the various types of abnormality in the spermatogram were related to patient history and epididymal abnormality, no differences were found between the 2 populations. (author's modified) (summary in ENG)
Reconstruction of birth histories from census and household survey data.
A new procedure for reconstructing birth histories from census or household survey data was developed. This method may be viewed as an extension of the own-children method of fertility estimation. This concept is extended by recognizing that the "own-children birth histories," i.e., the sequence of births in previous years corresponding to a woman's own children, contain substantial information on birth intervals and parity progression. The core of the reconstruction procedure is a probabilistic process that takes as input a partially complete birth history for a woman, derived from the listing of her own children by age, together with supplementary information for her on number of children ever born and number of children still living. From these data one can calculate the number of her children ever born who are deceased and the number who are surviving but no longer living in the maternal household. The total number of such children is the number of births that must be assigned probabilistically to estimate her complete birth history. The aim of the probabilistic reconstruction procedure is to reflect accurately birth intervals and parity progression ratios in the aggregate rather than for the individual woman. The new procedure was applied to the survey data of the 1974 Korea National Fertility Survey (KNFS). The resulting age-specific fertility rates and total fertility rates compared well with those derived from the same data by the own-children method. The results indicated that period parity progression ratios during 1960-74 remained quite steady for progression from parity 1 to parity 2, dropped slightly over the period for parity 2 to parity 3; and dropped precipitously over the period for the higher parities, interrupted only by a brief levelling in the late 1960s. To compare period parity progression measures during the 1960-74 period from the reconstructed histories of the household data of the 1974 KNFS with those from the birth histories component of the 1974 KNFS, a separate application of the reconstruction procedure was made to those women who were included in both components. There was reasonable agreement in the results despite certain incomparabilities and the small size of the comparison group. With adequate sample sizes, the procedure appears to give fairly reliable period parity progression ratios. Further, the procedure is amenable to refinement which may prove necessary in some instances in order to perform more detailed birth interval analysis.
A community-based case-control study has demonstrated a strong association between cigarette smoking and subarachnoid hemorrhage in men and women 35-64 years of age. Cases included 45 men and 70 women with subarachnoid hemorrhage identified as part of a large study of stroke, while the control group was comprised of 1017 men and 569 women drawn from a survey of cardiovascular risk factors conducted in the same community. After adjusting for age, the relative risk of subarachnoid hemorrhage among cigarette smokers compared with nonsmokers was 3.0 for men and 4.7 for women. The strength of the risk increased with the amount smoked: the risk for men and women smoking 1-20 cigarettes/day was 3.3 compared to nonsmokers, while the risk for heavier smokers was 5.4. Those who both smoked and had a history of hypertension had a 15-fold increased risk of subarachnoid hemorrhage. Overall, 43% of all cases of subarachnoid hemorrhage in this study could be attributable to the independent effect of smoking and 23% of all events could be ascribed to the independent effect of having a history of hypertension. No significant associations were observed between subarachnoid hemorrhage and oral contraceptive use; however, information on pill use was available for only a small subset of the study population. The results of this study closely parallel the findings of similar analyses of all other stroke types. This is the first study to suggest a synergistic effect between cigarette smoking, hypertension, and the risk of subarachnoid hemorrhage.
Health and health services on plantations in Sri Lanka.
The health status of Sri Lankan plantation workers and their families has dramatically improved since nationalization in 1975. Before this time, the health status of estate workers, most of whom are Indian Tamils, was adversely affected by poverty, overcrowding, poor water and sanitation, and inadequate health services. After independence, most of the estates joined the Planters' Association Estates Health Scheme, which undertook activities such as collection of vital and disease statistics, family planning education and mobile clinics for vasectomy, laboratory services, and in-service training of medical assistants. However, as privately owned, profit-making concerns, the estates did not implement a uniform policy or provide uniform health services. As a result, health indicators remained static on the estates while they improved steadily in Sri Lanka as a whole. State ownership of the plantations and the uniform health policies that followed have had a clear impact on the health status of estate workers. The infant mortality rate, for example, has dropped from 74/1000 live birth in 1982 to 46/1000 in 1985, and the gap in mortality rates between the estate and village sectors is narrowing. The components responsible for this shift in health status include full-time staff responsible for health and social development within the plantation organizations; systematic provision of maternal-child health services in the form of antenatal and family planning clinics, improved access to facilities for delivery, and immunization services; recruitment and training of assistant medical practitioners and midwives by the Ministry of Health; and the establishment of a health information system. At present, the Ministry of Health is debating whether health services for plantations should be integrated with national health programs and structures.
Third World women--the invisible tobacco users.
Health policy makers have been slow to recognize the devastating effects of cigarette smoking on women in the Third World. This situation is largely a result of 4 fallacious beliefs: 1) smoking is a bigger problem for men than for women; 2) everyone smokes for the same reasons, so there is no need for a special focus on women; 3) more men than women suffer from smoking-induced diseases; and 4) the rise of the modern women's movement is responsible for the current smoking epidemic in developed countries. Although accurate data are not available, women's smoking rates in developing countries often equal those for women in developed countries. In addition, women's death rates from smoking-related diseases such as lung cancer and cervical cancer are increasing. Women, more than men, appear to use smoking as a means of suppressing negative emotions and dealing with stress. Moreover, female smokers see themselves as more dependent on cigarettes than men and are less confident about quitting successfully. The tobacco industry's advertising exploits women's desire for independence, power, and emancipation to sell a product that, in reality, means dependence and ill health. The longterm solution to the problem of cigarette smoking is for governments to ban tobacco promotion. In the interim, women's issues should form an integral part of any smoking control program, and women should be involved at every level of program implementation.
Trends in the incidence of endometrial and ovarian cancers.
Data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute were used to calculate age-specific endometrial and ovarian cancer rates for the years 1973-81. Corresponding rates for endometrial cancer were also calculated based on the estimated true population at risk, i.e., women who have not had a hysterectomy. The SEER program was founded in 1973 as a network of population-based regional cancer registries. To study trends in the incidence of endometrial and ovarian cancer, data from 7 registries (Detroit, San Francisco, Connecticut, Hawaii, Iowa, New Mexico, and Utah) that reported cancer cases to SEER each year from 1973-81 were used. Together, the 7 areas include about 7.5% of the US population. Endometrial and ovarian cancer rates were calculated for the 7 registries combined, by year and by 10-year age group. The incidence of endometrial cancer among women 50-69 years reached a peak in the mid-1970s and then declined. During the same period, incidence of endometrial cancer also declined among women under age 50 and remained essentially unchanged among women 70 years and older. Rates based on the estimated true population at risk, i.e., women with intact uteri, were higher, but overall trends were similar. Between 1973-81, the age-specific incidence of ovarian cancer changed little. No increasing trend was observed in any age group. In the mid-1970s the recognition that estrogen replacement therapy was associated with endometrial cancer led to a change in physicians' prescribing practices. A reduction in endometrial cancer incidence followed within a few years. Recently, prescriptions for noncontraceptive estrogens have increased but at lower doses and frequently in combination with progestins--regimens thought to mitigate the associated risk of endometrial cancer. Case-control studies have shown that a history of oral contraceptive (OC) use is associated with a reduced risk of developing endometrial and ovarian cancer. The growing proportion of "ever-users" of OCs in the age groups at highest risk should result in a decline in the incidence of both of these cancers.
Definitive birth control and the physician--ethical issues.
The ethical issues relating to the physician's role in informing about, advising, rejecting, or performing sterilization are analyzed. Attention is directed to the following: what constitutes a rational request for this definitive procedure; the proper use of guidelines--rules or criteria--by the physician in responding to a request; the dimensions of adequate information; the implications of recommending an alternative, 2nd-best treatment; and the options and obligations of the physician. To harm oneself without adequate reason is an irrational act; as tubal ligation is an intrinsically harmful act, it must be justified by an adequate reason. An adequate reason is precisely defined as a conscious and rational belief in the direct or indirect benefits to be gained from the procedure. The future good resulting from tubal ligation must outweigh the intrinsic harm. A guideline whose intent is to reject functions as an absolute barrier. A guideline whose use may lead to a delay serves to give the individual time to act thoughtfully, wisely, and carefully. The guidelines, rules, or criteria for performing, advising, accepting, or rejecting tubal ligation appropriately fall into this latter category. The function of these guidelines is to test whether a woman is likely to regret her decision to have a tubal ligation. Age, parity, marital status, socioeconomic state, and general health each are relevant considerations in testing a request for permanent birth control. None are absolute barriers. Each of these considerations, including any medical disorders the patient may have, are subsidiary rather than primary determinants. They are weighted by the physician as he or she decides on the likelihood of the patient regretting her decision. A woman can make a rational request for sterilization only if she has been properly informed. The woman of reproductive age should be well informed about all accepted methods of birth control, including methods directly involving her partner. It is unlikely that there will be any intractable disagreements if: the rationality of the request is appreciated by the physician; his or her application of the guidelines for tubal ligation requests reflects an understanding of the limited purpose of these guidelines; and he or she is impeccable in fully informing the woman of her rational options.
Economic growth with below-replacement fertility.
Taking below-replacement fertility as the premise in this discussion, an attempt is made to identify and weigh economic outcomes that plausibly follow. Attention is directed to the industrialized nations, particularly the US. As reported in several earlier studies, the effects of low fertility on labor supply, technological change, and investment and consumption seem to be relatively slight. It is argued here that there are serious, potentially adverse, economic consequences of low fertility, primarily found in the distributional changes that are generated or accentuated under these demographic circumstances and in the international setting in which low-fertility countries will find themselves. Total population size roughly sets the overall scale of the economy for a developed country. Yet, in view of the current plausible range of population growth rates, this attribute of a population is a given over the time horizon of most economic calculations. It would be difficult to claim that economic outcomes are neutral over differences in population size of a factor of 2 or more, but such variation is generated, for example, by fertility assumptions within what is deemed a realistic range over the 100-year horizon of the most recent official US population projections -- total fertility rates (TFRs) of 2.3 (high), 1.9 (middle), and 1.6 (low). The working-age population grows roughly in line with the total population. In the prime early labor force age groups, absolute declines set in sooner -- in the 1990s for the age group 20-24 in most Western nations. Changes in participation rates, unemployment, or hours worked per worker can potentially offset changes in aggregate labor force numbers, but these factors have other determinants and may not in fact do so. The economic effects of fertility fluctuations, without policy response, are manifold. In most instances, institutional adjustments would go far to remedy the resulting problems. Where adjustments have been neglected, it has not been for lack of lead time. Clearly, there are technological effects of population growth, mediated through factor prices. A labor shortage can elicit shifts to more capital-intensive production methods. The pace and direction of innovation brought about by demographic change are more difficult to identify. Social security problems generated by population aging are widely recognized to be important and are accurately perceived as an aspect of an intricate mesh of distributional relationships -- some involving age categories, other family units, and still others socioeconomic and ethnic groups -- that are part of the fabric societies need to weave in their effort to reconcile often conflicting goals of solidarity and economic growth as well as their conceptions of entitlement and equity.
Altruism and the economic theory of fertility. Comment.
The contributions made by Gary Becker and Robert Barro can be appreciated best if one puts aside what has been learned empirically about the socioeconomic determinants of fertility behavior in modern societies. In their article, they explore the economic implications of altruism toward children along lines first indicated by Becker and Barro in previous theoretical writings. The authors concentrate largely upon presenting the model's microeconomic underpinnings and identifying what these imply about the behavior of fertility in successive generations of a representative family lineage. They describe such lineages as "dynastic families," presumably because the family members must attend to the succession of economic welfare down through the generations of their descendants. Whatever one thinks about the realism of the constrained intertemporal optimization problem addressed by Becker and Barro, something useful may be learned about the causes of below-replacement fertility in contemporary societies. To do justice to Becker and Barro's article as a contribution to the economic theory of fertility, it is necessary to identify some reservations about 3 aspects of their analysis: its extremely atomistic conception of society; the dependence of many of its theoretical conclusions upon assumptions whose empirical content is not examined; and its implied view of uncertainty as a peripheral rather than central aspect of the phenomenon of below-replacement fertility. Becker and Barro, in maintaining their focus primarily upon the determinants of the relative sizes of successive generations in a closed population, shut down the parts of their apparatus that generate macroeconomic, general equilibrium phenomena. Their expositional strategy closes off discussion of policy issues arising from divergences between private optimality and social optimality in regard to fertility decisions. Parents in Becker and Barro lack any direct means of inducing a change in the consumption behavior of their offspring. This is 1 reason everything turns upon the adjustment of fertility levels in this analysis. Economic models are not supposed to replicate reality but to facilitate clear thinking about the greater complexities of reality. Allowing uncertainty into the Becker-Barro model may yield a further formulation, in which altruism toward children is suddenly revealed to be the root cause of the inexorable progress of populations toward below-replacement fertility.
Use of oral contraceptives and risk of invasive cervical cancer in previously screened women.
Within the context of a larger hospital-based case-control study carried out to assess the efficacy of cervical cancer screening, the possible association between oral contraceptives and risk of invasive cervical cancer has been studied as well. Because cytological screening is an integral part of basic gynecological care in the German Democratic Republic, only a few women reported oral contraceptive use but had no Pap smears in that study. Thus, the analysis was confined to those 129 cases and 275 controls who had at least 1 Pap smear screening in their history and were under age 55. The significantly increased relative risks for users decreased after adjustment for factors such as sexual behavior and interval since last Pap smear; however, some risks remained statistically significant or borderline significant for some categories of usage. This concerns, in particular, longterm use (7 or more years) and early onset of use (< or= 24 years) with relative risks of 1.8 and 3.0, respectively. (author's modified)
Breast milk was analyzed in 9 undernourished Nigerian mothers and 23 well nourished mothers who served as controls and whose babies were attending various clinics at the University of Benin Teaching Hospital, Benin-City, Nigeria, over the June 1, 1985, and August 20, 1985, period. The undernourished mothers were selected on the basis of a clinical assessment of their nutritional status as well as a measurement of their mid-arm circumference, weight for height, and hematocrit. All samples were collected between 10 am and 11 am, usually corresponding to the 2nd meal of the day. All milk samples were mid-flow collections. Bile salt-stimulated lipase activity was determined at 37 degrees Centigrade using a pH titrimeter. The 9 women clearly were undernourished by clinical assessment, and their mean mid-arm circumference was significantly less than that of the well nourished group. Their weight-for-height index also was significantly decreased. The energy content of the milk of the undernourished women was greater than that of the milk specimens of the well nourished women; this difference was accounted for by a 25% increase in the lactose content of the milk of the underprivileged women. The fat contents of the 2 groups of milk samples were not significantly different. The milk of the malnourished women contained only 2/3 as much protein as that of the well nourished women, and this difference was statistically significant. The bile salt-stimulated lipase (BSSL) activity in the milk samples from the 2 groups of women differed significantly. The milk of the undernourished women contained only about half as much BSSL when compared with the milk of the well nourished group. Thus, although the undernourished women produced milk that contained the normal amount of fat, their milk was deficient in BSSL activity. In sum, the concentrations of 2 classes of fuel, i.e., lactose and triglycerides, are maintained in milk of undernourished Nigerian women. Once it has been determined what level of BSSL in milk is required to support efficient fat absorption in infants, it then will be possible to assess objectively whether the 50% reduction of the BSSL activity in milk of undernourished Nigerian mothers might compromise fat digestion in the sucking infants.
Over the November 1981 to December 1985 period, a questionnaire was completed by the counselor on 163 patients attending the Parkview clinic (Wellington, New Zealand) for termination of pregnancy due to failure of oral contraception (OC). The reasons for selecting reliable pill takers for special study were: to obtain data on the characteristics of this group; to confirm to what extent previously recognized factors in OC method failure are operating in New Zealand; to determine the numbers who failed on antibiotic medication; and to explore other factors not previously studied such as weight, smoking, stress, and amenorrhea; and, on the basis of the findings, to make practical recommendations for improved instructions in the use of OC. Patients were excluded if there was any question regarding their reliability in OC use. The questionnaire was completed after the abortion had been performed to minimize the effect of withholding information in order to present a better case for termination. 41 patients (25%) were aged 15-19 years, 60 patients (37%) were aged 20-24 years, 40 patients (25%) were aged 25-29 years, and 20 (12%) were aged 30 years and older. 91 patients were under 70 kilograms, and 17 patients were 70 kilograms or more. 82 patients (50%) were nonsmokers; 68 patients smoked more than 10 cigarettes a day (42%), and 13 patients smoked less than 10 cigarettes a day (8%). In 27 patients (7%), there was a history of previous pill failure and in 6 patients there was a previous failure while using an IUD. In 8 of the 27 patients who experienced a 2nd pill failure, there was no obvious predisposing factor on this occasion. In 11 cases (7%) failure occurred in the 1st month of use. In 51 cases (31%) it occurred between 1-6 months. In 35 cases (21%) it occurred between 6-12 months. In 50 cases (31%) it occurred between 1-5 years. In 16 cases (10%) patients had been on the for more than 5 years. In the 11 cases where failure occurred in the 1st month of use, 7 patients had been using another brand in the month before, and this was not necessarily a higher dose pill. In 3 cases they were starting the pill after abstinence and in 1 case after the use of a barrier method. In 6 cases predisposing factors such as diarrhea and/or vomiting, antibiotic use, or breakthrough bleeding were present, but in the remaining 5 cases there were no known predisposing factors. Excluding patients who had failed on a progestogen-only pill when irregular menses may occur, there were 29 patients who gave a history of breakthrough bleeding on the combined pill (21%). This associated with other predisposing factors in 18 cases (13). Vomiting only was associated with 14 failures (9%); diarrhea only was associated with 23 failures (14%). Diarrhea and vomiting was associated with 19 failures (12%). In 37 cases (23%), failure was associated with the use of antibiotics. 2 failures occurred on anticonvulsant medication. Recommendations are made for improved instructions to patients.
Termination of normal and pathological pregnancy with Sulprostone.
262 patients with normal pregnancy in the 1st and 2nd trimester and 55 patients with pathological pregnancy (missed abortion, intrauterine death of the fetus, molar pregnancy) were treated with the prostaglandin E2 analogue Sulprostone to evaluate the safety, effectiveness, and acceptability of this drug to induce abortion in the 1st and 2nd trimesters of normal and pathological pregnancy as well as to dilate the cervix prior to surgical artificial abortion. The patients, ranging in age from 16-38 years, were admitted to the Institute of Obstetrics and Gynecology of the Medical Academy of Poznan, Poland. All patients volunteered to participate in this study. Among those patients admitted because of artificial abortion, duration of amenorrhea ranged from 6-12 weeks. The patients were divided into 3 groups. To the 23 patients in the 1st group, Sulprostone was given 2-3 times 500 mcg intramuscularly at 3-6 hour intervals to induce abortion. Curettage was performed after abortion or within 24 hours when abortion failed to occur. In the 2nd group of 10, Sulprostone was used for pharmacological cervix dilatation prior to curettage. 25 mcg of the drug was administered intramuscular-cervically to 32 patients 12 hours before surgical evacuation of cavum uteri. In 191 pregnancies Sulprostone was administered intramuscularly with 1 dose of 500 mcg also 12 hours prior to curettage. In the group of missed abortion (n = 23), 1-3 doses of 500 mcg were injected intramuscularly. In the case of 10 patients admitted for therapeutic abortion in the 2nd trimester group of intrauterine fetal death, a total dose of 1000-1500 mcg of Sulprostone was infused for over 12 hours. The incidence of gastrointestinal side effects in all groups was limited and clinically acceptable. In the case of induced uterine pains, the analgesic Dolantin was offered on an as-needed basis. Systemic side-effects requiring discontinuation of therapy with Sulprostone were not observed. The 262 patients with normal pregnancy and the 55 patients with pathological pregnancy were treated successfully with Sulprostone. The intramuscular administration seems to be preferable in the 1st trimester for cervical dilatation and other indications and intravenous infusion in the 2nd and 3rd trimesters.
Attributable risk ratio estimation from matched-pairs case-control data.
A methodology is presented for estimating attributable risk ratio along with their large-sample standard errors, and corresponding confidence intervals from a matched-pairs case-control study design. The methodology is illustrated with an example from a matched-pairs case-control study of endometrial cancer and oral conjugated estrogens. The complete methods and study results are provided by antunes et al.; the portions of the data used in this example is reproduced by Schlesselman. Each case in this study was matched to a hospital control on the basis of hospital, data of admission (within 6 months), age (within 5 years), and race. These 183 matched pairs then were classified according to their exposure status (ever versus never) with regard to the use of estrogens. The sample odds ratio of 6.14 indicates that the risk for endometrial cancer was over 6 times as great among women who used estrogens compared with women who never used oral conjugated estrogens. The sample attributable risk of 0.837 among the exposed suggests that among women who have taken oral conjugated estrogens, 83.7% of endometrial cancers were associated with such use, reflecting the sizable strength of the exposure-disease association as measured by the odds ratio. Because less than 1/3 of the cases were so exposed, it is estimated that only 25% of the disease in the general population can be attributed to taking oral conjugated estrogens. This highlights the appeal of population attributable risk in incorporating both the strength of the association and the prevalence of exposure to the risk factor.
Exposure opportunity in epidemiologic studies.
Poole's examples in his article on the relationship of exposure opportunity to validity and efficiency of case-control studies clearly demonstrate that the validity of a case-control study is not affected by inclusion or exclusion of persons who had no opportunity for exposure, provided that opportunity for exposure is not associated with other factors that alter the risk of the study disease. With regard to validity, in other words, exposure opportunity is important only insofar as it indicates confounding by some other factor. On the basis of Poole's reasoning, one might be led to think that opportunity for exposure is irrelevant to planning case-control studies. It will be shown, to the contrary, that consideration of exposure opportunity is important not only for the design of case-control studies but also for epidemiologic studies generally. The rationale for restricting a study to persons with an opportunity for exposure is principally a matter of focus, i.e., designing studies to answer questions of relevance and importance. Thus, despite Poole's suggestion to the contrary, one does not study the effects of oral contraceptive (OC) use in men when the real issue is the risk of disease in women who choose this contraceptive method. Poole's assertion that "exposure opportunity does not seem to concern researchers when they conduct follow-up studies" is clearly wrong. The prototypic followup study is a study that employs randomization to ensure that opportunity for exposure is identical for all participants. Observational followup studies, when appropriately designed, apply enrollment criteria based upon exposure opportunity to approximate the effects of randomization. Examples are cited to show that the target population for epidemiologic studies consists of persons at risk of both the study exposure(s) and disease(s). As a consequence, opportunity for exposure should be a criterion for enrollment of subjects. In case-control studies, opportunity for exposure, like other eligibility criteria, must be applied equally to cases and controls in order that they be sampled from the same target population. In practice, confounding by factors related to exposure opportunity is common. Any exposure that involves an element of choice should be considered a candidate for confounding. Poole's arguments for studying sterile women, based on considerations of "precision" are misleading. Even if a study's precision were "improved" by including subjects with no opportunity for exposure, investigation still should be restricted to persons with exposure opportunity, first, by reason of properly focusing the study, and second, to avoid the possibility that the assumption of no confounding by exposure opportunity might be wrong. Poole exaggerates the practical difficulties of determining exposure opportunity and underestimates its value in avoiding wasted effort. Consideration of exposure opportunity is crucial to planning epidemiologic investigations because it focuses studies on questions of relevants, helps to identify links to variable that can distort the assessment of an exposure's effect, and it reduces the cost of investigation.
Pelvic inflammatory disease, laparoscopy, and the expenditure of health care dollars.
Pelvic inflammatory disease. Attention is directed to the medical consequences of (PID) such as recurrent/chronic infection, chronic pain, ectopic pregnancy, infertility, and mortality. Risk factors for PID are also discussed, as well as clinical diagnosis, the use of laparoscopy in the diagnosis of PID, laparoscopic grading, intraoperative laparoscopic treatment, "pelviscopic" surgery, and the expenditure of health care dollars on PID. Pelvic inflammatory disease, a nonspecific clinical term, is used to describe acute and/or chronic inflammation involving the upper female genital tract with particular reference to the uterus, fallopian tubes, ovaries, and pelvic peritoneum. Inflammation of the upper genital tract can result from conditions such as endometriosis or extensions of intraabdominal infection, but in most instances infectious PID is considered a sexually derived disease resulting from sexually transmitted organisms. Sexually transmitted disease that predominatly involve the vulva, vagina, and urethra are not included under the term PID. The precise incidence of PID is unknown, either in the US or in other parts of the world. During the 1970-75 period, it is estimated that an average of 210,000 females above 10 years of age were hospitalized annually with a diagnosis of PID. Data for the 1975-81 period document an increase in the estimate of hospitalizations for PID to more than 267,000 women per year. Coital sexual activity generally is regarded to be the underlying basis for PID, except in rare instances. In the decade between 1974-84, numerous papers associated the onset of PID with the use of an IUD. The majority of these reports failed to study concomitantly the sexual behavior of patients who had requested an IUD for the sole reason of prevention of pregnancy. At this time the IUD is considered the only contraceptive method that fails to afford some protection against the ascent of bacteria from the cervix to the upper generative tract at midcycle. There are no universally accepted criteria for the diagnosis of PID despite the use of a variety of diagnostic aids. Recently developed American data suggested that the standard in-hospital medical therapy of clinically diagnosed PID may not be economically beneficial in that the money is being spent to treat a condition with an average rate of inaccurate diagnosis of 38%. At this time, laparoscopy represents the most nearly definitive means to confirm or reject the diagnosis of PID. On the basis of the available data in the literature and the conclusions reported by Method, who demonstrated no economic disadvantage to the use of laparoscopy in all women clinically suspected of having PID, it is believed that laparoscopy should be used routinely in the diagnosis of PID in women hospitalized with a provisional diagnosis of this condition.
Infant feeding in the Third World.
Breastfeeding has been on the decline in the 3rd world for the past 20 years or so. Modernization has been blamed, yet in the industrialized nations of Sweden, Britain, and the US, women play significant roles in the labor force, are active in professional and public life, and in most Western nations the educated women and those from the professional and upper classes are most likely to breastfeed their babies. Regarding milk substitutes, many products unacceptable in the Western market are on sale in developing nations. In the absence of strong governmental controls, consumer pressure, and professional vigilance, bottle feeding is taken lightly with disasterous consequences. 3 main dangers have been identified: those arising from the nonavailability of protective substances of breast milk to the infant; those arising from the contamination of the feed in a highly polluted environment of poverty and ignorance of simple principles of hygiene; and those arising from overdilution of feeds on the account of the costs of the baby foods. Market forces and competition led the manufacturers of baby foods to stake their claims to the markets of the 3rd world, and almost all of them adopted undesirable promotional methods. The ensuing uproar led to an International Code of Ethics being adopted at the 33rd world Health Assembly under the auspices of the World Health Organization. Although the matter should have rested there, some manufacturers developed their own codes and have persuaded governments to adopt alternative codes. The present situation with regard to infant feeding in the 33rd world should be considered in the context of the international developments identified and also in light of several social and demographic processes. At the current rates of growth in population up to 80% of humanity will be living in the 3rd world by the end of the 20th century. The 2nd demographic phenomenon of social and political significance is the unprecedented increase in the growth of the urban population with national health and social services failing to respond adequately to the challenge of this growth. In many developing countries national planners and economists are beginning to look upon human milk as an important national resource, and the need for a network of services to ensure the nutrition and health of pregnant and lactating women is obvious and is recognized internationally. With regard to the question of adequacy of breast milk, there are many gaps in knowledge. Each community needs to be studied separately, and those involved in scientific research in 1 environment should resist the temptation of extrapolating the results to communities and societies with a different set of circumstances.
2 groups of consecutive patients who were sterilized either by laparoscopic tubal diathermy or by laparoscopic application of tubal rings were reviewed. Particular reference was paid to the evaluation of late occurring problems such as safety, low abdominal pain, dyspareunia, and bleeding pattern changes. The total of 285 healthy women were sterilized over the 1978-82 period. All the operations were performed electively at the patient's request, and they were informed that the sterilization was an irreversible procedure. The laparoscopic sterilizations were performed in essentially the same manner in both groups, using a Benveniste uterine guide for better stabilization and manipulation of the uterus. The median observation time was 36.5 months (range 21-50 months). At the time of admission, 28% were pregnant, all in the 1st trimester. These women underwent sterilization immediately after induced abortion. The study patients were selected to receive different occlusion techniques with respect to the time period they were sterilized. In Group 1 (electrocoagulation), a total of 106 (50.2%) women sterilized consecutively from 1978-80 had both fallopian tubes unipolarly electrocoagulated twice without tubal division. In Group 2 (tubal ring), a total of 105 (49.8%) women sterilized consecutively from 1980-82 had both fallopian tubes ligated by means of silastic band application approximately 2 1/2 cm from the uterine corner. There was no statistically significant difference between the 2 groups of women in terms of median age, age-distribution, number and distribution of induced abortions, and number of children prior to sterilization. In the electrocoagulation group, 1 woman became pregnant after the sterilization. The pregnancy occurred 21 months after the operation. The reason for the failure was not established as the pregnancy was ectopic and had ruptured. In the tubal ring group, 3 women became pregnant after the sterilization. The failures occurred from 6-23 months after the operation. In 2 cases the tubal rings were found on the round ligaments or completely missing at 1 salpinx. In the 3rd case, both rings were situated in the correct position. 13.2% of the electrocoagulation group reported low abdominal pain and 6.6% dysparunia as new symptoms appearing after the sterilization. The corresponding rates in the tubal ring group were 8.6% and 1.9%. These differences were not statistically significant, and there also was no difference between the rates in the decades. Changes in bleeding pattern following the sterilization procedure were equally related to age and reported by 33 women in the electrocoagulation group and 45 in the tubal ring group. It is concluded that the rates of late sequelae following laparoscopic sterilization using unipolar electrocoagulation or ring application to the fallopian tubes are independent of the method used, but combining these data with the results of other studies, the ring method is found to be more suitable because of fewer ectopic pregnancies and a greater potential for reversal.
Early oral contraceptive use and breast cancer: theoretical effects of latency.
Some studies show a significant association between breast cancer and the use of oral contraceptives (OCs). Stadel et al. have emphasized bias in recall and the selection of controls as a possible explanation for the results of the positive studies. This is plausible yet difficult to prove. This study investigates the existence and magnitude of another possible source of bias, i.e., latency, when combined with recent and rapidly changing exposure patterns. A computer program was used to simulate the exposure to OCs and subsequent diagnosis of breast cancer in hypothetical cohorts of women "born" in each calendar year from 1930-65. To estimate the prevalence of exposure to OCs, the data from 2246 controls included in case control studies of breast cancer conducted in the Department of Community Medicine and General Practice (Radcliffe Infirmary, Oxford, UK) between 1968-84 were analyzed. The controls are women who matched within 5 years of age with breast cancer and who were being treated in hospital; some also were matched for parity. Incorporated into the simulation were the England and Wales age-specific risks of breast cancer so that each woman generated had the appropriate age-specific incidence applied to her. The incidence for a woman exposed to OCs was multiplied by a factor some time after her exposure. Although analyses were performed at 2 levels of exposure, the report focuses on the results of estimated relative risks associated with 4 or more years' use of OCs before 1st pregnancy. Cohorts of 50,000 women born in each calendar year between 1930-65 yielded enough cases in each quinquennium to minimize the effects of chance on relative risk estimates and provided sufficiently narrow confidence intervals on these estimates to be secure in estimating the effects of bias. Due to the fact that the biases entirely attributable to plausible latent periods are large, an obvious implication is that even positive studies may underestimate the ultimate relative risk. The simulations were repeated with double the "true" relative risk to see if even these hypothetical estimates could be consistent with the currently observed results if there happened to be a particularly long latent period. An exponential or log Gaussian distribution of latency with the same mean values as had been used and similar standard deviations made little difference to the extent or time pattern of the biases. As indicated, plausible latent periods can be associated with serious bias in case control studies. Restricting the generation of simulated cases and controls to those "collected" before 1985, the latency period imposed becomes clear, with the correct analysis.
Breast-feeding and HIV infection [letter]
Data on the first 83 infants enrolled in the European collaborative study of infants born to HIV-positive mothers were reviewed to examine the possible role of breastfeeding in the transmission of HIV infection. 11 infants (13%) were breastfed for 1 week to 7 months. 6 infants lost antibody, were clinically well, and have been negative on virus and antigen tests. 3 infants were antibody positive and remained well but were too young to be sure whether they were infected or retaining maternal antibody. 2 of the 11 breastfed infants were infected and have Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related complex. At least 6 of the 11 breastfed infants have apparently escaped HIV infection despite feeding for up to 7 months. These figures are too small to make any definitive statement, yet they contribute to the impression that the relative contribution of breastfeeding to HIV transmission is most likely small compared with that of intrauterine transmission. Breastfeeding shortly after acquisition of HIV, as in the case of postpartum transfusions, may be a special case carrying a higher risk of viral transmission.
[Contraception in adolescent girls: prevention]
Contraception for adolescents presents problems for physicians because the pediatricians and child psychologist with the greatest knowledge of adolescents are not the ones who prescribe contraception. Customary medical procedures may be inadequate for dealing with adolescents. Older women consulting for contraception usually themselves decide what method to choose, and their resistence to contraception and ambivalence to pregnancy can be explored. For adolescents, contraception may be a constraint rather than a choice. It may be imposed despite their conflicting desire for pregnancy and motherhood. Adolescents are usually accompanied by another person, who may make establishment of rapport difficult. If communication is not possible, it can be suggested that the examination be postponed. Attentive patience may eventually permit the examination to progress. The attitudes, preconceived notions, and emotions of the physician may prevent establishment of rapport with the adolescent patient. When contraception is imperative, there are usually no great risks in prescribing oral contraceptives even if the examination is refused. If the examination is done, the parts of the genital anatomy should be named and perhaps shown in a mirror to reassure the client that she is "normal", an important concern at this age. The examination should be used as an occasion to provide adolescents with the information they need to prevent gynecological and breast disorders, sexually transmitted diseases, cervical cancer, and other problems, and to seek prompt treatment if necessary. The immature reproductive systems and immune defenses of adolescent patients limit contraceptive choices for them, but lack of contraception brings its own serious risks of unwanted pregnancy, abortion, ectopic pregnancy, and even eventual sterility. Oral contraceptives (OCs) are completely effective, provide protection against some pelvic infections, and are safe when contraindications have been ruled out. OCs can be used before sexual activity commences, without risk to later fertility, and no interruption of the sexual act. OCs are generally well tolerated, but the daily discipline they require may be beyond the capabilities of some adolescents. The formulation should be changed if needed. Local methods provide some protection against sexually transmitted diseases but they are expensive and perhaps difficult for adolescents to obtain. Condoms can be useful if the male agrees to use them. Natural methods are unsuitable in very young girls with unstable cycles. IUDs are almost always contraindicated for adolescents because of the heightened risk of infection. Contraceptive methods should only be proposed for adolescents, never imposed. The physician should be readily available to answer questions. In the final analysis, a medical consultation is probably not the ideal approach to providing contraceptive information for adolescents, specialized centers or families might be better.
A workshop on techniques for evaluating educational materials was held in Honduras in February 1983 to train a group of workers prior to implementation of an educational communication program. The workshop was attended by all the personnel of the Health Education Division as well as representatives of the 3 health regions in which the program was to be developed in 1983 and 2 representatives of the Division of Vector Control. The workshop was the 2nd in a series of 3 and coincided with the stage of pretesting communication materials concerning malaria. The 2nd workshop designed instruments for pretesting the content of 5 radio messages and 2 printed posters produced during the first workshop. The instruments were then applied during a week of practical training in the field. During the week of theoretical training in Tegucigalpa, a new guide to pretesting prepared as a self-teaching tool for future training purposes was the basis for analysis of the theory and methodology of pretesting. The 15 participants were divided into 3 subgroups, each of which followed all pretesting steps for 1 of the educational materials from design of instruments to field interviews to codification, tabulation, and analysis of results. The week of fieldwork took place in health region 7 in the department of Olancho. 2 versions each of 3 radio spots and the 2 posters were pretested. The 3 sites selected for pretesting were the head of a municipio, an easily reached hamlet, and a hard-to-reach hamlet. 1 person from each of the 5 subgroups went to each of the 3 places. 15 men and 15 women were interviewed for the radio pretest and 2 illiterate and 3 literate persons for the poster pretest in each site. 2 full days were devoted to data tabulation so that the participants could do all work themselves. Evaluation of the participants was done through a final examination for the theoretical part and by supervisor evaluation for the fieldwork. In general the workshop was considered to have been successful in meeting its objectives. Some organizational and infrastructural improvements were suggested for the next workshop. Annexes to the report include the daily workshop agenda and the work guide for pretesting educational materials.
This study compared locus of control scores and guilt among men whose wife or partner had had an abortion with those of men who had no personal abortion experience. The 76 study subjects were males living in the San Diego, California, or Santa Fe, New Mexico, areas in 1985 who volunteered to complete a demographic and abortion questionnaire. The average respondent was in his mid-30s, had 1 child, was college educated, and had an annual income of US$25-30,000. 64% of study subjects were white and 27% were Hispanic. Of the 37 subjects who reported a personal experience with abortion, 6% were married or cohabitating at the time but 61% of them were not with this partner at the time of the survey. 44% had jointly made the decision for abortion with their partner. The results of the Rotter Internal-External Locus of Control Scale and the Mosher Forced-Choice Guilt Inventory failed to indicate any significant differences between men with and without a personal experience with abortion. In addition, there was no association between the locus of control score and scores on the guilt scales. Although it was hypothesized that abortive men would report more guilt and more external locus of control, the only significant finding in this study was that abortive men have less sexual guilt than controls. It is recommended that future investigators obtain the cooperation of abortion clinics and carry out pre and post-abortion analyses of the affective responses of men who accompany women to have an abortion.
The objective of this research was to develop a methodology for estimating levels and trends in child mortality from the retrospective child survivorship data collected through the Infant Mortality Surveys in the Sahel (EMIS). In contrast to the usual retrospective studies, which are based on unconditional random samples, women in the EMIS samples were interviewed at the time of birth of a child (conditional sample). An implication of this timing is that the previous births in the EMIS surveys are on average older than those represented in unconditional samples, making the Brass technique for estimating mortality from child survivorship data inapplicable. The approach advocated in this study differs from others in that mothers are grouped by parity rather than by age. For each parity group, the range of variation of exposure time is narrowed down to the range of variation of the interbirth interval. The age or duration of exposure of previous births to the risk of mortality is a direct function of the mean length of the birth interval. Application of the methodology to EMIS Bobodioulasso data suggest that the infant mortality rate in Bobodioulasso in 1980 was similar to that prevailing among US Whites in the Birth Registration Area in 1918--about 96/1000 live births. The Bobodioulasso data further suggest a mean birth interval of 2.4 years. Demographers should make greater use of the pregnancy histories routinely collected by some maternity clinics in Sub-Saharan Africa to study child mortality. Existing civil registration and health care systems may thus be used for monitoring mortality trends with little additional cost. Data from conditional surveys also can be used to study fertility differentials, including age-, parity-, and group-specific fertility rates.
The 292 abstracts in this handbook summarize papers on the topic of contraception that were presented at the 12th World Congress on Fertility and Sterility, held in Singapore October 26-31, 1986. Each abstract is 1 page in length and presents largely clinical data. Among the many areas covered are: new delivery systems for contraceptive steroids, surveillance of various IUDs, postcoital contraception, microbiological review of the vaginal flora of users of different contraceptive methods experimental male methods of fertility control, the metabolic effects of oral contraceptives, research evidence regarding RU 486, and treatment of infertility.
The 34 abstracts in this handbook summarize papers on the topic of hormonal factors that were presented at the 12th World Congress on Fertility and Sterility, held in Singapore October 26-31, 1986. Each abstract is 1 page in length and presents concise data from clinical research. Among the many areas covered are: releasing hormones, hormonal monitoring in early pregnancy, immunology in human reproduction, immune reactions to spermatozoal antigens in cervical mucus, Norplant implants, and the role of lupus anticoagulant in habitual abortion.
An experimental group of adolescents who became pregnant after induced abortion (n=320) were compared with 514 primigravid adolescents, 391 women ages 20-24 years who became pregnant after induced abortion, and 368 primigravidae of the same age. Spontaneous abortion appeared more frequently in the experimental group (5.9%) than in all control groups (5.1%, 3.3%, and 3.8%, respectively. Preterm delivery was more frequent in the experimental group (9.3%) than in the control groups (6.8%, 6.4%, 5.7%, respectively). In the young adolescent group (14-16 years) of the experimental group, spontaneous abortion was almost twice as frequent (10.7%) as in the older adolescents of the same group (5.5%) and preterm delivery 2 1/2 times as frequent (24.0%) as in the group of primigravid adolescents of the same age (10.3%). The weight of the newborns in the experimental group (3155.7 +or- 536.3 g) was significantly lower than that in the primigravid adolescent group (3228 +or- 488 g; t=1.97, P < 0.05), in women ages 20-24 with an earlier induced abortion (3303 +or- 556 d; t=3.49 P < 0.01), and in primigravid women ages 20-24 (3331 +or- 508; t=4.30, P <0.001). The adolescents of the experimental group had term deliveries in weeks 40-42 significantly less often (31.6%) than primigravid adolescents (47.1%), women ages 20-24 with earlier induced abortion (47.4%), and primigravidae ages 20-24 (53.8%). (author's modified) (Summaries in SCR, ENG)
Perinatal and infant mortality in urban slums under I.C.D.S. scheme.
Perinatal and infant mortality during the year 1985 was analyzed through a prospective study conducted in 12 Anganwadis (total population of 13,054) located in slum areas of India's Jabalpur city. Overall, the infant mortality rate was 128.7/1000 live births and the perinatal mortality rate was 88.5/1000 live births. 58.5% of deaths occurred in the neonatal period. Causes of neonatal deaths included prematurity, respiratory distress syndrome, birth asphyxia, septicemia, and neonatal tetanus. Postneonatal deaths were largely attributable to dehydration from diarrhea, bronchopneumonia, malnutrition, and infectious diseases. All mortality rates were significantly higher in Muslims than among Hindus. Muslims accounted for 28% of the study population, but contributed 63% of stillbirths and 55% of total infant deaths. This phenomenon appears attributable to the large family size among Muslims coupled with inadequate maternal-child health care. The national neonatal and postneonatal mortality rates are 88/1000 and 52/1000, respectively. The fact that the neonatal mortality rate in the study area was slightly lower than the national average may reflect the impact of ICDS services.
Evaluation of Village Family Planning Program, USAID Indonesia Project: 497-0327, 1983-1986.
This evaluation of the village family planning program in Indonesia is prepared for USAID, which has supported the program for 15 years, and is to complete support in 1986. It is in general a positive evaluation, prepared by interviews, and visits to 7 out of 27 Provinces, 14 out of 246 Kabupatens (Districts), and 16 Villages. Village distribution centers have increased 38%, new acceptors by 38%, continuing user levels by 57%, and overall contraceptive prevalence by 38%. Access to varieties of contraceptives, especially longer acting methods, has improved, and costs per capita have decreased. Some problems were pointed out, generating several recommendations: physical conditions of the clinics need attention; motivation by consciousness raising has not been matched by better knowledge; the surgical program needs to be expanded; self-sufficiency in cost recovery should be fostered; operations research is needed on payment for field workers and volunteers; and social marketing should be expanded. USAID should continue support for the Outer Islands. In a final list of recommendations were the suggestions that USAID assist clinical programs further, support training of field workers, do more statistical review, continue to support the IEC program, operations research on community-based distribution, and program integration.
[The adolescent and contraception. Part 2]
Educational programs should be based on appropriate learning theories. 2 theoretical approaches with possible relevance to family planning education for adolescents are the theory of attitudes developed by Fishbein and the theory of social learning developed by Bandura and modified by Zimbardo and colleagues. According to the theory of social learning, social approval is a major reinforcement. And according to Festinger, the cognitive system, which includes beliefs, attitudes, and knowledge of external information or that originating in one's own behavior, tends to equilibrium so that inconsistencies between elements of the system are reduced to a minimum. A possible approach to inducing a change in behavior would be to introduce a transitory disequilibrium in the cognitive system. The intervention could be at the level of beliefs through provision of correct information, at the level of attitudes through experiential or emotional approaches using groups of couples or similar techniques, or at the level of behavior, which could be modified with approaches such as role playing or modeling. The objectives of the desired intervention would be to prompt males to ask their partners whether contraception is available before initiating sexual activity, to substitute other forms of sex play if contraception is unavailable, and to increase usage of condoms. In order to attain the objectives, it is necessary to ask why the behaviors are not already present. The reasons appear to be in part that theoretical knowledge is lacking, belief systems of individuals involved are sufficiently consistent, and practical experience is lacking. Interventions concerning beliefs about contraception would fall into 1 of 6 categories concerning: 1) efficacy of contraceptive methods 2) interactions with the partner 3) sexual pleasure 4) the relationship between love and pregnancy risk 5) sex roles or 6) shame. Contraception is partly a matter of information and education. It would seem that sex education would have a better chance of success if it encouraged participation in couples. Schools, the natural focus of adolescent life, appear to be the ideal site for sex education. A complementary intervention should be undertaken to make condom purchases in pharmacies easier for adolescents.
[Screening cytology and genital actinomycosis]
Actinomyces are known to be relatively innocuous endogenous saprophytes incapable of crossing a normal mucus barrier. Their original habitat was the buccal cavity where they participated in formation of tartar through their phosphatases. Despite the fact that the normal vagina is too acid and aerobic for Actinomyces, a vaginal smear examined in 1976 showed grains of Actinomyces. Since then, several other authors have confirmed the finding. The question arises as to how far vaginal Actinomycosis is implicated in upper genital Actinomycotic infection and whether such vaginal infections in IUD users should be treated or whether the IUD should be removed. 3 of the 6 species of Actinomyces described in human beings have been found in the vagina. 458 of 180,000 vaginal smears, or .25% examined for Actinomyces at the parasitology laboratory of the University Claude Bernard in Lyon and the Institute Pasteur in Paris were positive. Vaginal Actinomyces infections are associated with lower socioeconomic status and with the presence of a foreign body in the vagina or uterus. 97% of positive smears in the present series were associated with IUDs. The frequency of Actinomyces among IUD users was estimated at 3.5% for the estimated 12,525 IUD users in the series. The rate was lower than previous estimates by other authors, probably because the use of copper IUDs has increased greatly in the past few years. Among 215 cases of vaginal Actinomyces in the series, 208 or 96.74% were in IUD users. In the great majority of cases, the IUD was well tolerated. There were 14 cases of pelvic pain, 13 of spotting, and 20 of metrorrhagia or menorrhagia. There were 6 cases of endometritis and 1 of salpingitis that responded to simple medical treatment. The 7 cases of Actinomyces without IUD use include 2 cases of uterine adenomyosis and 5 with no associated findings. Vaginal Actinomyces reveals the existence of specific combinations of alkalinization and anaerobiosis of the vagina due to infection, microhemorrhagic conditions such as polyps, fibroma, or adenomyosis, or degradation of a foreign body in the uterus or vagina. These etiologies should be sought and treated. Until results of prospective studies become available to guide clinicians, it is recommended that Actinomyces discovered in vaginal smears be reported and that IUDs be removed from the 3% of affected users to ensure the disappearance of the vaginal Actinomyces and prevent the rare but very grave upper genital tract Actinomycosis.
392 secondary and technical school students in the Val-de-Marne area of France returned questionnaires in May 1985 about their menarche, menstrual cycles, and related topics. Only the responses to each question that were clearly stated and accurately dated were retained. For some questions, the results were combined with data from 180 students in the same area collected in 1984. The average age of the respondents was 16.06 years, of all secondary school students 15 years, and of the technical students 17.48 years. The average age at menarche was 12.98 years. There was no monthly predominance in occurrence of menarche, but menarche occurred in the summer in 33% of cases, in the winter in 25%, in the spring in 21%, and in the fall in 20%. 50% of respondents reported irregular cycles in the first gynecological year, averaging 7.55 cycles for the year for 89 girls with irregular cycles. In the second year 63% and in the third year 68% had regular cycles. 10 of 252 respondents reported they had ever had a flow heavy enough to require special treatment. 50% reported dysmenorrhea in the first year, 54% in the second year, and 65% in the third. 36% reported pain severe enough to cause absence from school. 67% of those with pain sought treatment, 67% with self medication, 22% with a prescription from a general practitioner, and 11% with a prescription from a specialist. 31 girls out of 305 reported taking oral contraceptives (OCs). Their average age was 17.3 years and they had been menstruating for 3.97 years on average. Their average duration of OC use was 15.4 months. 25 of the 31 mentioned irregular or painful cycles as a reason for OC use. 1% reported taking progesterone to regularize their cycles. The very small proportion of girls receiving progesterone treatment for irregular, painful, or heavy cycles is related to a failure of practitioners to recognize luteal deficiency as a problem in young girls.
It is easy to accept Dr. Binning's assertion (Anesthesia 1986; 41: 786) that recovery times with methohexitone are comparable to those achieved with propofol, because of his considerable experience of termination of pregnancy. My continued advocacy of propofol is based on morbidity studies conducted with some 600 patients attending for termination of pregnancy, and our results are comparable with those of other workers in terms of patients' assessments of their postoperative morbidity. However, the replies provided by patients when leaving hospital and returned by patients on the day following the terminations are, for patients receiving propofol, entirely different from those provided by patients who had other intravenous induction agents. Patients' comments that they were hungry, that they should have been fed sooner and that they were able to return to normal activities earlier, represent an entirely different quality of recovery for this procedure. Our experience with methohexitone is that patients complain of headache, nausea and drowsiness on the same night, and are seen by the ward staff to be unhappy when they awaken. It is this difference which, in my view, commends propofol for this procedure. (full text)
Retained products of conception [letter]
Therapeutic abortions performed in Wellington are virtually all carried out in 1 designated center. Abortions are performed by suction curettage following paracervical block with lignocaine. Normally patients are discharged 3-4 hours following the procedure. In the period 1 January to 31 July 1986, 568 legal abortions have been carried out. Following these procedures 28 patients (5%) have required hospital admission at between 3 days and 2 months after the abortion because of abdominal pain and persistent vaginal bleeding. In 25 cases a clinical diagnosis of retained products of conception has been made and dilatation and curettage performed. 5 patients have had ultrasound scans prior to the D and C and on each occasion retained products have been reported as being seen. Material collected at the time of curettage had been examined histologically. In only 5 cases have chorionic villi been identified. (All patients have previous confirmed chorionic villi in the material collected at the time of the abortion). In the remaining 20 patients histological examination demonstrates only decidual endometrium. This retrospective study demonstrates that 20 women underwent unnecessary general anesthesia and curettage as the endometrium would likely have been shed in the physiological way such as occurs postpartum. Only 5 patients had confirmed retained conceptual products necessitating D and C. Unfortunately ultrasound scanning did not prove helpful and all 5 patients though to have retained products had decidual endometrium. Ultrasound scanning in our hands appears unable to distinguish between blood clots within the uterine cavity and retained placental tissue. This analysis requires further clarification by a prospective study. The data has however resulted in our clinicians advising a more conservative approach in women presenting with bleeding following therapeutic abortion with a view to obviating unnecessary hospital admission, general anesthesia and curettage. (full text)
Torsion of the fallopian tube--a late complication of sterilisation.
Torsion of an intact fallopian tube, unaccompanied by torsion of the ipsilateral ovary, was noted as a complication of bilateral tubal occlusion by the Pomeroy method in a 45-year old Indian woman. The sterilization was performed 5 years previously, at the time of Cesarean section delivery. The patient presented with a history of pain in the right iliac fossa. Laparotomy showed that the distal segment of the right fallopian tube was twisted 3 times on the distal mesosalpinx and appeared tense and gangrenous. The right ovary was normal and a 2 cm gap was noted between the proximal and distal segments of the tube. As a rare complication of the Pomeroy method, the gap in the tube can allow the distal mesosalpinx to act as a pedicle, and with a long mesosalpinx, the fimbriated segment of the tube lies free and may swing and twist to produce torsion. The occurrence of torsion is further promoted by a vascular disturbance leading to venous congestion, edema, and increased weight of the free fimbrial end of the tube. In those patients with a history of sterilization, torsion of the fallopian tube should be considered in the differential diagnosis of acute lower abdominal pain. Torsion of the fallopian tube has also been reported following other methods of tubal occlusion, including cautery and clips.
Conservative estimates project over 500,000 cases/year of new active corneal lesions and 6-7 million cases of noncorneal xerophthalmia attributable to vitamin A deficiency on a worldwide basis. Vitamin A deficiency affects growth, the differentiation of epithelial tissues, and immune competence. The most dramatic impact, however, is on the eye and includes night blindness, xerosis of the conjunctiva and cornea, and ultimately corneal ulceration and necrosis of the cornea. Vitamin A deficiency occurs when body stores are exhausted and supply fails to meet the body's requirements, either because there is a dietary insufficiency, requirements are increased, or intestinal absorption, transport and metabolism are impaired as a result of conditions such as diarrhea. Vitamin A deficiency is the single most frequent cause of blindness among preschool children in developing countries. The younger the child, the more severe is the disease and the higher the risk that corneal destruction will be followed by death. The most important step in preventing vitamin A deficiency is ensuring that children's diets include adequate amounts of carotene containing cereals, tubers, vegetables, and fruits. An overall strategy designed to prevent and control vitamin A deficiency, xerophthalmia, and nutritional blindness may be defined in terms of action taken in the short, medium, and long term. A short-term, emergency measure includes the administration to vulnerable groups of single, large doses of vitamin A on a periodic basis. In the medium-term, the fortification of a dietary vehicle (e.g., sugar or monosodium glutamate) with vitamin A can be initiated. Increased dietary intake of vitamin A through home gardening and nutrition education programs comprises the longterm solution to this problem. The World Health Organization plans to launch a 10-year program of support to countries where vitamin A deficiency is a significant public health problem.
Norplant contraceptive subdermal implants.
All available evidence suggests that the Norplant contraceptive subdermal implant system, developed by the Population Council, will have a significant programmatic impact on family planning efforts throughout the world. At this point, the Council's objective is to coordinate an orderly transition from its research and development program for Norplant implants to widespread distribution by Leiras Pharmaceuticals, selected for the manufacture and distribution of the implants. Once this contraceptive method has been accepted and informational and training networks have been established, the Council's role is expected to diminish. Historically, efforts to introduce new contraceptive technologies into the developing world met with limited success, largely because of gaps between knowledge about the performance of a new technology and use. The Population Council is undertaking to inform decision makers and family planning program managers in the international population community and in developing countries of the advantages of Norplant implants for women who desire long-term protection against pregnancy yet do not want sterilization. An interdisciplinary project team of biomedical research and international program specialists has been established to manage and give scientific and technical support to the introduction of the implants. The regional coordinating offices will identify leading institutions in selected countries to serve as model country-level resource centers. These resource centers will provide professional trainers, develop programs for management of all aspects of training, and establish a network of trained personnel. The marketing activities of Leiras will be the primary conduit for information dissemination through private channels, while the Council will launch an information program for the public sector.
AIDS, social sciences, and health education: a personal perspective.
The acquired immunodeficiency syndrome (AIDS) epidemic has raised numerous ethical issues. Above all, it has served to highlight the fact that individual liberty always exists in a precarious balance with public interest. The invasion of privacy, loss of confidentiality, and coercive approaches proposed for testing and disclosure of infected individuals threaten to turn this into and underground epidemic. Health education is the only feasible strategy for containing the AIDS epidemic at this time, yet such efforts have been hindered by the government's reluctance to issue explicitly written materials dealing with homosexual sex practices. The need to convey accurate information is important not only to preventing further infection in the gay community, but also in limiting the likelihood of reinfection should repeated exposure to the AIDS virus prove to be of pathogenic significance. Despite government prudery, the dramatic decrease in rates of rectal gonorrhea in New York and San Francisco indicate that homosexuals are listening to appeals to practice "safe sex." In addition, self-reports on the number of sexual partners among gay men suggest that AIDS has had a chilling effect on life-style. Resolution is needed of the non-health-related problems--including confidentiality and the possible loss of job, insurance, and friends--that make it difficult or unwise to advocate widespread screening for antibody to the AIDS virus at this point.
[Oral contraceptives and metabolic changes]
Sufficient evidence has accumulated to relate oral contraceptives (OCs) to various cardiovascular diseases in which metabolic alterations play a role. Although epidemiological studies have shown OC users to be at greater risk of venous thrombosis than nonusers, blood coagulation studies of OC users have yielded conflicting results due to variations in the methodologies used, the factors studied, the different formulations and doses of OCs, and the duration of use. Moreover, no satisfactory method exists of measuring coagulability in its totality, which is the sum of the effects of individual variations in coagulation factors, fibrinolysis, and platelet function. Numerous studies have shown that OC users have increased levels of several coagulation factors, which are believed to indicate hypercoagulability and increased risk of thrombosis, but the pathogenesis of venous thrombosis is complex. Accompanying changes in the fibrinolytic system can be interpreted as attempts to equilibrate the hypercoagulability induced by OCs. Further, there is no proof that in vitro changes are related to thrombosis in vivo. The alterations appear to be dose-related, produced primarily by estrogens, unrelated to duration of use, and to disappear a few months after termination of OC use. OC users have been shown repeatedly to have elevated levels of glucose and insulin, which are especially pronounced in glucose tolerance tests. The changes vary in intensity according to the dose and progestational components and the existence of other risk factors for diabetes. Deterioration of glucose tolerance appears related to duration of OC use, but serum insulin levels maintain the same initial elevations. The estrogens have been shown to have few effects on carbohydrate metabolism in the lower doses currently used. Norgestrel has the most marked effects on glucose and insulin levels, ethynodiol diacetate has moderate effects, and norethindrone has the least effect. The combination of .15 mg levonorgestrel and 30 mcg ethinyl estradiol has no effect on oral glucose tolerance and little effect on insulin secretion. It is hypothesized that OCs affect carbohydrate metabolism by decreasing the number and affinity of insulin receptors in target tissues. The mechanisms by which OCs produce undesirable effects on the cardiovascular system are not completely understood, but are believed to be related to alterations in lipid metabolism. The majority of laboratory studies have shown that OC users had elevated levels of cholesterol, triglycerides, and the (LDL) fractions, and a diminution of the high density lipoprotein (HDL) fraction, which has antiatherogenic properties. The changes are atherogenic in nature and produce a lipid profile similar to that of men and postmenopausal women, who are at greater risk of thrombotic cardiovascular disease that premenopausal women who are protected by estrogens. .
Report of the Consultation on International Travel and HIV Infection, Geneva, 2-3 March 1987.
A consultation was convened by the World Health Organization (WHO) Special Program on Acquired Immunodeficiency Syndrome (AIDS) to consider 3 issues related to human immunodeficiency virus (HIV) infection and world travel: 1) possible HIV screening of international travellers, 2) the use of public conveyances by HIV-infected persons, and 3) the need for information for international travellers on the prevention of HIV infection. The consultation noted that International Health Regulations limit the measures that national authorities can take with respect to international travellers. It was noted that no screening program of international travellers can prevent the introduction and spread of HIV infection. In fact, such screening could divert resources away from educational programs, protection of the blood supply, and other measures to prevent parenteral and perinatal transmission. In general, the consultation concluded that HIV screening programs for international travellers should not be advocated, nor should the use of public conveyances by AIDS-infected persons be restricted given the lack of risk of transmission. Educational materials should be made available to increase the awareness of international travellers as to how HIV is transmitted; however, preventive measures against AIDS are the same worldwide, whether the individual is a traveller or not.
Taking games seriously: the primary health care exercise.
The objective of India's Primary Health Care Exercise, which recreates a small rural community, is for each family to produce enough rice crop to feed the family members, to keep them alive and healthy, and, if possible, to make a profit. To realize this objective, each farm family needs to decide how to maintain or employ the necessary labor to plant each acre, what medicines or preventive action to take to ensure full production from each laborer, the steps to be taken to prevent family increases by introducing birth control, and the purchases which might modify the environmental effects on the rice crop. These choices call for cooperation with other village families and skill to decide and negotiate production plans. All materials for this Exercise come in a box consisting of small plastic figures representing adults and children, card packs, plastic trays representing land, tokens for rice, pesticides and fertilizers, and paper money. The Exercise is designed for 20-30 players who participate as farmers; a banker, who handles the community financial dealings; a community health worker, who makes medicines available to the community; and the manager. Participants are divided into farm families with at least 2 players per farm and are given a total number of farm people and farm land based on the random draw of a card. Each farm must ensure that it has enough people to work its fields and that the land produces enough rice crop to feed all family members. There are no rules about the interaction among farms. The Exercise is played in seasons, 2 seasons constituting 1 year. During the production season, the manager generates the weather and pest attacks by turning cards. Based on these environmental factors, each farm calculates the amount of rice it has produced and then informs the banker as to how much rice it wants to sell. During the marketing season, families collect money for their rice sales or pay their deficits and make purchases which will improve their crops and their family's health. At the end of the Exercise, the manager leads a debriefing, focusing on both the reactions of individual farmers to the environmental factors and interactions with community members.
[Salpingoclasia by laparoscopy using silastic rings. Comparative analyses of 1500 cases]
2 groups of patients undergoing laparoscopic tubal sterilization by Yoon rings in the National Medical Center of the Mexican Institute of Social Security were compared. The 642 patients in group A were sterilized in 1975-77 and the 858 in group B were sterilized in 1978-83, using the same procedure. The only significant age difference in the 2 groups was in the cohort age 40-46, which included 9.5% of cases in group A and 6.6% in group B. Group B showed a significantly greater use of the IUD and condom than did group A, but its frequency of oral contraceptive use was lower than that of group A. The proportion of patients with 4 or fewer children increased from 34.7% in group A to 58.9% in group B, while the proportion with more children correspondingly decreased. 4 pregnancies occurred in each group, giving failure rates of .53% overall, .6% in group A and .46% in group B. 1 of the pregnant patients was lost to follow-up, 5 pregnancies began in the luteal phase and 2 resulted from incorrect placement of the ring. The overall rate of complications was low, 2.23% for transoperative complications and .72% for postoperative complications including infection, pulmonary thromboembolism, and salpingitis. The result of laparoscopic interval sterilization by Yoon rings is safe and effective.
201 women who sought abortion and sterilization were randomly assigned to 2 study groups to compare the incidence of psychosocial sequelae. The 1st group (95 women) had abortion and concurrent sterilization, while the 2nd group (106 patients) had abortion followed by interval sterilization 6 weeks-3 months later. 6 weeks after concurrent abortion and sterilization, 96% of the women in the 1st group were satisfied with the concurrent approach. In contrast, at 6 weeks after sterilization, only 75% of women in the 2nd group were satisfied with the interval approach. At 12 months, 2-3% of women in both groups expressed regret at having been sterilized. There was no difference in the self-perceived health status of the women in the 2 groups, nor were there any significant differences in perceived changes in menstrual patterns, marital relationships, and libido. There was a tendency for women in the 2nd group who failed to return within 6 weeks for interval sterilization to be Moslem Malays, to have a nuclear family, and to have 1 or no sons. In general, factors to be taken into account in determining whether sterilization should be concurrent or interval include whether the couple has any sons, whether the woman has thought about sterilization before the current pregnancy, and whether the husband and wife have reached agreement on sterilization.
Why people refuse to face population problems.
Many people are unable to accept the facts of population growth due to unrecognized and irrational fears. The fact is that at the present rate of growth of approximately 1% per year, the world population will double in 70 years; 9 more doublings could be achieved in 630 years. It is deep-seated fears due to a threatened sense of security that prevent many people from accepting the idea that a lower birthrate is desirable. The illusion that to control fertility is somehow dangerous to future security and morally reprehensible leads many individuals to look for some alternative which does not exist. Recognition of the need to balance births and deaths involves an acceptance of the fact of limited resources. This realization is terrifying and undermines one's sense of security. 2 commissions have warned the people of the US within the past 2 years that resources are being rapidly depleted. Subtle, psychological factors which block a rational understanding of the need to balance births and deaths are the unconscious feelings about sexual potency of impotency, projected a group of national level. A high birthrate generates a national sense of pride, and sometimes a declining birthrate is associated with decadence. The illusionary nature of this view is illustrated by the fact that those nations which have realized a balance in births and deaths are centers of progress in the modern era. Another fear which is felt about a static and aging population is the fear that other groups will outbreed one's own group. Fortunately, people have begun to realize that there is no quick and easy solution to the problems created by population pressure, and recognition of these problems is the 1st step toward a solution.
Pregnancy following minilaparotomy tubal sterilization--an update of an international data [letter]
We are pleased to note that the authors have concluded that minilaparotomy has a higher efficacy when compared with the mechanical tubal occlusion technique. However, we are disappointed to note that the authors have forgotten to mention our publications in the same Journal which also provide similar information. These articles are "Immediate sequelae following tubal sterilization" (Contraception 28:369-385, 1983) containing the experience of our study sample of approximately 32,000 female sterilizations as well as "Tubal sterilization with Filshie Clip" (Contraception 30:339-353, 1984) containing the experience of our study sample of 869 women. The net conclusion from these largescale studies conducted by the Indian Council of Medical Research supports the views of Dr. I-cheng Chi and colleagues that compared to mechanical occlusion, minilaparotomy is more efficacious. (full text)
[Birth control: psychological effects of the sympto-thermal method]
Very little research has been done on the psychological effects of the symptothermal method of fertility regulation or those of other methods, partly because of methodological problems related to the subjective nature of the problem. A list of 100 current or former symptothermal method users was supplied by a branch of SERENA, a Canadian family planning organization specializing in natural methods. The 100 couples lived in or near Drummondville, Quebec, and were mostly or all French Canadian Catholics. The husbands were primarily working class and were aged 23-58 years, with an average age of 35. The wives were aged 23-50 years and averaged 33. The couples had been married for 0-34 years. 50 women and 47 men representing 51 households returned questionnaires. 39 couples currently used the symptothermal method and had done so for an average of 5 years. 11 couples had used it in the past for an average of 3 years and 8 months. Clusters of 5-10 questions were used to assess effects of symptothermal method use in 7 areas: on the sense of responsibility, self-esteem, and disposition of an individual without regard to the spouse; on the respondent's feelings of respect, esteem, and understanding for the spouse; on the understanding, communication, cooperation, and happiness of the couple; on the relationship of the couple; on the family, social, and religious life of the couple; on the couple's love and sex life; and on abstinence (2 clusters). Few men or women reported negative effects on any question groups except those dealing with abstinence. For the most part, respondents either reported no effect of method use or a positive effect. A high proportion reported improvement in their love and sex life resulting from method use, with fewer reporting no effect. A higher proportion also reported negative effects of abstinence, but the majority of respondents reported no effect in 1 cluster of questions about abstinence and positive effects in the other. Most men and women reported that abstinence without other demonstrations of affection was more difficult. Results of the survey indicate that the negative psychic effects attributed to the symptothermal method by its critics are not based on facts, and that confidence in and enthusiasm for the method are justified.
[Clinical and biological justifications for the use of Triella]
The principal preclinical studies of the biological properties of norethisterone and the clinical research leading up to development of the low dose triphasic oral contraceptive (OC) Triella are described. Triella mimics the natural cycles of women, allowing effective contraception with a small dose of estrogen and progesterone and excellent cycle control. Preclinical studies demonstrated that norethisterone is an active progestin whose luteo-mimetic and antiovulatory activity are equivalent to those of other progestins. Unlike levonorgestrel, norethisterone shows no notable androgenic activity in experiments with rats and does not modify serum levels of SHBG in rabbits. These findings support the conclusion that norethisterone effectively inhibits ovulation without androgenic secondary effects. The increased intermenstrual bleeding experienced by early users of low-dose formulations necessitated new protocols for evaluation. Each user noted on a daily calendar whether the pill was taken or forgotten and whether "bleeding" requiring sanitary protection or "staining" not requiring protection had occurred on that day. A formulation combining 35 mcg of ethinyl estradiol (EE) and .5 mg norethisterone was effective but caused frequent intermenstrual bleeding, especially during the 2nd phase of cycles and in the 1st cycles of use. Research was then directed toward finding a multiphasic mode of administration to reduce the norethisterone dose to the lowest possible level that would be effective and still permit good cycle control. Several biphasic combinations showed bleeding in the middle of the cycle. The Triella formulation therefore contains 3 levels of norethisterone for the 21 days of treatment: .5 mg for the first 7 days, .75 mg for the following 7 days, and 1 mg for the last 7 days. The EE dose is constant at 35 mcg/daily for the 21 treatment days. Midcycle bleeding was eliminated and the frequency of late cycle bleeding was minimized. Tolerance to Triella equalled that of Ortho-novum 1/35 despite its much smaller total dose. Later studies showed that intermenstrual bleeding in the early cycles of Triella use later diminished.
A health priority for developing countries: the prevention of chronic fetal malnutrition.
A prospective study of 3557 consecutively born neonates from a lower middle class district in Guatemala City documented a 23.8% incidence of intrauterine growth retardation due to fetal malnutrition. Those infants whose weights are below the 10th percentile of a sex- and race-specific birthweight and gestational age distribution, based on a developed country population, were considered to manifest intrauterine growth retardation. Ponderal index values were then used to further classify this population as having chronic fetal malnutrition (above the 10th percentile of the standard distribution) or subacute fetal malnutrition (below the 10th percentile); the incidences of these conditions were 79.1% and 20.8%, respectively. The results of numerous studies carried out in various populations suggest that developing countries have a higher incidence of chronically malnourished infants within the intrauterine growth retardation population, while subacute fetal malnutrition is more prevalent in developed countries. Moreover, it has been shown that chronically malnourished infants do not recover from their intrauterine damage and score the lowest in mental development tests even up to school age. They remain lighter, shorter, and with a smaller head circumference until at least 3 years of age. Based on the incidence rates ascertained in this study, it can be estimated that at least 2 million infants born each year in Latin America are at risk of chronic intrauterine growth retardation. Screening programs are needed to identify at-risk mothers early in pregnancy so that medical and nutritional interventions can be implemented.
Cigarette smoking and breast cancer.
The association between cigarette smoking and breast cancer risk was investigated in a case-control study involving 1547 patients and 1930 controls identified in 1973-80 through a multicenter breast cancer screening program. A total of 47.8% of the cases and 43.4% of the controls reported ever having smoked 100 or more cigarettes--resulting in a relative risk of 1.2 (95% confidence interval, 1.0-1.4). There was little variation in risk according to whether women were current or noncurrent smokers or by number of years smoked, number of cigarettes consumed/day, and age at which smoking began. In addition, no substantial variations in risk were noted by menopausal status, and there was no support for the notion that smoking is associated with a reduced risk among naturally menopausal women (relative risk, 1.1). The data further provided no evidence that smokers experience an earlier menopause than nonsmokers. The conclusion that smoking status does not appear to affect breast cancer risk remained unaltered even after evaluation of numerous other sources of confounding and effect modification, including family history of breast cancer, weight, age at 1st live birth, and oral contraceptive use.
The influence of breastfeeding on the severity of illness in shigellosis was assessed in a case-control study involving 540 children presenting with shigellosis to a Bangladesh diarrheal disease hospital in 1980-82. The 53 cases were children under 3 years of age with severe illness (i.e., rectal temperature above 102 F, severe neurologic manifestations, or severe dehydration), while the 487 age-matched controls had non-severe shigellosis. 42% of the cases compared with 59% of controls were breastfed, yielding an odds ratio of 0.49 (95% confidence interval, 0.28-0.86). This finding suggests that breastfeeding substantially shifts the spectrum of severity in Shigella infections from severe to non-severe illness. The high degree of protection against severe shigellosis was also seen in malnourished children and in children reporting a recent history of measles. The protective effect of breastfeeding persisted even when the analysis was corrected for the confounding effects of age, nutritional status, and earlier receipt of medication. These results are consistent with data from both developed and developing countries indicating that breastfeeding reduces the severity of illness in childhood diarrhea. In Bangladesh, about 1/3 of mothers breastfeed for 3 years. In other areas of the developing world, however, breastfeeding beyond infancy is relatively uncommon. Because shigellosis accounts for substantial morbidity and mortality in developing countries, prolonged breastfeeding is recommended.
Training and utilization of traditional birth attendants.
Midwifery training for traditional birth attendants (TBAs) has reached over 600 TBAs in northeastern Brazil since the program began 10 years ago. In contrast to the general rule of rejecting the involvement of TBAs, the formal health system in this region has sought to build upon the respect these women are awarded in their communities. TBAs are being trained to recognize high-risk patients and to refer them to a hospital where they can receive more specialized care. As a link between the health post and the maternal-child population, the TBA can influence women to seek postpartum care at a facility where they can learn about child nutrition and child spacing. The essential prerequisite to any TBA training program is to gain the confidence of these women. Lectures should be short (10-15 minutes) and free of technical or medical terminology. Materials covered in the trai