[AIDS: for or against tracking down its carriers]
For some time, a debate has been occurring in Africa and elsewhere on the desirability of systematic testing of the population to identify carriers of the acquired immune deficiency syndrome (AIDS) virus. Large elements of the public demand such testing, but physicians are generally opposed, for several reasons. The different governments of Africa have followed the advice of the Physicians. Epidemiologists realize that a systematic screening is never complete or systematic except in theory; the existence of individuals whose disease escapes detection would pose a grave danger by causing a relaxation of vigilance and respect of rules for AIDS prevention. The AIDS diagnostic tests currently in use are indirect, and detect antibodies rather than the virus itself. Over 90% of individuals have a positive reaction within the 8 weeks following exposure, but persons exposed a week or 2 before testing would in all likelihood test negative. Such persons would be unaware that they were carriers able to infect others. The idea of systematic preoperative screening has also been abandoned by most surgeons because it would cause a false sense of security and relaxation of vigilance in seronegative cases, some proportion of whom would in fact be carriers of the disease. Maximal protective measures must therefore be adopted when treating any patient. A national screening effort would cause a similar relaxation of protective measures by the population, with perhaps tragic result. The decisive argument against systematic screening is economic. No African country currently has the funds to finance systematic screening, which could cost the equivalent of 10% of the national revenue of poor countries like Mali, Burkina Faso and Guinea. There is no cure to offer seropositive cases, and there is the danger that they would face isolation and discrimination from the rest of the society.
Contraceptives: break due after decade of drought.
The decade of the 1990s will not bring a product with the impact of oral contraception (OC), but birth control options are about to expand for the 1st time since the sponge was introduced in 1984. Leaders in the contraceptive establishment blame decreased funding, increased liability, along with excessive federal regulation for the putative demise of the contraceptive industry. At this time, public funding for contraceptive research and development amounts to about a dime/year for every man, woman, and child in the US. Most major pharmaceutical companies either have scaled down or scrapped their research programs. Liability problems in the contraceptive industry are public knowledge. In 1984 A.H. Robins Company began to lose lawsuits over its Dalkon Shield IUD, and late in 1987 the company was ordered to set aside $2.48 billion to pay tens of thousands of claims filed in injured women. The combined public outrage over the Dalkon Shield and the long-acting injectable form of medroxyprogesterone acetate (Depo-Provera) led the Food and Drug Administration (FDA) to intensify its resting requirements for contraceptive drugs and devices. Yet there will be an increase in the availability of clinical choices in coming years: both the IUD and the cervical cap will enter the US market in 1988; better barrier methods will be available, their development motivated by Acquired Immune Deficiency Syndrome (AIDS) and other sexually transmitted diseases; most likely long-acting steroidal contraceptives will become available as implants, injections, and transdermal patches; and incremental progress in sterilization techniques may increase the possibility of reversibility. The cooper IUD is making a comeback in the form of a T-380A, described by Dr. Howard Tatum as better than "any of the IUDs that were in use before the crisis." When the copper IUD becomes available, it will be the 1st product sold by Gyno Pharma, Inc, a new company targeting the obstetrics gynecology market. At this time, Gyno Pharma and the FDA are negotiating the product's labeling, which will specify that the ideal user is a woman over age 25 who has completed childbearing and is in a stable, mutually monogamous relationship. 2 new and supposedly reversible contraceptive methods for men have entered clinical trials, but they are not expected to be available in the US market before the 1990s, if then. High cost and unpredictable effects on subsequent menstrual cycles make the French drug RU 486 ineffective as a contraceptive when used alone, but when combined with prostaglandins this progesterone antagonist is mostly likely the best abortifacient agent ever developed.
Do family planning facilities meet the needs of the sexually active teenagers?
To increase understanding of the sexual practices and family planning needs of adolescents, a questionnaire was administered to 133 females and 10 males attending a UK high school. The students were 16-18 years of age. 70% of the males and 42% of the females were sexually active. Knowledge about contraception was cited as coming primarily from friends, followed by parents, teachers, magazines, and, lastly, physicians. 64% of the girls indicated they used contraception at every act of sexual intercourse; however, only 47% of these girls were using a reliable method. Although 58% stated they knew how to obtain contraception, 50% indicated they would be too embarassed to actually procure them. Of the sexually active contracepting teenagers, 38% get their contraceptive supplies from a pharmacy, 2% from a family planning clinic, 20% from a physician, and 20% from other sources such as hairdressers and public lavatories. It is notable that the city in which this study took place has only 1 family planning clinic that holds sessions for teenagers, despite the fact that there are 10,000 teenagers in the population. It is recommended that local health authorities set up informational centers for teenagers where they can obtain family planning counseling. Nurses and physicians with family planning responsibilities should establish regular contact with the schools. Finally, non-sexually active teenagers should be provided with support to help counteract peer pressure.
This special feature on condom promotion describes projects in Belgium, the UK, and Sweden. In all 3 areas, condoms are being aggressively promoted as part of the campaign to prevent the spread of acquired immunodeficiency syndrome (AIDS). In Belgium, where only 7% of contraceptors use the condom, the family planning association distributes condom samples with an informational leaflet for free at clinics and for sale through mail order. However, condom promotion has been hindered both by a lack of government financial support and threatened legal prosecution. In Britain, the government has participated in condom promotion efforts as part of AIDS prevention and has been instrumental in setting standards to improve the quality of condoms. In Sweden, the National Commission on AIDS funded a project in which buses toured summer vacation spots with information on condoms and free samples. Exercises on responsible sexual behavior are part of the curriculum in Stockholm high schools. In addition, conscripts in the Swedish Armed Forces are now issued a supply of condoms, both for personal use and for distribution to others as part of a campaign to defend the country against AIDS.
Problems and prospects for health services research on provider-patient communication.
The effectiveness of medical practice is largely dependent on the quality of provider-patient communication. Inputs to the provider-patient encounter include prior experience with medical care, patient objectives for the visit, patient age, type of medical problem, the number of patient concerns, and characteristics of the physician's practice setting. Outcomes linked to the communication process include patient knowledge, provider-patient congruence on problems or recommendations, patient satisfaction, patient compliance with provider recommendations, and resolution of patient concerns or symptoms. The development of interactional analysis systems for the description of provider-patient communication processes in medical encounters should permit reasonably detailed descriptive research on these phenomena. Among the problems in this area have been the lack of a theoretical base for taxonomic categories of behavior, overlapping categories, the arcane nature of many disciplinary taxonomies, and lack of rigorous operational definitions for measurements. Given the rudimentary state of development of this field, descriptive designs for research will continue to be appropriate. However, interactional analysis systems will require additional development so that provider-patient encounters can be understood as episodes of information transfer through several channels. The development of hypotheses for experimental testing of efficacy of clinical strategies for communication requires measurement of pre to postencounter change.
Egypt has successfully implemented a nationwide program of oral rehydration therapy (ORT) for acute diarrheal disease which should make a substantial impact on diarrhea-specific mortality. However, ORT alone cannot alleviate or prevent the malnutrition which commonly accompanies diarrhea. Traditional practices in Egypt result in food being withheld from children who have diarrhea, thus contributing to the vicious circle of diarrhea and malnutrition. Early and continued feeding of children with diarrhea has been shown to be effective when practiced; however, it requires specific efforts to educate mothers appropriately. This study was designed to address the operational problem of promoting the nutritional repletion of children with diarrhea. Specifically, the tasks were to design an appropriate and practical message for the education of mothers, to test its delivery through the existing primary health care (PHC) system, and to incorporate it into the nationwide program of diarrheal disease control. A baseline survey of knowledge, attitudes, and practice (KAP) of mothers and health center professionals was carried out in July 1985 in 3 areas of Egypt. A simple educational message was developed based on knowledge of existing practices, consistency with existing mass media messages, and the addition of a component specific to this project. The message was delivered through the PHC system for 3 months. No special infrastructure or training was developed; the directors of several programs in 3 governorates simply incorporated the message into their existing systems of information flow and training. A 2nd KAP survey was conducted in the same centers in December 1985. The follow-up survey indicated several significant findings. Of mothers who had attended any PHC center in the previous 3 months, 78% reported that a staff member had talked to them about feeding their child during and after diarrhea. Behavioral differences were also reported. There was a statistically significant increase in the proportion who continued to give breastmilk during diarrhea and a significant increase in ORT use. Health care providers in the follow-up survey reported giving more, and more appropriate, dietary advice. In conclusion, the PHC system, with no additional infrastructure, was able to successfully incorporate this educational component. The message has now been adopted by the mass media and other health education channels. (author's)
An investigation conducted among the Jhora Muria--a population subgroup in Bastar, Madhya Pradesh--in 1978-80 suggests that both mortality and reproductive wastage are less pronounced in villages with low levels of exogenous contact. Of the 25 villages studied, 13 were classified as more exposed and 12 were classified as less exposed on the basis of factors such as distance from the tahsil town, quality of roads connecting the village to other areas, the presence or absence of weekly market, and the presence or absence of development agencies. Pedigrees were then analyzed for 388 mothers from more exposed villages and 718 mothers from less exposed villages. Reproductive wastage per mother averaged 0.05 in less exposed villages compared with 0.10 in more exposed areas. Mortality per mother did not differ significantly between the 2 groups--0.89 in more exposed villages versus 0.82 in less exposed villages. In the more exposed villages, rural residents tend to work as daily laborers on government road construction projects. Women employed in such activities must carry heavy loads on their heads. Wages are often expended on alcohol consumption and gambling, lowering nutritional quality. In addition, there is a higher likelihood of exposure to contagious diseases and venereal diseases in the less isolated villages. In contrast, residents of the more isolated villages are engaged in cultivation as a source of income and collect forest products such as seeds, roots, tubers, fruits, and honey.
The role of health in community development.
The concept of community health should be broadened to view health as a state of physical, mental, social, and spiritual well-being. An integrated approach is required that attends to the physical and social environment, malnutrition, poverty, social deprivation, housing, work, and employment status. Despite the fact that 85% of India's population resides in rural areas, 80% of the medical care available is in urban areas. Medical care in the urban areas is moreover based on a model borrowed from Western countries that emphasizes high technology and costly treatments. This type of medical care is beyond the financial as well as geographic reach of rural Indians, who can afford to spend only Rs 5/year on medical services. More effective would be a preventive approach that addresses the root causes of the diseases that cause problems in India. Good nutrition, proper hygiene, sanitation and waste disposal facilities, healthy drinking water, prenatal care, and child health programs are all important measures that can build up resistance to disease. The costs of a preventive approach to the health care system in terms of funds and manpower are significantly less than when disease has taken hold and sophisticated hospital care is required.
Should the pill be stopped preoperatively? [letter]
We would like to confirm the comments of Mr H Sue-Ling and Professor L E Hughes on the risk of pregnancy caused by the advice to stop oral contraceptives before surgery. We have a practice of 14,000 patients and in the past year two 19 year old unmarried women have become pregnant after being told to stop the contraceptive pill before surgery. The 1st underwent a nephrectomy and the other shaving of an exostosis of the clavicle. They both conceived despite being advised to use other contraceptives until they had restarted the pill. (full text)
Population in India's development.
India's high rate of population growth has intensified social problems, especially unemployment and poverty. Future population growth will be largely determined by mortality and fertility trends. A 30% decline in mortality is projected by the end of this century; interventions have been organized around the issues of nutrition and child survival, water and health, and health-related social factors. Declines in fertility will be achieved largely through increasing contraceptive prevalence from its present level of 32% to 60% of eligible couples. There is recognition that the contraceptive mix will have to shift away from its emphasis on sterilization. It has been estimated that there must be a 3-fold increase in the number of couples using birth spacing methods--an event that will require both a reorientation of the national family planning program and changes in public attitudes toward currently available contraceptive methods. However, survey data on unmet need indicate that, if couples who want no more children and are not currently contraceptive acceptors began using contraception, contraceptive prevalence would be expanded to 2/3 of all couples. Of concern is the research finding that many couples prefer private sources of medical care to government primary health care centers. Sterilization camps have tended to be substituted for the development of high quality, routinely available, accessible health services. The preoccupation with sterilization, the mechanical fixation on targets, the poor reception given to patients, and the poor quality of services in some facilities must be addressed and local initiative must be encouraged to meet population control goals.
To establish strategies and quantifiable targets, decision makers require a better understanding of the interaction between demographic changes and development initiatives. There must be a concerted effort by demographers to identify, compile, and standardize data and to develop techniques for translating conventional population projections into projections that can be used by planners. Toward, this end, a Regional Training Workshop on Demographic Estimates and Projections in Africa was held in Accra, Ghana, in July 1985. Workshop participants came from Algeria, Botswana, the Congo, Egypt, Ethiopia, Gabon, Ghana, the Ivory Coast, Kenya, Mali, Nigeria, Senegal, Sierra Leone, Togo, and Zambia. It was reported at the workshop that, by the end of the 1980 round of population censuses, 49 of the 50 Economic Commission for Africa Member States had held at least 1 census and several had a history of data collection. The 4 principal objectives of this workshop were: 1) to train personnel to produce basic demographic estimates and projections for the purposes of social, economic, and regional planning; 2) to facilitate the sharing of problems and solutions; 3) to provide training opportunities with the latest analytic techniques and with the use of software programs; and 4) to formulate recommendations for future activities in the field of demographic estimates and projections. This document contains a detailed account of the lectures presented at the workshop. A second document (Volume 2) focuses on the quality and use of the data made available at the workshop.
The politics of abortion in Ireland.
A political analysis of the process surrounding Ireland's recent abortion amendment campaign makes clear both the complex ways in which Roman Catholic dominance is maintained and underlying forces for change. A September 1983 referendum resulted in an amendment to the constitution that reinforced the existing prohibition on abortion. The Pro-Life Amendment Campaign, launched in 1981, had the support of many prominent obstetricians and gynecologists as well as 13 national organizations. Feminist groups, which in other countries have blocked efforts to restrict abortion rights, are fragmented in Ireland and were unable to mount an effective response. Many have suggested that abortion itself was not the issue in the amendment campaign; rather, the amendment was needed to shore up the influence of the Catholic Church. The forces of modernization--urbanization, economic improvement, increasing exposure to international influence through membership in the European Economic Community, and the mass media--have contributed to weaken the dominance of the Church, especially its position on sexuality and family planning. The fact that 67% of voters supported the anti-abortion amendment represented a symbolic victory for the forces of traditional Catholicism. In the long run, it can be expected that continuing social and economic change will further undermine the hold of traditional Catholicism, with the consequences for abortion policy seen in other Western countries. On the other hand, in several of these countries abortion reform has itself given rise to highly effective anti-abortion lobbies. In the short run, liberalization of Ireland's abortion law seems unlikely without the existence of strong, united women's movement.
Abortion policy in France under governments of the Right and Left (1973-84).
Abortion rights became an issue in France later than it did in other European countries and abortion policy has been more restrictive than in neighboring countries. France's abortion law, which took effect in 1975 and became a permanent statute in 1975, permits termination of pregnancy up to the 10th week of gestation if a women is not a minor and is in a "state of distress." Abortion was not made available under the national health service until 1982. The law is unusual in that it was developed by a government of the Right, without the support of its constituency, and was almost unchanged by the succeeding Left-wing government, despite the efforts of communist and socialist politicians to amend the bill's provisions. Most striking is the way in which each side attempted to disguise or remove the contradiction between its concern to appear ideologically consistent and its desire to gain political advantage. In the 1973-79 period, deputies on the Right argued for less restrictive abortion legislation on 3 grounds: 1) the humanitarian argument that, while wealthy women could travel to another country to obtain pregnancy termination, poor women were forced to resort to unsafe back-alley abortions; 2) the legal argument that the existing law was being flagrantly violated, undermining the authority of the entire legal system; and 3) the scientific argument that abortion legislation could produce a decline in the birth rate. The limitations of the bill, particularly its time limit of 10 weeks and lack of emphasis on a woman's right to control her own body, reflected the Government's efforts not to antagonize its constituency. When the Left came to power in 1981, it did not, as expected, attempt to liberalize the abortion law. This is attributed both to a lack of public support and to concerns over France's declining birth rate (1.8/woman by 1983).
The abortion controversy: a study in law and politics.
The abortion controversy is considered in terms of the political reaction it engendered. Attention is directed to 2 aspects of the ongoing protest against the Supreme Court's 1973 decision of Roe v. Wade: the post-Roe legislation at both the state and federal levels purporting to regulate abortion through time, place and manner restrictions; and the various proposals designed to overrule Roe. Many states gave constitutional ground most grudgingly and enacted legislation in response to Roe. This strategy of "massive resistance" served at least 3 objectives of the states: to circumvent Roe by achieving indirectly what the Roe decision prohibited them from doing directly; to impress the Supreme Court with the intensity of public hostility to Roe, persuading the Court to limit Roe significantly or perhaps even reconsider it; and to create a political climate receptive to a constitutional amendment overruling Roe. These objectives have not been accomplished. Many state legislatures implemented strategies for the indirect regulation of abortion to test the Court's resolve to stand firm on Roe. The statutes have come in 2 general forms: "power investiture," the delegation to a 3rd party of the power to prevent an abortion; and "burden creation," the enhancement of the costs or risks associated with abortion, thereby reducing its appeal to pregnant women. The Supreme Court has refused to retreat from the basic principle of Roe. A significant although essentially unexplored reason for the failure of the constitutional amendment process has been the division among the opponents of the Roe decision about the most appropriate means of realizing constitutional change. Some proponents of a constitutional amendment believe that Roe could be overruled by a clarification of the term "person" as used in the due process and equal protection clauses of the Constitution or by a declaration of the moment when life begins. The prospect of accommodation on abortion standards has prompted a few amendment proposals that would require the states to enact a general ban on the performance of abortions. In 1983, Senator Orrin Hatch introduced an amendment maintaining that "A right to abortion is not secured by this Constitution." Virtually all abortion amendments proposed during the last 10 years have included a section authorizing the enactment of enforcement legislation. In sum, the alternative of constitutional amendment has not succeeded in producing a significant erosion in the rights recognized in Roe any more than the strategy of massive resistance.
The social sciences and the population problem.
"Four essentially independent conceptions of the population problem are visible in current discussions. One is derived from macroeconomics, one from microeconomics, one from the health sciences, and one from ethical concerns about the just relation between man and nature. After describing these conceptions, this paper addresses the population problem principally using the economic definitions. It cites five reasons why discussions of the economic hazards posed by population growth have become markedly less alarmist in the past decade. Failures of highly quantified input-output models to account for human progress are emphasized. The paper presents examples of how technical demography has shed light on the dimensions of and solutions to the population problem and concludes with a brief discussion of contemporary population problems in the U.S." (EXCERPT)
The authors provide an overview of the issue of abortion in the United States, including discussions of the dynamics of fertility control, the legislative history of abortion, and attitudes toward abortion. "Our overriding goal is to inform readers about abortion in the United States. By taking a concise, factual, objective approach--insofar as we possibly could--we hope to provide an understanding of the historical, moral, legal, medical, emotional, and cultural aspects of abortion in the United States." Both pro-life and pro-choice sides of the controversy are presented, and there is also a chapter containing predictions for the future of the debate. (EXCERPT)
Community action for family planning: a comparison of six project experiences.
"This study examines a number of experiments which have tried to build up community support for family planning, usually in conjunction with health and other activities, by getting the people concerned to play an active part in the planning of those activities and in the actual work of carrying them out." The study is based on six case studies conducted in India, Indonesia, the Philippines, Mexico, and Peru. It is the result of a cooperative venture involving the World Health Organization (WHO), UNICEF, the International Planned Parenthood Federation (IPPF), and the OECD Development Centre. This report is a result of a seminar held at the OECD Development Centre at which papers written by the directors of the projects concerned were presented and discussed. It consists of an overview of the projects, including information on their environment, the extent of community participation, project management, and results in the areas of health, family planning, and community empowerment. (EXCERPT)
This paper describes an experiment with a community-based contraceptive distribution system in Cheju, an island province of the Republic of Korea. The use of village-level canvassers to encourage couples to accept contraception was the principle innovation. This paper summarizes the study design, field operations, cost effectiveness, and findings on changes in contraceptive prevalence and fertility levels in the experimental area. The role of accessibility to birth control methods in these changes is also assessed. The new delivery system increased contraceptive use dramatically and lowered fertility considerably, particularly in the rural areas of the island. The cost per acceptor and per couple-years of protection in the experimental area was competitive with the national program. When the project began in 1975, Cheju had the highest fertility and lowest family planning performance in Korea. By the end of the project in 1980, Cheju ranked highest on several performance indicators and rural Cheju had lower fertility than the rest of rural Korea. The program was particularly successful in the rural areas. In the urban areas, because the program was less well implemented there, the results were somewhat less successful. (author's)
This statistical yearbook, the 11th in a series, presents statistics on the Turkish Republic of Northern Cyprus in 16 sections, including 1) climate, 2) population and vital statistics, 3) health, 4) education, 5) justice, 6) social security and welfare, 7) labor force and employment, 8) agriculture, 9) industry, 10) construction, 11) money and banking, 12) transportation and communication, 13) tourism, 14) external trade, 15) national accounts and public finance, and 16) prices. The material presented in this volume have been selected and compiled from various bulletins and periodical reports of ministries and public and private institutions of the Turkish Republic of Northern Cyprus.
Gaining people, losing ground: a blueprint for stabilizing world population.
The population explosion is no longer a prediction; it is a reality. The world increased by 87 million people in 1986, enough people to add an Akron, Ohio--238,000--every day of the year. Overpopulation produces a terrible irony: having babies produces more suffering and, frequently, more death. This year, 15 million infants will die before reaching their 1st birthday. Moreover, 1400 women die every day from the complications of pregnancy and abortion. By no later than the year 2020, the combined populations of Asia and Africa will be between 6 and 8 billion, significantly more than now inhabit the entire planet. The miseries and troubling consequences of rapid world population growth are clear. A concerted international effort to provide family planning information and the resources necessary to prevent unwanted pregnancies can improve the quality of life for millions now alive and billions yet to be born. The chief obstacle to building that effort is ignorance--ignorance on the part of Third World couples about the means and benefits of family planning and ignorance on the part of Americans and other Westerners about the threat of overpopulation. This book has been written in an attempt to reduce that 2nd ignorance. It presents clearly and concisely the facts about global population growth and its implications so that Americans can rise to the challenge.
This guide is the official catalog of the data holdings of the Inter-university Consortium for Political and Social Research (ICPSR). ICPSR provides 1) a central repository and dissemination service for machine-readable social science data, 2) training facilities in basic and advanced techniques of qualitative social analysis; and 3) resources which facilitate the use of advanced computer technology by social scientists. The Archive of ICPSR receives, processes, and distributes machine-readable data on social phenomena occurring in over 130 countries. It maintains surveys of mass and elite attitudes, census records, election returns, international interactions and legislative records. Beginning with a few major surveys of the American electorate, the holdings of the Archive now include comparable information form diverse settings and for extended time periods. The Archive contains data ranging from 19th century French census materials to the last session of the United Nations, from American elections in the 1790s to the socioeconomic structure of Polish poviats, from the characteristics of Knights of Labor Assemblies to the expectations of American consumers. Leading scholars throughout the world continually deposit surveys, aggregate data, and computer-based teaching packages in various substantive areas. The Archive contains machine-readable records of individual attitudes and social experience relevant to the full range of social science disciplines. The content of the Archive extends across economic, sociological, historical, organizational, social, psychological, and political concerns. The largest data collections are US election data, US census data, roll call votes of the US Congress, and French census data for the 19th and early 20th centuries. This guide also contains sections on the studies produced by the Criminal Justice Archive and Information Network and the National Archive of Computerized Data on Aging. This guide lists its holdings by subject. There are indexes by study number, title, and principal investigator. The subject index is a separate volume.
The United States population data sheet of the Population Reference Bureau, Inc. 7th edition.
Based on statistics and projections from the US Bureau of the Census, this chart shows various population statistics for each of the 50 states in the years 1980-1987. For each geographic region, state, and the country as a whole, the chart shows 1) population in 1987, 2) population in 1986, 3) population in 1980, 4) population change from 1986-1987, 5) population change from 1980-1987, 6) percentage of population change from 1980-1987, 7) population projected to 2010, 8) rank order of population size in 1980, 1987, and 2010, 9) total area in 1000s of square miles, 10) persons/square mile, 11) total number of births, 12) total number of deaths, 13) estimated net migration from 1980-1987, 14) black population projected to 1988, 15) dependency burden, 16) voting age population, 17) change in voting age population from 1980-1988, 18) voter participation in 1984, 19) seats in the House of Representatives in 1988, 20) average population per house seat, 21) number of electoral votes in 1988, and 22) projected seats in the House of Representatives in 1990.
The papers included in this document, originally presented in a workshop held May 24-25, 1982, address environmental influences on fertility, pregnancy, and reproductive outcomes. Participants attempted to deal with research priorities, the utility of various research strategies, methodological and design considerations in the selection of end points to be evaluated, and the contribution of animal data to human studies. This selection of papers makes it apparent that discussion covers a spectrum of chemically induced adverse health outcomes including prezygotic effects, effects during in utero exposure, as well as genetic damage induced during spermatogenesis and detected in the F1 generation. Zenick et al. deals with teratogenic studies in rodents. Lewis reviews various approaches for evaluating genetic damage in the mouse including identifying genetic mutations by scoring mice for various enzyme activities. Adams et al. describe the induction of behavioral anomalies in rats following chemical exposure during spermatogenesis. The sperm morphology studies of Wyrobek presents a technique for monitoring adverse effects in both animals and man. The studies of Omenn, Rosenberg and Halperin, Whorton, Hogue, and Scialli and Fabro summarize the status of human monitoring studies for reproductive outcomes and present examples of what has been learned from past experiences with chemicals such as dibromochloropropane. The work reported by Peters and Preston-Martin indicates childhood tumors after paternal exposure.
Demographic transition in Kerala.
On the basis of the general conceptualization of the demographic transition, in which high birth and death rates in the early periods are followed by a decline in mortality and subsequently a decline in fertility, so that population growth is very rapid only in the middle period, the Indian state of Kerala can be viewed as having just entered the final stage. For the 1st time in recent years, Kerala's decennial growth rate declined in 1971-81, from 26.29% to 19.00%, while the decline in all-India was far more modest--from 24.80% to 24.75%. Mortality declined 1st, as a result of improvements in hospital services, environmental sanitation, and hygiene. The main causal factors contributing to a reduction in the birth rate have been changes in age distribution, marital status, and acceptance of family planning. According to Bogue's index for measuring progress in attaining demographic transition, 50% of Kerala's transition was completed by 1969 and 70% by 1978. In general, many of the classical theories of demographic transition--the income approach at the macro level, the threshold hypothesis, and the Easterlin and Becker hypotheses--do not fully explain Kerala's social development. In recent decades, Kerala has not had a society based on familial production, meaning that fertility was not as high as in other developing countries. The matriarchal system moreover granted women high status. Wealth flows have traditionally been from the young to the old in the lower strata, which increased fertility levels; however, the imposition of mass education and the emergence of new, more progressive ideals in the lower strata contributed to an acceptance of the concept of family size limitation.
Socio-psychological determinants of urban fertility.
The determinants of fertility behavior in the slum and nonslum populations of Hyderabad City in South Central India are compared, with particular emphasis on social and psychological dimensions. The crude birth rate in the year preceding the survey (1980) was 20/1000 among the 240 nonslum families surveyed compared with 28.19/1000 among the 240 slum dwellers. On average, the nonslum dwellers had 2.96 live births compared with 4.49 live births for the urban slum dwellers. Multiple step-wise regression analysis was performed to estimate the amount of variance in fertility behavior that could be explained by the following independent variables: psychological correlates--value of children, son preference, infant and child mortality; modernization factors--general planning, aspiration for education of children, interspouse communication; socioeconomic status--perceived economic capacity to raise children; and demographic factors--age at marriage, duration of marriage, closed birth interval. The total variance in fertility explained by all 24 independent variables considered was 68% for slum dwellers and 52% for nonslum dwellers. Sociopsychological and demographic factors were of equal importance in predicting the fertility of nonslum dwellers, accounting for 24% and 25%, respectively, of the total variance in fertility; on the other hand, in slum dwellers, demographic factors were the prime determinants of fertility, accounting for 50% of the variance compared with only 13% for sociopsychological variables. Differentials in the duration of marriage accounted for most of the variation in fertility, particularly among slum dwellers. Among the psychological factors, differentials in value of sons and perceived ease of raising children were the predominant predictors of fertility variance among the nonslum and slum dwellers, respectively.
Cost of rearing children and fertility.
To facilitate the delineation of policy options for reducing fertility, a study was carried out in the South Central region of India on the actual and perceived costs of raising children. The sample included 600 couples, 300 from the Scheduled Caste (SC) and 300 from the non-Scheduled Caste (NSC) population. Couples' decisions regarding family size were found to be significantly influenced by the direct financial costs of raising children. The mean number of live births for respondents reporting child rearing costs of Rs 200 and under/year was 4.3 compared with 2.4 for couples whose child rearing costs were RS 1000 and above/year. Although the percentage of parents spending Rs 201 and above was higher in the NSC group than the SC group, both populations were equally influenced in their family size decisions by cost factors. Couples were further asked whether having 4 or more children involved any indirect costs such as inconvenience, problems between spouses, and financial burdens. Again, fertility was lower among couples who perceived significant indirect costs of child rearing. More than half of the sample population with 2.8 mean live births agreed that the indirect costs affected their fertility behavior compared with only 25% of the sample with 3.7 mean live births. Moreover, multivariate regression analysis of 31 variables indicated that the costs of rearing children accounted for the single largest variance in fertility among both SC and NSC respondents. The cost factor explained significantly more variance in fertility among the poorer SC population, however. Overall, these findings suggest that, to achieve reductions in fertility, policy makers should attempt to educate people about the higher cost involved in bringing up children and to provide suitable alternatives for any economic benefits that may be expected to accrue from large family size.
Blessed events and the bottom line: financing maternity care in the United States.
Payment for prenatal and obstetric care in the U.S. is presented in all its detail: demographics, sources, implications, including tables, graphs and illustrations. In the U.S., maternity care is financed by a mix of private insurance, government insurance, out-of-pocket and charitable sources. The typical pregnant woman has a family income of $20,000. Pregnancy expenses account for 20% of a year's income on average. Families having babies are more likely to be young, just starting careers, or employed in low paid, service or part-time work. 27% of hospital admissions are for delivery, yet the continuing, preventive care needed for maternity care is not the aim of most crisis-oriented health insurance plans. Increasingly, employment-linked plans are requiring co-payments and larger deductibles or do not cover maternity. Government coverage includes CHAMPAS insurance for civilian dependents of military, or 1 million women, and Medicaid insurance primarily for persons on welfare, including 4 million women. 60% of privately insured couples must contribute toward maternity expenses. 26% of women of reproductive age have no maternity coverage; many become eligible for Medicaid when they become pregnant, leaving 15% uninsured. 550,000 women deliver each year at public expense. These women are likely to be poor, black, teenage or unmarried, and also more likely to have had little or no prenatal care. While 37% of births overall are unplanned, the percentage rises to 55% of blacks, 62% of those on Medicaid, 73% of the never-married and 79% of teenagers. 27% of hospital admissions of persons of reproductive age are for delivery. The high cost of insurance is abetted by availability of expensive high technology to save high risk infants of those who do not attend prenatal care because they cannot afford insurance or care, as well as malpractice costs in obstetrics. Suggested recommendations are primarily variations on legislation to fund prenatal care for all who need it, to remove stigma felt by Medicaid recipients, to coordinate existing programs or provide a system of consistent prenatal, obstetric and infant care nationally. All these expenses are already being paid by someone, even if by charity or higher hospital costs and insurance premiums: the only new expense would be relatively inexpensive early prenatal care.
Parents' behavioral norms as predictors of adolescent sexual activity and contraceptive use.
The influence of parental factors on adolescent sexual behavior and contraceptive use has been examined previously, and findings have been contradictory. Previous US studies, which found little relationship between parental norms and adolescent sexual activity, have been limited by their failure to recognize developmental differences in the relative weight of parent and peer influences between younger and older teens and by use of selected samples, resulting in a restriction of range. The current study differs in that it utilizes a clustered sample household survey of 329 males and females, aged 14 to 17, and 470 of their parents. Using multiple regression analysis, it was found that parents' reported behavioral norms account for 5% of the variance in whether adolescents have had intercourse, and for 33% of the variance in use of contraception at last intercourse. The study suggests that while parents' normative beliefs have limited effect in the decision to become sexually active, they have considerable impact on later contraceptive use. (author's modified)
[Ultrasound control of the uterus immediately after termination of pregnancy: 144 cases]
The most feared risk of induced abortion is secondary sterility due to an infection, generally resulting from retention of ovulatory debris. A prospective study was conducted from October 1985-June 1986 of 144 women undergoing induced abortion to determine whether ultrasound examination immediately after the procedure could confirm complete evacuation of the uterus. 80% of the ultrasound examinations were conducted within 8 hours of the abortion and the remainder within 36 hours. Median sagittal, transversal, and frontal exposures were obtained. No curettage was performed unless there was certainty of retention. 96 patients were examined 8-10 days after the abortion and 48 were not. In 84 cases there was no sonographic evidence of retention. In 4 of them, there was isolated secondary metrorrhagia, in 2 there was nonretentional endometritis, and in 1 there were adhesions diagnosed on medium term follow-up. In 60 cases the evidence of evacuation was unclear. Among them, there were 7 cases of secondary metrorrhagia, 2 of partial retention, and 1 of endometritis. In 13 cases the sonogram suggested retention. The absence of an intracavity sonographic image permits the possibility of retention to be excluded, but the presence of echoes does not signify that there has been retention. Instrumental abrasion during curettage or aspiration may cause the endometrium to disappear almost completely, leaving behind sometimes significant amounts of blood which do not cause any complications before spontaneously disappearing in the days following the operation. One of the major problems of intracavity sonographic images is the difficult or impossible distinction between blood and debris. Systematic sonography immediately after abortion can lead to fortuitous diagnosis of uterine malformations, which may be of medicolegal significance in some cases. There were 2 such diagnoses in the 144 cases of this series. Routine use of sonography immediately after abortion does not seem to be reliable enough to permit prediction of complications, but it may in some cases rule out suspected retention.
Old age security and fertility behaviour: some research issues.
Data from a household survey in southern India confirm the contribution of old-age security to persisting high fertility in developing countries. The data were collected by means of a pretested questionnaire from each of the 242 households in the village where the author was doing field research. The majority of elderly in the study village were living with their own married or unmarried children, implying acceptance of a social obligation on the part of the young toward elderly parents. However, large variations were noted in the level of support received according to factors such as age, sex, presence of spouse, land holdings, and number of surviving sons. Retirement per se was unknown in the village, and all elders were involved in some productive activity: but there was a shift from hard manual labor to lighter work or supervisory duties in families with several sons, and especially in families where sons earned a steady income from urban employment. Elderly women were engaged in household work, mat making, and babysitting. When the 122 men in the sample ages 25-54 years were asked what means of financial support they expected in the future when they were too old to work, 47% identified help from children and 38% expected to reside with their adult children. Overall, it appears that in subsistence economies the inability of the majority of people in rural areas to save or invest in old age support promotes a dependence on children as a source of security in later life. If birth control programs are to be successful in such areas, they must be coupled with pension systems and old age security schemes.
The [Indian] Environment (Protection) Act, 1986.
The background, content and implications of the [Indian] Environment (Protection) Act of 1986 are summarized. The legislation grew out of an impetus generated by the UN Conference on the Human Environment of 1972, as a result of which a National Committee on Environmental Planning and Coordination was established. The Committee continued to work, recommended reform of existing laws, and was instrumental in the institution of a Department of Environment in 1980. The present, comprehensive Act empowers the central government to coordinate environmental actions of the state governments. Its terms are very broad, including all aspects of environment, not merely human health. Nowhere, however, does the statute specifically protect habitats or vegetative cover. It allows the government to set standards on environmental quality, procedures for handling materials, rules for siting industries, provide for compulsory reporting of pollution and recovery of costs of cleanup from the polluter, and allows any person to make a complaint to the courts. Critics have noted that implementation of the law is dependent of available funds and speedy court processes, both limiting factors in India.
The ways in which better prenatal, intrapartum and postpartum care of mothers in Papua New Guinea could decrease perinatal mortality are discussed. Papua New Guinea has a fairly well developed system of rural health care, with teams visiting villages monthly. Emphasis on immunization and acute treatment of children, however, often consumes workers' time so that pregnant women are neglected. Tabulations of perinatal mortality in the Port Moresby General Hospital suggest that 14 to 49% of these deaths could have been prevented. 90% of babies born in the Central Province and National Capital District were delivered in this hospital. There were 132 stillbirths at the hospital in 1985, of which 10 were considered preventable. Prematurity is a common cause of neonatal mortality at the hospital, while infection, often associated with difficult labor, is more common in the rural highlands. There are 3 essential components of good antenatal care: selection of high-risk women for institutional delivery, prophylaxis for anemia, malaria and tetanus, and management of obstetric problems. Often good nutrition, rest from hard physical labor and cleanliness will make a significant impact. Cephalopelvic disproportion frequently complicates delivery, therefore sending all small primigravidae for institutional delivery would be ideal. The most important element of postpartum care is establishment of lactation. In Papua New Guinea, cultural mores regarding sexual abstinence after pregnancy are breaking down, necessitating the introduction of modern family planning.
Neonatal care in perspective: results of neonatal care at Port Moresby.
An analysis of the causes of death in the neonatal nursery of the Port Moresby General Hospital in Papua New Guinea from 1982-1985 is presented, and conclusions were enumerated. The nursery has beds for 24 babies, subdivided into intensive care, infection and growing areas. Dormitory space for 12 mothers is available, and breast feeding is encouraged, whether by sucking, cup or tube: no bottle feeding is done. Up to 9 sisters staff the unit. A total of 2948 infants were admitted, including 831 cesarean births. 343 deaths occurred. 80 deaths were previable babies less than 1000 g. The neonatal mortality was 10/1000. The most common causes of death were septicemia or meningitis (24%), perinatal asphyxia (20%), respiratory distress syndrome (15%), congenital abnormalities (12%), meconium aspiration 7%, apnea of prematurity (7%). Other causes included pneumonia, hypothermia, intrauterine infection syndrome, cerebral hemorrhage and kernicterus. Note that hypothermia can occur in tiny babies, even in the tropics. Both respiratory distress and jaundice appear to be rare in melanesians compared to caucasians. Infections were due to tetanus, E. coli, S. aureus a Strep. faecalis, rather than the Group B hemolytic Strep. more often seen in the West. It was concluded that several inexpensive measures can be put in place to markedly enhance survival: train birth attendants to prevent perinatal asphyxia; maintain body temperature by available means; feed adequately, using expressed breast milk if necessary; maintain oxygenation properly using simple equipment such as a nasal catheter or perspex head box; prevent infection by scrupulous hand washing, cord care and overall cleanliness; manage neonatal jaundice.
Condoms are gaining in popularity in Nigeria, according to the executive director of the Planned Parenthood Federation of Nigeria (PPFN). Condom use had increased before the AIDS scare, as a result of the Male Motivation Programme which sought to increase male participation in birth control. Actual figures of numbers of condoms distributed by the PPFN are down from 142,000 in 1985 to 132,000 in 1986, because of a hitch in supplies from international donors. Condoms are sold for the nominal price of 4 for 50 kobo, or free of charge during demonstrations by organizations. A list of tips on proper condom use is given. Although condoms are known to protect against AIDS and sexually transmitted diseases, most Nigerians will only use them as a last resort. They prefer to buy antibiotic capsules from street vendors after unprotected intercourse. Hopefully the mounting AIDS epidemic will change this practice.
[Day-care anaesthesia and abortion. Comparing propofol-alfentanyl and ketamine-midazolam]
The use of propofol alone or with alfentanil in the day-case anesthesia for abortion was compared with that of ketamine with midazolam. 200 young women were assigned to 2 successive series of 2 groups each. The 4 groups were: group 1 (2 mg/kg -1 propofol only); group 2 (0.5 mg/kg -1 ketamine with 0.25 mg/kg -1 midazolam); group 3 (2 mg/kg -1 propofol with 4 mcg/kg -1 alfentanil); and group 4 (1 mg/kg -1 ketamine with 0.1 mg/kg -1 midazolam). All patients were premedicated 1 hour before anesthesia with 0.25 mg/kg -1 midazolam orally. All patients were asleep at the end of the propofol injection (60 seconds) and 10-15 seconds later for the ketamine-midazolam groups. The hemodynamic parameters did not vary much during induction with ketamine-midazolam. In the propofol groups, the heart rate remained steady, with an 8-12% fall in blood pressure. A fall of the mandible was seen in 40 and 84% of the patients in the propofol group, with a short apnea period in 32 and 48% of the same patients. Clinical recovery was very quick, less than 12 minutes for all groups. The 4 psychomotor and sensory tests were carried out at the 30th minute by 95% of the patients in the propofol groups, whereas only 50% of those in the ketamine-midazolam groups did so. Speed and quality were significantly better in the propofol groups. The most frequent adverse effect of propofol was pain during injection in 32 and 14% of patients. 6% and 18% of the ketamine-midazolam patients presented with postoperative vomiting; 18% also presented with visual disturbances. Propofol with alfentanil seemed to be well adapted to carrying out abortions on a day-case basis. (author's)
The potential for immunizing against gonadotropins without using Freund's complete adjuvant was explored in bonnet monkeys by using tetanus toxoid (TT) as carrier and Salmonella lipopolysaccharide (LPS) as adjuvant. Pure hCG beta subunit and or sheep LH beta subunit was coupled with TT by employing N-succinimidyl-pyridyl-dithio-propionate reagent. Fertile female bonnet monkeys were injected with 50 mcg gonadotropin equivalent monthly. 1 mg sodium phthalyl derivative of LPS was added to the 1st injection. Animals with low titers were also given a booster on Day 145 with Leiras adjuvant. 3 of 5 monkeys immunized with ovine beta-LH subunit bonded to TT had strong responses, and 2 produced high antibody titers after a booster with Leiras adjuvant. A 2nd group of 3 monkeys treated with both ovine beta LH and beta hCG conjugated to a common carrier, TT, showed high titers, between 750 and 1300 ng/ml, which were sustained for nearly a year. Scathard analysis indicated that the combined antigens raised antibodies of high affinity, with Ka values ranging from 5 x 10<9> to 6 x 10<10> per M. There were no cross reactions with either human FSH or TSH. 2 of the monkeys immunized against the combined antigens remained infertile for 6 and 3 cycles respectively, or until their antibody titers fell to 35 and 5 Monkeys in the 1st group also were infertile for several cycles before their antibody levels fell below 120 ng/ml against hCG.
Legislation on the health protection of children of school age.
Legislation on children's health during school ages is common in developing countries, in contrast with regulation of earlier stages in industrialized countries. Schools provide access to children, especially in developed areas such as Europe, where 90% of children are in school. School health services answer to the health minister in Spain, to the public education minister in France, to local authorities in East Germany, and to provincial governments in Canada. Decades after instituting compulsory immunization and periodic annual medical screening, recently European countries have updated their requirements. They may concentrate on high risk groups, set up ad hoc programs, institute dental clinics or emphasize preventive medicine. The Council of Europe, after a study of 19 countries in 1981, recommended that independent school health services become integrated with other identical programs. A seminar on Vaccinations in Africa, held in Niamey, Niger, in 1987 reported that immunization in Africa remains patchy. A WHO publication revealed that children in the Third World often suffer from poverty, illiteracy, homelessness, lack of health education or medical care, and may be working at an early age. UNICEF recommended after the International Conference on Primary Health Care at Alma-Ata USSR in 1978 that 1) minimum immunization be implemented; 2) health and hygiene education be provided; and 3) growth be monitored.
Public opinion and the legalization of abortion.
Variation in Canadian public approval for legalized abortion was analyzed by bivariate and multivariate methods. 341 respondents from Edmonton, Alberta answered a 6-point questionnaire in 1977. Results of the questionnaire indicated that 85-93% felt that abortion should be available to women for health or genetic reasons; 47-51% thought that abortion should be available for choice. 37% believed in abortion on demand, while 5% were totally opposed to abortion. One-way analysis of variance showed that there were no differences in abortion approval scores by the social status variables of age, gender or income. Higher education, British ancestry, dominant religious or no religious affiliation, however, were correlated with higher approval scores. The expressive variables of frequency of church attendance and values such as disapproval of married women working, or of couples remaining childless, were related to lower scores. Multivariate analysis of the status variables only predicted significantly that religious denomination and age affected approval score. Expressive variables were more powerful in predicting public opinion on abortion. Being Catholic or a frequent attender of Catholic services had no bearing on approval. Legal models of affecting change on criminal statues, and practical implications of Canadian law on abortion were discussed. Current Canadian law is considered to reflect public opinion accurately, especially since its interpretation can be controlled so broadly by local regulation by hospital boards.
Developing counseling skills in family planning: a training guide.
This manual is a set of training units for family planning counselors on refining their interpersonal skills, introduced by chapters on counseling, training and supervision in general. It was designed to assist trainers in all kinds of agencies, by allowing them to select the units and exercises they need. Each unit includes general purposes, a lecturette, several exercises, and specific evaluation materials. The counseling process is understood as skillfully enabling the client to clarify her problem, deal with feelings and concerns, and responsibly make choices. Counseling skills include active listening, contracting, paraphrasing, identifying feelings, modeling behaviors, helping initiate actions and confirming realities. Training increases knowledge but also provides practice in skills and raises awareness. The topics covered in the training units are: nonverbal communication, active listening, attitudes about family planning, reflecting feelings, asking and answering questions, structuring the counseling session, decision making strategies, dealing with anger, fear and pain, ambivalence, working with adolescents, sexuality, referral, feedback and evaluation. A bibliography on counselor training is provided.
Women and the media in South Asia.
This article gives a brief overview of women's access to journalism and communication training, status of women in the media, their needs for development of skills, and portrayal of women in the media, in Bangladesh, Nepal, Pakistan, India and Sri Lanka. 5 authors from those countries contributed sections subdivided into each of these subheadings. In India, women have access to training, but their positions in the media are limited. They are often falsely stereotyped, sensationalized or exploited, or totally absent. In Sri Lanka, however, women are closer to being equal to men, in terms of training, hiring and employment, although they tend to work in women's periodicals. Women are shown in most of the advertisements, and are generally portrayed as perpetually in pursuit of glamour, food, clothes and cosmetics. Media in Nepal are comparatively new; for example, television is only 1 year old. Therefore, opportunities for women are few, and men dominate the hierarchy. Women are portrayed in the media negatively or sensationally, and used extensively in commercials. Women's position in Pakistan is limited in the cities by purdah and in rural areas by the feudal heritage, in which women are chattel. A minority of women are enrolled in journalism schools a employed in the media: those are excelling. Women are often either idealized, abused or caricatured as interested only in consumption. Women have recently entered the journalism profession in Bangladesh, now totaling 24 women. Mores do not permit women to work at night or on outside assignments. The media are liberal in Bangladesh, airing news about dowry abuse and female oppression openly. In most of the countries, women tend to work only until marriage, or afterward are limited by domestic duties.
Women and the media in Malaysia.
The contributions of and portrayal of women in the Malaysian media are summarized here in detail. Women's access to training in journalism and education is on average better than that of men. There are 3 communications departments in institutions of higher learning in Malaysia, and all enroll more women than men, probably because of women's better language skills and desire to enter a "glamourous" profession. Women's participation in journalism, except for women's magazines, is much more limited, especially at higher levels. Women's abilities are not lacking, as shown by the number of awards Malaysian women journalists have won, but it is felt that women are not assertive, cannot work late or night shifts, cannot be transferred, because of family and domestic obligations. Perhaps journalism curricula should offer women extra courses in effective family management, public speaking or human relations, or assign cadet journalists women mentors. In Malaysia women are generally portrayed in print, electronic and advertising media as either decorative, foolish, consumption driven, or sex objects. Exploitative poses predominate in ads for male markets, such as automobiles and liquor. Sexual roles for women and girls are depicted as those of subservient or silly housewife or in other negative or traditional roles.
Women in media in the Philippines: from stereotype to liberation.
The success of women in the Philippine print and electronic media is contrasted with the negative image in which they are presented in mass media such as television, radio, comics, tabloids and magazines. Philippine women began entering journalism early in the century, becoming established in the female oriented press by the 1960s. As the repression of the Marcos regime intensified, women journalists excelled in writing vanguard pieces, using allusion, allegory, indirection or metaphor, interviewing prisoners, founding alternative newspapers and even initiating the successful boycott of the 3 major crony papers when Aquino was killed. The participation of women in television journalism is parallel, but more limited due to the nature of the medium. Women's cultural role as multi-track organizers of family, finance and work is credited for this success. Dozens of names with titles and paper names are cited, as well as tabulated in an appendix. In contrast, women's image in the popular publications and electronic media is that of sex object, victim, ideal submissive wife-mother, or gracious lady shows little evidence of improving. This deleterious, backward and inaccurate image is likely due to all-male ownership, management and profit motive of these popular, vernacular mass media.
A general introduction to the prospect of vaccines for birth control precedes a practical discussion of feasibility of several current research vaccines, including 1 that has reached preliminary clinical trials. The plausibility of using hormonal or gamete antigens for fertility control has been demonstrated in nature, when clinical infertility was recognized as due to immunological factors, and in the laboratory in animal experiments. Passive immunization has been accomplished with anti-GnRH (gonadotropin releasing hormone) in dogs, zona pellucida antigens in mice, anti-sperm antibodies, and anti-progesterone in mice. Conceivably, antibodies against some specific antigen characteristic of pregnancy would appear to be safer and more efficient, but current research on anti-hormone agents is more advanced. Hormone structures are known, they can be synthesized, and they circulate in the blood. Hormones currently successful as fertility control antigens include GnRH, FSH (follicle stimulating hormone), LH (luteinizing hormone) and hCG (human chorionic gonadotropin). Anti-GnRH is not acceptable because it lowers sex hormones, but it may be useful for precocious puberty or treatment of hormone-dependent cancers. Anti-FSH is effective in male bonnet monkeys, inhibiting sperm penetration without effecting azoospermia. Anti-LH studies in rhesus monkeys have produced infertility for up to 7 years without blocking ovulation. Anti-hCG vaccines have reached the Phase I clinical trials at 2 dose levels in 5 centers in India. The beta subunit of hCG combined with alpha-oLH linked with either tetanus toxoid or cholera toxin has been found more effective than hCG alone. In the future, birth control vaccines will be polyvalent, like prophylactic vaccines given to children today. In India, research is already underway on beta-hCG combined with hepatitis B antigen or recombined genetically with live vaccinia virus.
Structured vaccines for control of fertility and communicable diseases.
The most successful antifertility vaccines to date have been raised against the beta subunit of hCG (human chorionic gonadotropin), either a peptide derived from the last 37 amino acids, or a conjugate with tetanus or diphtheria toxoid. The difficulty with producing a vaccine against hCG, which is produced by the implanting blastocyst, is that the woman's body recognizes hCG as a "self" protein. Research has determined that the body makes highest levels and most effective antibodies against the shape or conformation of the peptide. This is probably the reason why antibodies against the carboxy terminal peptide (CTP) of hCG in several animal species were of low or variable titers, and rarely protected against pregnancy. The second approach toward making hCG immunogenic is to link the peptide with a good antigen, such as tetanus toxoid. Pure tetanus toxoid has been used on millions with low incidence of hypersensitivity, good cell and humoral immunity of long duration. The hCG-TT complex was effective on 61 of 63 women in Phase I clinical trials in India for both antibody production and prevention of pregnancy. A few pregnancies occurred when antibody titers were low. No side effects, loss of libido or disruption of menstrual cycles were reported. In baboons, offspring from immunized animals had normal developmental landmarks. Since there was some variability among individuals in antigenicity, it is likely that structured vaccines in the future should contain a mixture of antigens to offer the best protection. Preformed antibody, or passive immunity, is also being examined, for example against the zona pellucida, a distinct possibility with the availability of hybridomas or "cloned" antibodies.
[Promotion of breastfeeding through an educational program for pregnant women]
Observations among women of Latin American background living in the US and the literature on studies of breast feeding in Latin America were the main sources for an analysis of factors affecting breast feeding among Latin American women. The 2 crucial factors in the success of breast feeding are the mother's motivation and the supply of milk. The mother's motivation is affected by several secondary factors such as attitudes and beliefs, support or opposition of family and friends, employment plans, and previous experience with breast feeding. Many Latin American women in the US have beliefs impeding successful lactation, such as the belief that bottle feeding is more modern or that lactating women must exclude certain foods from the diet. Many women who prefer bottle feeding are unaware of the health and psychological advantages of breast feeding. 4 factors determine the quantity of milk: the frequency of feeding, the strength of the baby's suckling, the milk let-down reflex, and the use of hormonal contraceptives. The frequency of suckling is the most important single factor. It is influenced by the woman's knowledge of breast feeding, infant feeding practices in the hospital nursery, and the promotion of breast-milk substitutes by the hospital, the pediatrician, and others. Most of the factors affecting breast feeding can be modified through prenatal education. A series of 1-hour classes attended by 5 to 10 women were held for women of Latin American background in San Francisco. The participants, led by a health worker with good interpersonal skills, introduce themselves and state their experience and plans regarding breast feeding. The women then discuss the advantages and disadvantages of breast feeding, a process that provides support for those planning to bottle feed who may reconsider. Such women are psychologically prepared for the difficulties of the 1st few weeks of lactation and are conscious of the benefits that will come from their efforts. The discussion of alternatives should include common problems of breast feeding such as frequency, ways of combining employment and breast feeding, appropriate contraception for lactating women, what to do about inverted nipples, and countering opposition from family and friends. The information presented should be reviewed at the end of the session and the group leader should signal her availability to answer further questions.
Epidemiology of AIDS in Africa--part 2.
A recently completed study involving over 10,000 people from 6 Central African countries found seroprevalence rates generally under 1% for the acquired immunodeficiency syndrome (AIDS); however, rates were significantly higher for urban residents, prostitutes and their sexual contacts, and patients attending sexually transmitted disease clinics. The 4 major modes of transmission of AIDS in Africa are sexual contact, perinatal transmission, transfusion of infected blood or blood products, and the reuse of equipment such as needles and syringes. In 1985, a 2nd AIDS virus, human immunodeficiency virus (HIV)-2, was discovered in West Africa--a finding with important implications for epidemiologic surveillance, screening programs, and clinical diagnostic testing. Although 45 of the 50 African countries have developed concrete public health policies and strategies for the prevention and control of AIDS, most nations of sub-Saharan Africa lack the economic and social resources to implement these programs effectively. Thus, international cooperation and a commitment on the part of the US and Western Europe to provide assistance will be essential. Needs must be addressed on 2 fronts: treatment of those already infected or suffering from the disease and containment of the AIDS epidemic. Public health efforts should focus initially on high risk behaviors through health education. At the same time, it should be recognized that AIDS is not the largest health issue facing Africans, and there is a complex interaction between AIDS and other health problems such as malnutrition, genital ulcers, diarrhea, and tuberculosis. An approach to AIDS requires an expansion of public health initiatives in areas such as clean water supplies, maternal-child health programs, nutrition and immunization programs, and sexually transmitted disease clinics.
Nigeria's new population policy.
Nigeria has launched its 1st population policy, reflecting new approval on the part of policymakers of national efforts to curb population growth. Specifically, the policy seeks to reduce fertility from the present level of 6 children/family to an average of 4 children/family, suggests an optimum marriage age of 18 years for women and 24 years for men, and advocates that pregnancies be restricted to the 18-35-year range and at intervals of 2 years. US$100 million has been allocated for a national family planning program, $67 million of which is being provided by the US Agency for International Development (AID). The Nigeria program is AID's largest population program in Africa. Most of the funds will be used to bring family planning services to government-sponsored maternal-child health programs and for public education through the mass media, particularly radio. Without such an effort, Nigeria's population could be expected to double to 160 million by the year 2000.
A radio broadcasting and print material campaign aimed at supporting community-based distribution programs was conducted in rural Honduras in 1984-86. The campaign was based on a collaborative agreement between the Honduran Family Planning Association (ASHONPLAFA) and the Johns Hopkins University Population Communication Service. Specifically, the project sought to improve the technical capabilities of ASHONPLAFA's IEC Department. Workshops were held on the production of radio broadcasts and print materials, and 2 IEC staff members received intensive training in the use of the mass media in contraceptive promotion. Over 110,000 broadcasts of 14 radio spots on family planning were aired, and 7 new print materials were developed. Also established was a national radio network on family planning. During the project's duration, there was an 11% increase in the number of contraceptive users in rural Honduras. 71% of those sampled were aware that contraceptives could be obtained from family planning posts, and 93% indicated agreement that fertility control is beneficial for individual and family well-being. In addition, the IEC Department's staff developed extensive skills for the management of mass media campaigns. It is recommended that ASHONPLAFA should continue to carry out mass communication campaigns aimed at increasing family planning acceptance in rural areas.
Effective evaluation strategies and techniques: a key to successful training.
The curriculum set forth in this handbook is designed for trainers, leaders of workshops and seminars, curriculum writers, or program administrators who seek to improve their skills in evaluating classroom training. The activities and examples provided in the handbook are designed to help trainers to develop an effective evaluation system that is an integral part of training. Specific course objectives are to understand what an effective evaluation system can reveal, begin to develop evaluation standards within the training field, practice writing effective evaluations, plan how to implement evaluations, discover and correct ineffective evaluation procedures, and correlate training goals and evaluations. Evaluation is essential so that organizations can determine whether their investments in training are worth the time, money, and effort. Once it is built into the training process, evaluation is able to set ground rules, gather specific data, summarize achievements, determine learning, determine transference, and reveal areas of training effectiveness and weaknesses. The handbook's chapters contain both individual and group exercises designed to reinforce material in the text.
This document contains the curriculum for 2 5-day workshops on family planning and oral rehydration therapy that involved a total of 60 nurse-midwives in Nigeria's Anambra State. The workshop trainers were from the Program for International Training in Health. The training consisted of a series of role play exercises in which health personnel were asked to enact a provider-client interchange. Among the situations simulated were a follow-up visit for oral contraception, an annual check for IUD users, a teenage girl seeking advice on contraception, clients who complain of side effects such as heavy bleeding or decreased breast milk, a husband who objects to his wife's use of contraception, and dispelling misconceptions about family planning. Workshop participants were also given detailed instruction in how to respond to and evaluate client reports of complications of family planning methods. This trip took place from October 13-November 3, 1985.
Guidelines for disclosing AIDS antibody test results: a protocol for health professionals.
This protocol, adopted by the Acquired Immunodeficiency Syndrome (AIDS) Health Project of the University of San Francisco, sets forth principles and procedures for disclosing AIDS antibody test results. This model has been used by the staff of the Project in giving test results to over 30,000 individuals tested through the San Francisco Department of Public Health Alternative Test Sites since 1985. Health professionals who administer any AIDS antibody test should provide information about the possible social and psychological consequences of taking the test, ensure that anonymity or at least strict confidentiality is maintained, see that testing sites are accessible to all at-risk individuals, and provide emotional support and education about ways of managing the test information to prevent negative outcomes. The process of disclosing test results should seek to help the client cope with the immediate psychological reactions, manage the information, and develop a health plan. While the guidelines set forth in this protocol offer a general structure for the disclosure of antibody test results, special consideration should be given to the unique psychosocial issues for women, people of color, gay and bisexual men, and intravenous drug users. Finally, it is stressed that receiving a test result is only the 1st step in a long process and follow-up is especially critical.
Push and pull: manipulating social distance in Zairian multilingual medical consultations.
Observations of medical consultations in a variety of clinic settings in Zaire suggests that physicians use language as a tool to create social distance from patients. This is manifested in the physician's use of his higher authority to select the language that will be used for the consultation. Since language in Zaire is an indicator of ethnicity, region of origin, nationality, and socioeconomic status, it can be ranked according to a hierarchy of prestige--i.e., French, linqua francas, and the local ethnic languages. In some cases, physicians were observed to create closer social distance by using a language that both physician and patient are able to speak comfortably, selecting one's ethnic language to convey ethnic solidarity with the patient, speaking a common linqua franca, or speaking French to demonstrate common elite status. In other cases, physicians accentuated the social distance by insisting on speaking French when it was not understood by patients, communicating through a translator, or using the lingua franca even when the physician was not able to speak it well and the patient wanted to use French to indicate superior social status. It was observed that patients, too, sometimes tried to use language to negotiate social distance by initiating choice of a language different from the one initiated by the physician. Finally, there was clear evidence that the selection of language for the medical consultation influences the type and quality of communication that occurs, including the information provided by the patient. Overall, these findings indicate that physicians should develop a greater sensitivity to the cultural and social significance of the choice of language and its role in interpersonal dynamics in the provider-patient relationship.
A history and theory of informed consent.
This volume provides a historical and conceptual review of informed consent, with particular attention to the special conditions under which such consent is obtained. Topics covered by the book's 10 chapters are: foundations in moral theory, foundations in legal theory, pronouncement and practice in clinical medicine, the emergence of legal doctrine, the development of consent requirements in research ethics, the evolution of federal policy governing human research in the US, the concept of autonomy, the concepts of informed consent and competence, standards of understanding, and coercion, manipulation, and persuasion. A distinction is made between 2 concepts of informed consent--informed consent defined in terms of the conditions of a particular kind of autonomous authorization and informed consent where the nature and acceptability of effective authorizations are established by operative informed consent rules in a particular policy system. Required is a complex balancing of policy objectives, moral considerations, and the interests of various parties in the setting of consent requirements.
Condoms: the contraceptive whose time has come -- again.
Both the acquired immunodeficiency syndrome (AIDS) epidemic and the removal of the IUD from the marketplace have contributed to renewed interest in the condom as a contraceptive method. These 2 events have further coincided with increased emphasis on the part of family planning programs in male involvement. Today condoms are used by an estimated 40 million couples throughout the world and are the 2nd most widely used form of contraception. Active promotion of condom use by family planning practitioners requires the belief that this is indeed a positive, viable method. The myths that condoms are unnatural, insensitive, and unreliable are widespread even among family planning workers and must be addressed directly. Condom educators must be able to confront clients about the need either to accept that they are sexual beings and plan to be prepared for sexual encounters or to choose not to engage in unprotected sex. The concern that condom use decreases sensitivity is to a certain extent valid, but it is important to note that this decreased sensitivity occurs only after the condom is put on and many enjoyable sexual experiences take place before this point. In terms of reliability, most breakage is due to improper use. Addressing such myths through counseling an education will begin to break down some of the barriers to condom comfort among users.
Africa not interested in EEC help on AIDS.
African countries have rejected attempts by the European Commission and the World Health Organization (WHO) to promote a program to halt the spread of acquired immunodeficiency syndrome (AIDS) in Africa. To date, WHO has been notified of 2324 AIDS cases in Africa; however, this represents only a small fraction of the actual number of cases on the African continent. Africa's stance in part reflects objection to a European Commission proposal that all students from African countries should be screened for AIDS before being awarded scholarships to study in Europe. It has also been proposed that foreigners seeking residence permits obtain certificates showing they are not carrying the AIDS virus. There is a new concern that AIDS can be spread by vaccination programs for other diseases as a result of unsterilized needles. The vaccines themselves could prove fatal to children who are already harboring the AIDS virus since they would have no immunity to the vaccine. Moreover, vaccination of any type stimulates the immune system to develop change and could precipitate the onset of AIDS in infected but asymptomatic children. At present, however, mass immunization programs in developing countries will continue since present estimates indicate the risk of a child dying of 1 of the 6 major diseases covered by large-scale immunization programs is far greater than the risk of the child dying of AIDS.
Africa: frontline against AIDS.
The Panos Report, the most globally comprehensive report on acquired immunodeficiency syndrome (AIDS) produced to date, indicates there is no conclusive proof that AIDS started in Africa but shows that the problem is now more serious in Africa than in any other area of the world. It is now considered most likely that AIDS started in Haiti, Central or South America, or even in a laboratory in the US. At least 1 million Africans, largely from the central and eastern parts of the country, are expected to die of AIDS in the next decade. In some African countries, 20% of the urban population is already infected with the AIDS virus. The situation in Uganda, Tanzania, Rwanda, Zaire, and Zambia is 20-50 times worse than that in New York City, yet financial and medical resources are sorely limited. In countries such as Zaire, up to 10% of babies born are infected with the AIDS virus. Moreover, it seems increasingly likely that the AIDS virus can be transmitted from mothers to infants through infected breast milk--a finding with serious public health consequences. There is also recent concern that immunization can have serious side effects for children already infected with AIDS. In case of both breastfeeding and immunization, governments must determine whether the risks of AIDS transmission through these means outweigh the risks of discouraging these practices--both of which are essential to child health in developing countries. Screening blood is generally regarded as the best first step that African governments can take in the fight against AIDS, but outside assistance will be necessary to fund such and effort.
The effects of the low-dose oral contraceptive combination 0.150 mg desogestrel + 0.020 mg ethinyl estradiol (EE) on serum cholesterol (total cholesterol, HDL-cholesterol, and % HDL-cholesterol in total cholesterol), sex hormone binding globulin (SHBG), apolipoprotein A-I, and glycosylated proteins and plasma antithrombin 3 activity were studied in 25 healthy fertile women. Blood samples were taken before treatment and after 1, 3, 6, and 12-15 treatment cycles. The contraceptive combination had no effect on total cholesterol, glycosylated proteins, or antithrombin 3 activity. During treatment, there were small but significant increases in HDL-cholesterol, % HDL-cholesterol in total cholesterol, and apolipoprotein A-I, and a substantial increase in SHBG. Thus, the combination of 0.150 mg desogestrel + 0.020 mg EE appears to have no adverse effects on lipid metabolism, serum glycosylated proteins, and plasma antithrombin 3 activity. (author's)
Results of reversal of sterilization performed in Danish women 1978-1983.
To follow up the outcome of refertilization after female sterilization, the Danish women refertilized from 1978-83 were contacted by questionnaire, and the operative reports from sterilization and refertilization were obtained. 90% (132/147) responded. The median follow-up time was 39 months (range 18-83). 44% of the women became pregnant, 26% had livebirths, 7% had miscarriages only, and 11% had tubal pregnancies. The results of sterilization reversal by means of conventional surgery (n=101) and microsurgery with microscope or magnifying glasses (n=31) did not differ in terms of number of livebirths. Refertilization after sterilization by laparoscopic methods was more successful; 34% of these women had livebirths whereas 19% had livebirths after sterilization reversal performed by tubal resection. The predictive value of peropative tubal patency for subsequent pregnancy was 32%, whereas the prediction of no pregnancy in cases of no patency was found to be 60% correct. Postoperative hysterosalpingography (HSG) showing tubal patency was of predictive value for later pregnancy in 45%, whereas no patency by HSG gave a correct prediction for no pregnancy in 94% of the cases. In order to improve the skill of surgeons, and thus, apply the microsurgical technique to full advantage, it appears necessary to concentrate female sterilization reversal within a few department especially interested in this technique. (author's)
Evaluating family planning print materials cross-nationally: the Mexico-Nigeria experience.
The preliminary results of an evaluation conducted in Mexico and Nigeria suggest that printed materials about contraception can have an impact on clients' knowledge levels. In Mexico, community volunteers instructed women on oral contraceptives (OCs) and the IUD either with or without the use of an educational pamphlet. The results of the correct knowledge responses about OCs did not differ significantly between the experimental and control groups; in fact, in several cases the nonpamphlets group scored higher. However, these findings are attributed to inadequate implementation of the case-control study design. None of the volunteers in the pamphlet group were actually observed explaining the booklet's verbal content and only 27% were observed explaining the illustrations. Moreover, 59% of those in the control group reported they had seen the pamphlet (already in widespread use before the evaluation) before being interviewed. In Nigeria, 209 family planning clinic clients were instructed in OC and IUD use with the pamphlet and 87 clients were instructed without use of printed materials. For most questions, the proportion of correct answers of the group instructed with the booklets was 5-10% higher than the group not so instructed. More time spent with clinic clients when the pamphlet was used, and clients asked significantly more questions. Other results from both Mexico and Nigeria indicated that nurses and field workers prefer to use printed materials when instructing clients; women lie pamphlets, want a copy to take home, and will share the materials with friends and neighbors.
These 2 documents -"Acquired Immunodeficiency Syndrome (AIDS): Update 1987" and "AIDS: Availability of Health Care Overseas"--are intended to provide US State Department employees with information on what AIDS is, how it is and is not transmitted, precautionary measures that can be taken to avoid infection with the AIDS virus, tips about traveling, and the availability of health care overseas for AIDS victims. The human immunodeficiency virus (HIV) is transmitted only through sexual exposure, contact with contaminated blood, and from mother to fetus. In the US, the groups at greatest risk to become infected with HIV are homosexual or bisexual men, especially those with multiple partners, and present or past intravenous drug users. For every female victim there are 10 males. Heterosexual spread is being increasingly documented, particularly in minority populations. Education about the cause and means to prevent the spread of HIV remains the most effective strategy for the control of AIDS. The following precautions are recommended: 1) develop a mutually monogamous relationship, 2) avoid sexual contact with multiple partners or with persons who have had multiple partners, 3) do not have sexual contact with persons known or suspected to have AIDS, 4) use a condom during intercourse unless there is absolute certainty both partners are not infected, and 5) avoid all sexual activities that could cause tears or cuts in the lining of the rectum or vagina. Among beneficiaries of the State Department's health care services, there have been 29 cases of HIV infection diagnosed and 6 deaths. The State Department's AIDS screening program was prompted by the realization that overseas health care facilities are unable to provide adequate care for AIDS patients.
Monitoring of social welfare programmes: family planning perspective.
If family welfare programs are to enhance their status as either a government activity or as an effort of the voluntary sector, there must be a greater emphasis on program monitoring and evaluation. Specifically, monitoring activities must be carried out to identify program strengths and weaknesses, provide feedback on program effectiveness, appraise the utilization of manpower resources, establish priorities and targets, ensure the program objectives are being met, and verify that funds are being properly used. The monitoring process must furthermore take into account all inputs into family welfare programs, including the selection of personnel, program resources and materials, program-client interactions, and community beneficiaries. Monitoring is a continuous process with both quantitative and qualitative components. It is important in a field such as family welfare where there are often gaps between planning and implementation and a lack of flexibility on the part of bureaucratic organizations. Welfare organizations seek to meet the basic needs of large numbers of people with limited resources, pointing to a need for maximum efficiency and cost-effectiveness. An overall goal of family welfare program monitoring should be to increase the involvement of communities in planning and programming.
Nigeria's underdevelopment and economic stagnation has been linked by many to its rapid rate of population growth and high birth rate (6.34 children/family). The World Bank, a leading force in the birth control for development campaign, maintains that rapidly growing populations increase the proportion of dependent and economically inactive people in society, thereby impeding capital accumulation needed for development. However, this approach ignores the inequitable structures for the distribution of wealth in developing countries that depend on poverty for their existence. A more sensible approach to population growth in Nigeria would include increased incomes, free education, improved public health and nutrition programs, and a changed social role for women. In fact, rather than being a barrier to development, Nigeria's growing population offers a rich labor reserve for the development of the country's vast resources. The anti-birth propaganda that has pressured the Nigeria Government to adopt a population policy has served to obscure and conceal the real causes of poverty and underdevelopment--the exploitation of the country by multinational corporations. If the income gap in Nigeria is reduced and the living standards of the majority rise, people will voluntarily lower their fertility without coercive family planning programs.
New approaches to family planning programme.
India's organizational and administrative strategies for the remainder of the 7th 5-year plan family planning program have been revised to place a greater emphasis on program evaluation and efficiency. Medical Officers at India's primary health care centers will receive special training in program planning and management and a structure of incentives has been developed to encourage professional advancement based on performance criteria. Steps are being taken to improve the regular availability of the necessary supplies and equipment such as surgical instruments, contraceptives, vehicles, and audiovisual equipment. The Eligible Couples Registry will be streamlined to make it an effective instrument of program monitoring, and each functionary will receive a regularly updated roster of couples falling within his jurisdiction. Another change is increased recognition of the need for differential approaches and region-specific family planning strategies. Each state will identify groups whose family planning acceptance levels fall below the national average and design programs targeted to reach these groups. Given the large number of government, voluntary, and corporate sector agencies involved in the family planning effort, a system will be developed to coordinate their efforts and avoid duplication. At the village level, community health supervisors will be trained to serve as liaisons between family planning field workers and Medical Officers. Family planning research will receive new emphasis as a critical element for improving the quality and outreach of the national program. Highest priority will be given to operational research aimed at improving utilization of the current delivery system and identifying the most cost-effective strategies. A Management Information System will be put in place to facilitate program evaluation and monitoring.
The results of 2 open Finnish multicenter studies on the effects of 2 oral contraceptive (OC) combinations containing 0.150 mg desogestrel + 0.030 mg ethinyl estradiol (EE) and 0.150 mg desogestrel + 0.20 mg EE, respectively were comparatively evaluated, with particular attention being paid to efficacy, cycle control, and tolerance. The 2 trials were carried out by 20 independent investigators and comprised a total of 270 women, 91 of whom the 0.150/0.030 mg desogestrel/EE combination for a total of 964 cycles in the 1 trial and 179 women who used the 0.150/0.020 mg desogestrel/EE combination for a total of 2096 cycles in the other trial. In addition, the ovulation inhibiting effect of the combination with 0.020 mg EE (based on serum levels of luteinizing hormone, progesterone, 17beta-estradiol) was studied in 5 healthy fertile women. No pregnancies occurred in this study. Both combinations showed a good cycle control and were well-tolerated. There were no marked differences between 2 preparations with respect to bleeding patterns, body weight, side effects, or drug-related dropouts. The efficacy of the lowest estrogen-dose combination was substantiated by results of the hormone determinations--all 5 volunteers displayed an anovulatory treatment cycle. It is concluded that despite its lower estrogen content, the clinical use of the 0.150/0.020 mg desogestrel/EE combination is as good as that of the 0.150/0.030 mg desogestrel/EE combination. (author's)
India's 6th 5-year plan seeks to achieve a net reproduction rate of 1 by the year 1986, a goal that requires increasing the proportion of couples covered by family planning to about 60%. Although India's family planning program has achieved considerable success, it has been almost entirely woman oriented. This is demonstrated in the proportion of male to female sterilizations performed in the country. In 1983-1984, 85% of sterilizations involved females. Induced abortion is relied upon by many couples as a means of fertility control, and over 50% of abortions result from contraceptive failure. A total of 3.64 million abortions were performed in India in 1972-84. These statistics indicate that the burden of family planning rests disproportionately on females. Greater male involvement in family planning should be encouraged and will maximize chances of attaining fertility control targets.
Chlamydia screening criteria must go beyond sex partners, OC use.
Broad-scale chlamydia testing of family planning clinic populations has been advocated by public health organizations such as the Centers for Disease Control, but the criteria for such screening remain controversial. The Family Planning Council of Central Pennsylvania found the following criteria to be predictive for chlamydial infection: age under 25 years, abnormal discharge, mucopurulent exudate, and cervical ectropion. The commonly accepted risk factors of number of sexual partners, oral contraceptive use, and gonococcal infection were not significant predictors of chlamydia. A large chlamydia screening project underway in Family Planning Region X (Alaska, Oregon, Idaho, and Washington) plans to screen any patient who exhibits 2 or more of the following criteria: age under 24 years, sexually active, has multiple sex partners, has a new sex partner, has a sex partner with multiple sex partners, or uses a nonbarrier method of birth control. California researchers have devised a cost analysis to determine whether the expense of testing all patients in state-supported family planning programs for chlamydia would be offset by the cost savings involved in avoiding hospitalization and treatment of infected women suffering sequelae such as pelvic inflammatory disease. Preliminary calculations indicate that, in populations with an infection prevalence of 2% or more (most family planning clinics have a chlamydia prevalence rate of 7-10%), such screening will pay for itself. The researchers believe that a state-wide screening program in California would eliminate 33,516 chlamydia infections/year, preventing 8379 cases of pelvic inflammatory disease, 1005 surgical procedures related to that disease, 335 ectopic pregnancies, and 1760 cases of tubal infertility, for a net savings of over US$13 million.
New progestins focus on eliminating side effects.
A generation of progestins is being widely used in Europe, and experts predict these agents will eventually replace the progestins in use today. Effects on lipid metabolism have been the focus for all new generation progestins. Gestoden, sold in an ethinyl estradiol combination called Femovan or Femoden, has no effect on carbohydrate metabolism and has a biologic effectiveness 3 times that of levonorgestrel. Desogestrel, which is available in 60 countries in a combination pill known as Marvelon, has no unfavorable effects on lipid metabolism. Norgestimate also does not affect lipid metabolism and minimizes such side effects as oily skin and acne thought to be related to androgenicity. Ortho Pharmaceuticals is developing a number of specialty products using norgestimate, including long-acting delivery systems for learning-disabled women. Pellet-type systems are also under exploration and would be biodegradable. Nonetheless, oral contraceptives remain the focus of most ongoing pharmacological research given their widespread acceptance by the public and the medical profession.
Effect of postcoital contraceptive levonorgestrel (Postinor) on endometrial oestradiol binding.
24 women under 30 years of age were given the postcoital levonorgestrel contraceptive Postinor on days 14-15 of the menstrual cycle and the effect of this agent on endometrial estrogen receptors was analyzed. Also examined were the receptor values of endometrial samples from 22 controls. 7-8 days after ingestion of Postinor, the estrogen receptor concentration of the endometrium and the distribution of receptors within the cell were significantly different between cases and controls. The estrogen receptor content increased almost 4-fold; also observed were significant increases in cytoplasmic receptor values and the amount of both types of nuclear receptors. Changes were also observed in the ratio of receptors following Postinor ingestion. The rate of cytoplasmic and nuclear I receptors increased to 18% and 32%, respectively, in cases compared with values of 6% and 5%, respectively, in controls. At the same time, the rate of nuclear II receptors fell from 89% in controls to 50% in cases. These findings confirm that levonorgestrel significantly increases the amount of estrogen receptors, especially nuclear I receptors, in the endometrium. After cessation of the progesterone effect, it appears that the estrogen receptor system is capable of functioning again in the estrogen sensitive cells.
Improving contraceptive practices -- an experiment in camp settings.
The Haryana Branch of the Family Planning Association of India launched an intensive campaign in 1986-87 to promote contraceptive use in remote rural areas. Supported by a sustained IEC campaign, 22 family planning camps were established and performed over 1000 sterilizations. Cash payments or bonuses in the form of blankets and utensils were provided. The camps were staffed by teams of surgeons and operating theater personnel provided by the district health authorities. A fleet of vehicles was also supplied to transport acceptors and motivators to the camps. Numerous community organizations volunteered at the camps and made financial donations. The program was publicized through handbills, pamphlets, and banners. In addition, there were opinion leader camps, film shows, and orientation programs for women, youth, and labor leaders. There were repeated requests from the communities in the area to hold camps at more frequent intervals.
Women with cervical Chlamydia trachomatis infection have been shown to be at high risk for acute salpingitis following induced abortion. This study analyzed sera from 52 women with cervical chlamydial infection undergoing therapeutic abortion, 10 of whom developed acute salpingitis within 1 month of the procedure. Immunoblotting demonstrated antibody deficiencies in both serum IgA and IgG antibody classes. Antibodies to high molecular antigens (75Kd, 60Kd, and 57Kd) were particularly discriminating. Among serum antibodies in the IgA class, reactivity with the 60Kd was found significantly more often in women who did not develop salpingitis compared to those who developed this sequelae. This study could not determine whether the observed absence of antibody to specific Chlamydia trachomatis antigens reflected a quantitative or qualitative difference in the immune response of infected women. However, antibodies to specific antigens did not demonstrate a significant variation with serum micro-IF titers. Thus, it is concluded that antibody to specific Chlamydia trachomatis macromolecules may protect against ascending chlamydial infection.
Handbook of training evaluation and measurement methods.
This handbook provides the tools necessary for the professionals in the field of human resource development (HRD) to evaluate their programs. Using a systematic format, the handbook presents the information from a practical perspective, including examples and illustrations. It is based on actual experience, and each technique/idea has been tested and proven. The 1st part of the book outlines the importance of measurement, documenting recent trends toward measurement. The handbook's 2nd part includes the necessary steps to prepare for evaluation. It discusses useful techniques for developing a results-oriented approach in the organization as well as an 18-step results-oriented model. The chapters on evaluation design cover evaluation instruments, participant selection, the overall evaluation strategy, and program costs. The next set of chapters describe methods of data collection, presenting the most effective techniques for the collecting soft and hard data. Other topics covered include techniques for analyzing the data after collection, approaches to measuring the return on HRD, and evaluation of outside resources. The final section of the handbook deals with the management influence on both program results and communicating results. This handbook will show its readers how to: assess the attitude toward results in one's organization; define the purposes of evaluation; develop programs with an emphasis on getting results; design instruments to use in program evaluation and measurement; select the optimum evaluation strategy; determine the costs of HRD programs; compare and select the most effective and efficient data collection methods; analyze evaluation data collected from HRD programs; assign dollar values to HRD program data; evaluate the use of outside resources such as seminars, consultants, and packaged programs; improve management commitment and support for the HRD functions; get management involved in the HRD process; and communicate the results of HRD programs.
Training individuals to engage in the therapeutic process.
The development of programs to train individuals to perform psychotherapy has received little attention. Cognitive or intellectual learning care provide therapists with a theoretical frame of reference for ordering their experiences, yet it is not a basis for engaging in psychotherapy. Most essential is experiential learning, which cannot be communicated--only facilitated. This component involves the experience of acceptance and empathy, of an intense person-to-person relationship, and of the anxiety that clients can arouse. Included among the methods that can be used in a program of faciliatation of experiential learning are listening to recordings of clinical interviews, role playing exercises with pairs of students, videotaping, therapy conducted before a group, participation in group therapy, the experience of individual therapy, and a supervised practicum. The overall goal of such training is that students should develop their own orientation to psychotherapy out of practical experiences. If the result of a training program is to turn out student who have an independent and open attitude toward their own experience in working with clients, they can then continually formulate and revise their own approach to the individuals with whom they are working. To move in this direction of providing experiential training demands individuals who are not afraid to leave the security of the past and help psychology change as a profession. Also needed is a shift away from the concept of psychotherapy as a cure for sick people to a view of therapy as an interpersonal process that can release in any individual greater potentialities for dealing with life.
Coping with AIDS: psychological and social considerations in helping people with HTLV-III infection.
The psychological realities of AIDS for AIDS patients, persons with positive blood tests for the disease those with ARC (AIDS-related complex), and health care workers are explained. AIDS presents special problems because it is a new, mysterious, and fatal disease, often affecting people in their prime and usually rendering them social outcasts. For health workers, the strain is also severe because of the burden of caring for these very ill patients, dealing with the heightened emotional responses of their families and friends, and because of the workers' own fears. There are 3 types of neuropsychological reactions to AIDS: direct organic damage to the brain due to HIV virus, sequelae due to opportunistic infections, and psychological reactions to the disease. AIDS patients frequently react with anxiety, depression, guilt, or denial, and all the responses conceivable to these reactions. Health staff should evince continuing human concern and assure patients of continuity of care. People with positive AIDS tests or the ambiguous ARC disorder typically react with even more anxiety and denial, just when they should be radically altering their sexual conduct and lifestyle. Accurate information and peer support groups are vital elements for relieving this anxiety. Inserts are appended that define AIDS and related conditions, describe the epidemiology of AIDS, explain transmission of AIDS virus and antibody testing, list common opportunistic infections, recommendations for preventing the spread of AIDS, and risks for health workers.
[The impact of urbanization and industrialization on health conditions: the case of Nigeria]
Data from Nigeria suggest direct and indirect patterns of influence of urbanization and industrialization on health conditions. Nigeria's remarkable urban growth--an average annual rate of 4.7-4.9% since the 1960s--has been accompanied by a deterioration in the quality of the urban environment. 85% of urban households live in 1 room and only 14% have a flush toilet. Houses with either a shared or no kitchen dispose their effluent waste into open drains that have no gradient or outfall. 55% of urban residents deposit their refuse or garbage in unauthorized places. Environmental conditions in the cities are aggravated by industrialization, which accounted for 39% of Nigeria's gross national product in 1982. Pollution from industrial effluent and smoke, as well as from traffic emission, is a regular feature of Nigerian cities. Regression analysis indicates that overcrowding and pollution account for 17% and 12%, respectively, of the variation in infant mortality and 12% and 16%, respectively, of the variation in life expectancy. 7 variables--room density, number of hospital beds/1000 population, urbanization index, tons of solid waste generated, per capita consumption of electricity, number of petrol stations/ 10,000 population, and industrialization index--explain 40% of the variation in the distribution of infant mortality and 43% of the variation in life expectancy. While overcrowding is more important than pollution for infant deaths, pollution is more critical than overcrowding to differential life expectancy. Nigeria's population is projected to reach 169 million by the year 2000, with urban areas absorbing the majority of this growth. The incidence of overcrowding and environmental pollution will thus continue to pose an ever-increasing threat to the health of Nigerians.
The indications and contraindications for tubal sterilization are outlined, then brief descriptions of the dozen or so versions of this surgery follow. The only indication for tubal sterilization is the desire for permanent contraception. The only absolute contraindication is failure to obtain informed consent; relative contraindications are surgical risks such as a pelvic infection. Surgical sterilization may fail in 2-3 1000 cases. This is a more serious concern today than a change in attitude toward pregnancy, since in vitro fertilization is now available. The surgical techniques explained here include the laparotomy methods, Pomeroy, Irving, Kroener, and Viennese; minilaparotomy; transvaginal approaches; laparoscopic methods, electrocoagulation, thermal coagulation, rings, Hulka clips and Filshie clips; and hysteroscopic sterilization using silicone, nylon plugs or sclerosing solutions. The methods with the best combination of effectiveness, few side effects, and reversibility are laparotomy with Pomeroy technique postpartum, or minilaparotomy with the Uchida technique or laparoscopy with either bipolar electrocoagulation or mechanical occlusion with Filshie clips for interval sterilization. The choice of method should be made in consultation with the women involved.
Traditional birth attendants and perinatal and neonatal mortalities.
2000 births to 500 mothers were included in a survey on neonatal mortality, stillbirths and tetanus, in Katangi Region, Machakos Area, Kenya since 1963. The goal of the study was to determine specific steps to take in training of traditional birth attendants (TBAs) to reduce perinatal loss. The survey, conducted in 3 stages, took place in a dispensary supported by the Danish volunteer organization Mellemfolkelin Samvirke. Every 7th woman attending the prenatal clinic was interviewed. The 1st questionnaire asked for number of births and survival; the 2nd questionnaire covered specific information about children who had died before age 15; the 3d questionnaire contained about 2 dozen questions to diagnose neonatal tetanus, such as asking the mother to mimic the facial expression of the child. Preliminary results indicate that the mortality rate was 61.0/1000 live births, and the stillbirth rate was 49.0/1000. Neonatal tetanus was diagnosed in 2/1000 live births, a low rate compared to reports from other areas of Africa, but 5 times as high as the figure reported from central Kenya in 1964. It is suggested that a TBA training program include antenatal care, tetanus immunizations of pregnant women, obstetrical care, proper care of the umbilical cord and motivation for TBAs to refer high risk women to clinics.
Trainer's guide to family planning counseling.
This manual is specifically directed toward African trainers of family planning counselors, be they clinical workers, community-based distributors or village health workers. There are sections on counseling techniques, the methods themselves, and further training tips, supplemented by a glossary and cartoon-like illustrations. The emphasis is on clients' motivation, informed choice, screening, providing accurate information including countering of myths and misinformation, and follow-up. Specific interpersonal skills are described. The methods included are condom, foam and foaming tablets, natural family planning, pill, injectable, IUD and diaphragm. Each method is presented in the following aspects: client screening, advantages and benefits, disadvantages and risks, method explanation, follow-up, and myths. The final section on tips is lengthy with many practical suggest and realistic examples for attaching specific training needs with extensive use of group participation. This booklet is provided with accompanying materials for family planning workers and for the client.
[Abortion in relation to reproductive behavior and the outcome of the subsequent pregnancy]
The authors submit the results of an analysis of a group of 6166 spontaneous abortions from the Gottwaldov district (1981-83). The abortions are frequently the result of an uncontrolled reproductive cycle, in particular its onset. A total of 33.1% of the abortions recorded in the history of those women studied was an interruption of their 1st pregnancy. Very often after the abortion there is an interval of less than 6 months followed by a conception -- 47.6% in women aged 18-19 years. An increased ratio of a new pregnancy within 6 months was recorded as well in women with abortions occurring in the 3rd pregnancy. In the group of women who did not plan for the birth of another child, 61.2% of the couples did not use contraceptives, 13.2% of the women became pregnant because of failed contraception, 16.3% admitted that they had failed to use contraception, and 9.3% reported ignorance with regard to contraception. Interruption of a previous pregnancy closely before the subsequent one increased the rate of complications in the latter (although to a lesser extent than reported in some sources). The risk is more marked in some defined age groups. Results do not advocate abortion as a means to regulate fertility but should spur experts to provide better education for parenthood and more intense effort directed towards development of better contraception. (author's modified) (summaries in CZE, ENG)
The course of pregnancy and delivery and the fetal outcome of women who smoked during pregnancy (n=1751) were compared with nonsmokers (n=4937). The following variables were studied retrospectively: duration of pregnancy, maternal weight gain, mode of delivery, fetal birthweight and maturity of the newborn, Apgar scores, pH of the umbilical artery, perinatal mortality, frequency of fetal malformations, amount of amniotic fluid and the incidence of meconium staining, placental weight, and the occurrence of placental infarctions. Birthweight, fetal length, and head circumference were significantly smaller in the group of women who smoked. The incidence of babies born with low birthweights and clinical signs of prematurity, as well as placental infarctions was significantly increased in the same group. Gestational age was not different in smoking and nonsmoking gravidae. No statistical difference was found in the rate of C-sections, in Apgar scores, umbilical arterial pH, the incidence of malformations, perinatal mortality, and placental weight. Social factors were not considered in this study. (author's) (summaries in GER, ENG)
Early chorionic activity in women bearing inert IUD, copper IUD and levonorgestrel-releasing IUD.
Early chorionic activity was compared in 100 IUD users (inert device, copper IUD, and a levonorgestrel-releasing IUD) and 22 controls through measurement of the serum human chorionic gonadotropin (hCG) beta-fraction. In the control group, 7 (32%) of the 22 women had h