[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 hCG beta-fraction values indicative of chorionic activity (i.e., > 5mIU/ml). In the group of women wearing an inert IUD (Lippes Loop), 8 (20%) were positive for early chorionic activity. In contrast, the incidence of premenstrual chorionic activity signs was very low among women with medicated IUDs: 5% among acceptors of the copper IUD and zero among women in the levonorgestrel-releasing IUD group. In general, elevated premenstrual hCG values are indicative of failed implantation. The high incidence of hCG activity recorded among Lippes Loop acceptors in this study is consistent with the anti-implantation effect postulated for inert devices. In contrast, medicated IUDs appear to act by preventing rather than interrupting implantation and therefore should not be regarded as abortifacient contraceptive agents.
Intrauterine contraception: technical advances, future prospects.
A promising research area is the development of an IUD releasing both an estrogen and a progestin. Such devices may retain the favorable qualities of the progestin-only device without the concomitant increased incidence of spotting. Because of the different rates at which each hormone diffuses through polymer membranes, 2-compartment systems would be needed. Such systems are difficult and costly to produce, however. A simpler solution would be to use fibrous delivery systems wrapped around a given IUD platform. Both monolythic and sheathed fibers made of various plastic materials and loaded with progesterone or estradiol could be produced easily, with the rate of steroid delivery controlled by the length of the fibers. A related approach would be to use estrogen and progesterone-releasing fibers lying loose in the uterine cavity. Such devices would automatically solve the problems of bleeding and pain by eliminating the bulky IUD frame. To prevent frameless IUDs from being expelled, they would have to be affixed to the uterus permanently.
Iron stores in users of oral and intrauterine contraception.
To determine the existence of possible iron depletion accompanying IUD use, serum ferritin levels and current hematologic parameters after 1 decade of uninterrupted use of copper-containing IUDs were measured in 58 women and compared to values obtained from 50 women who had used combined oral contraceptives (OCs) for a similar length of time and from 50 controls who had used neither the IUD or OCs. Dietary intake of iron was not measured, but was considered adequate given the socioeconomic status of the study population. None of the subjects took iron supplements. The serum ferritin concentration was measured with an enzyme immunoassay, while hemoglobin concentration was analyzed through use of spectrophotometry. There were no significant differences between the 3 groups with regard to hemoglobin concentration or hematocrit. However, the differences in mean ferritin concentrations were highly significant (p 0.001). Mean serum ferritin concentration was 86.4 mcg/l in combined OC users, 54.5 mcg/l in controls, and 36.2 mcg/l in users of copper-bearing IUDs. Thus, it appears that long-term use of copper IUDs does decrease body iron stores significantly, without producing iron deficiency anemia. In parts of the developing world where iron stores are endemically depleted due to verminosis and nutritional deficiencies, prolonged use of copper IUDs may pose a serious health hazard.
The risky business of birth control.
Fear of product liability suits and increased insurance premiums have had a dramatic negative impact on contraceptive research. The amount spent on such research decreased by 21% in the early 1980s from the 1979 level. Because it costs up to US$45 million to develop a new contraceptive, pharmaceutical companies are focusing on modifying and refining current methods. Triphasic oral contraceptive, which release lower levels of hormones than those found in earlier generations of birth control pills, are an example of this approach. Also in jeopardy is early-stage research of new products such as biodegradable contraceptive implants. Testing for the Capronor implant, for example, has been delayed for over a year because insurance coverage cannot be obtained for the manufacturer that would supply quantities for testing in humans. Pharmaceutical firms are being forced to set aside a major portion of their profits for liability-related expenses. These developments are further expected to delay research on a male contraceptive. It is ironic that, as more US women delay childbearing, there are fewer birth control options available to them than ever before.
Cleaning surgical instruments.
Research into user experiences with the Norplant implant method of contraception and with the service delivery system is currently underway. The findings of such research will have programmatic implications for counseling, information and education, training, service delivery, and program management when the Norplant method achieves large-scale utilization. A study conducted in Brazil compared perceptions of users of Norplant and the Copper T 200 IUD. At least 86% of users of both methods evaluated their experiences as good or excellent and preferable to oral contraceptive use. The characteristic that users of both methods most disliked were alterations in bleeding patterns. A PIACT study evaluated the acceptability of Norplant implants in the Dominican Republic, Egypt, Indonesia, and Thailand. More similarities than differences were noted in knowledge, beliefs, perceptions, and attitudes among Norplant acceptors. Ease of use was cited by respondents in all 4 countries as the major advantage of this method; again, irregular bleeding was identified as the most problematic side effect. In a Family Health International Study of 2500 potential Norplant users in Nepal, Bangladesh, Nepal, and Haiti, effectiveness, reversibility, and convenience were listed as the most positive aspects of the method. However, the findings underscored the need for thorough counseling to reduce apprehension and misinformation regarding the side effects of the method and removal and insertion techniques. Finally, in a US acceptability study, 80% of respondents cited ease of use as the chief advantage of the Norplant method, while 87% expressed concerns about menstrual changes. Again, respondents expressed a need for information about the method's side effects, effectiveness, and safety.
Perforation of the postpartum uterus with an intrauterine contraceptive device.
A case of perforation of the uterus at the time of insertion of the Birnberg bow IUD in a lactating, amenorrheic woman is presented. The patient, a 25-year-old gravida 2, had the IUD inserted 2 months after delivery. Perforation occurred at the time of insertion, causing a 2 mm puncture wound in the fundus. It appeared that the perforation was caused by the expulsion of the bow from the introducer, not by uterine dilation. Although the patient's uterus appeared grossly normal and well involuted, it was extremely soft. This case raises questions about the timing of the insertion of an IUD in a lactating, amenorrheic woman. It has been commonly assumed that involution requires about 6 weeks and that lactation speeds this process. However, it is recommended that this assumption be reassessed and that insertion of any IUD be delayed until regular menses have been re-established.
A forgotten factor in pelvic inflammatory disease: infection in the male partner.
Infection by Chlamydia trachomatis has been increasingly implicated in the etiology of pelvic inflammatory disease (PID) in women. However, little attention has been given to the male sexual partners of women with the disease. This study investigated women who presented at a sexually transmitted diseases clinic with symptoms of PID as well as their sexual partners in the preceding 3 months. The criteria for diagnosing PID were lower abdominal pain with or without vaginal discharge, adnexal tenderness with or without adnexal mass, and positive cervical excitation. 58 women were diagnosed with PID and C trachomatis was isolated from the cervixes of 16 (36%) of these women. 46 (56%) of the male sexual partners of these 58 women had nongonococcal urethritis, although 36 were symptom free. C trachomatis was isolated from 10 of the 36 men cultured, 7 of whom were asymptomatic. 11 of the 58 women with positive chlamydia cultures were taking oral contraceptives compared with 7 of the 29 women with negative cultures. Only 4 patients were using an IUD. These findings indicate a high incidence of nongonococcal urethritis among the male partners of women with PID and suggest a need to trace the sexual contacts of all women who present with PID.
Searle discontinues IUD's. News release.
Given the litigious climate in the US today, the G.D. Searle Company has announced its plans to discontinue the sale of its Copper-7 and Tatum-T IUDs. The Copper-7 device is the most frequently prescribed IUD in the US. Searle maintains a position of full confidence in the safety, efficacy, and medical utility of the Copper-7 and Tatum-T IUDs. Similarly, there has been no change in the status of Food and Drug Administration (FDA) approval of these devices as safe and effective products when used in accordance with FDA prescribing information. Searle's decision to withdraw the devices from the US market was based solely on litigation that has made product liability insurance virtually unobtainable. In recent months, Searle has successfully defended the Copper-7 in 4 jury trials at a cost exceeding US$1.5 million. Women who are currently using either the Copper-7 or Tatum-T device do not need to have it removed as a result of Searle's decision to discontinue sales of these products. However, neither device should be used for more than 3 years after insertion or its effectiveness may be compromised. This action is regretted by Searle because it limits the choices of the US public in terms of birth control options.
[Descriptions of three IUD projects in China]
The Program for the Introduction and Adaptation of Contraceptive Technology (PIACT) has served as the executing agency for 3 IUD projects in China. Until recently, the stainless steel ring, which is not as effective as copper or plastic IUDs, was the most widely used device in the country. With support from PIACT, however, the Chinese-Government has introduced technologies to manufacture a plastic and copper (Copper T 220C) in China under license from the Population Council. Financial and technical assistance provided to the Tianjin Medical Instrument Corporation from 1980-83 allowed for factory renovation and the purchase of modern equipment. The Copper T 220C IUD produced at this factory is being sold in more than 20 provinces and production is expected to reach 2 million units annually. The Wuxi Medical Instrument Factory has also been converted from production of the stainless steel IUD to the Copper T 220C, and annual output should reach 2-3 million IUDs within 5 years. A 3rd project will provide modern packaging and sterilization equipment to 6 Chinese factories currently manufacturing IUDs. This will replace the current clinical practice of disinfecting IUDs at clinic sites immediately before insertion.
The copper T 380 IUD: a manual for clinicians.
This manual describes clinical procedures for the insertion of the Copper T 380 IUD, outlines guidelines for the management of side effects, and sets forth procedures for removal of the device. It is intended for clinicians already familiar with IUDs and standard gynecologic procedures. The Copper T 380, which can remain in place at least 4 years, provides highly effective protection against pregnancy as a result of its large surface area of copper and high fundal placement of copper. The Copper T 380 is inserted through use of the withdrawal technique. If pregnancy is diagnosed, the Copper T 380 should be removed given the risk of septic abortion. In 918 woman-years of use of the Copper T 380, the following statistics were recorded: pregnancy, 0.8%; expulsion, 9.2%; removal for medical reasons such as pain or bleeding, 27.5%; removal for personal reasons such as desire for pregnancy, 12.1%; and continuation of use, 50.5%. These results compare favorably to those obtained for the Copper T 200 device.
Greater clarity is needed on the questions of how human immunodeficiency virus (HIV) affects the risks and benefits of various contraceptive methods, as well as how contraceptives affect the risk and clinical course of HIV. These questions are relevant because some contraceptives can change the microanatomy and physiology of the reproductive tract, their use is often associated with changes in the incidence of certain infections and neoplasms, and steroid hormones may alter the uptake or release of certain retroviruses by cells or change retroviral replication. HIV may be stimulated by sex steroids, in which case pregnancy and use of hormonal contraception may increase HIV acquisition or accelerate the development of immunosuppression. In addition, HIV may induce enzymes that influence the metabolic pathways for contraceptive steroid breakdown, thus jeopardizing contraceptive efficacy. On the other hand, there is at this point no indication that the risks posed by hormones in terms of HIV are any greater than those from IUDs, sterilization, or abortion. There is an urgent need to develop decision trees and risk/benefit equations for the use of different contraceptives in populations with high, medium, and low risk of HIV infection when the antibody status of individuals is not necessarily known. Much of the information needed to develop these models is currently lacking and must be provided by research. The acquired immunodeficiency syndrome (AIDS) epidemic has changed several priorities in the field of contraceptive development. 1st, barrier methods need to be re-evaluated and their technology and acceptability improved. 2nd, the continuous delivery of systemic or local viricidal agents through silastic implants, vaginal rings, and IUDs should be explored. And 3rd, clinical trials of new contraceptives should include assessments of their effects on the immune system.
Infectious diseases of the female genital tract.
The volume and quality of both basic research and clinic investigation of female genital tract infections have increased significantly in the past 2 decades. Included among the major changes in studies of reproductive microbiology have been: an interest in the pathophysiology of infectious processes; the realization that many infections are polymicrobic in nature; recognition of the importance of virus, mycoplasma, chlamydia, and anaerobic micro-organisms; elucidation of a role for newly developed organisms such as Mobiluncus and papillomavirus; the use of quantitative microbiology in reproductive tract investigations; development of a better diagnostic techniques for the identification of micro-organisms and diseases; and a revolution in the availability of antimicrobial agents and in antibiotic treatment strategies. This comprehensive volume was prepared as a resource for clinicians who provide health care to women in the area of infectious diseases. Topics of the book's 20 chapters include: clinical microbiology of the female genital tract, use of the microbiology laboratory in infectious diseases, sexually transmitted diseases, pelvic inflammatory disease, toxic shock syndrome, infectious vulvovaginitis, genital mycoplasmas, chlamydial infections, mixed anaerobic-aerobic pelvic infection, postabortal infection and septic shock, wound and episiotomy infections, pelvic abscess, perinatal infections, parasitic diseases in pregnancy, premature rupture of the membranes, intrauterine infection in late pregnancy, postpartum infections, urinary tract infection, antimicrobial agents, and antibiotic prophylaxis in obstetrics and gynecology. The authors' objective in preparing this book was to provide physicians with the diagnostic and therapeutic knowledge necessary to prevent the significant morbidity and occasional mortality that occurs secondary to infections in reproductive medicine.
Physicians in the field of reproductive health care have a special interest in reducing the incidence of human immunodeficiency virus (HIV) infection in women and their offspring. The majority of women with acquired immunodeficiency syndrome (AIDS) acquired infection through needle sharing. Sexual transmission of HIV appears to be less effective than transmission of other sexually transmitted diseases. The risk of male-to-female transmission from an infected partner has been estimated at 7-21%. The risk of perinatal transmission from the infected mother to her infant is far higher, however--at least 65%. There is also evidence that the immunosuppression of pregnancy may accelerate progression to AIDS in asymptomatic HIV carriers. In the absence of a vaccine or effective treatment, prevention of AIDS requires education about safe behaviors. A sizable decrease in the rate of transmission of HIV could occur if persons considered whether their partner might be infected before initiating sexual contact. Prevention of pediatric AIDS depends on the prevention of infection in women and the prevention of transmission from infected women. Women infected with HIV should be advised to avoid pregnancy and given highest priority for family planning services. Since many infected women are asymptomatic, HIV antibody testing is the only reliable way to determine whether a woman is actually infected. Such testing, however, should be limited to women believed at risk of HIV infection. Prenatal testing, if done early, can allow more options in the management of pregnancy, yet studies have found that women with positive HIV antibody tests do not elect to terminate their pregnancies at a higher rate than women whose test results are negative.
Interpersonal skills education for primary care.
Numerous studies have found an association between patient dissatisfaction, noncompliance, and poor practitioner-patient communication. Thus, teaching communication skills is critical in the training of health care providers. The Johns Hopkins University Health Associate Program has integrated interpersonal skills instruction into the curriculum for health associates. The program seeks to help students: 1) to recognize the impact of emotions as these affect interactions with patients, 2) to analyze patient and practitioner behaviors that occur during interactions, and 3) to use effective methods for facilitating the flow of information in patient encounters. It was presumed that communication skills encompass a body of information that cannot be formulated into prescriptions for students to learn; rather, such instruction should prepare students to respond with flexibility creativity to the diverse individuals and situations they will encounter in practice. As part of the course, each student has a practice interview with a simulated patient and a feedback session. Administration of the Hopkins Interpersonal Skills Assessment instrument before and after the course indicated that students gained significant benefits, especially in the areas of organization and structure of the clinical interview, sensitivity to patients' feelings, and attention to the environment. Further follow-up indicated that students who did poorly in their interpersonal skills assessment generally performed poorly overall in clinical situations. Student evaluations of the course noted that, while stressful, the experiential aspects of the training were most beneficial.
Ghana Social Marketing Programme contraceptive and family planning training manual.
The Ghana Social Marketing Program (GSMP) has been undertaken by the Government of Ghana with the objectives of expanding family planning availability, especially the proper use of oral contraceptives (OCs), foaming vaginal tablets, and condoms. The philosophical underpinning of this effort is the belief that family size has a direct bearing on the ability of citizens to realize their potential and to have an economically stable, healthy life. At present, national law mandates that OCs can be available only with a physician's prescription. However, to expand the availability of OCs, the Government is conducting a demonstration project in which specially trained pharmacists and chemical sellers will be able to distribute OCs without a prescription. The project will be monitored to ensure that retailers are responsibly counseling clients in family planning options and distributing OCs only when appropriate. This training manual was prepared specifically for Ghanaian pharmacists and chemical sellers with the objective of providing these retailers with the knowledge they need to help customers make informed choices about modern contraceptive methods. It includes basic information on the male and female reproductive systems and the 3 methods distributed through - GSMP -- OCs, foaming vaginal tablets, and condoms. It is stressed that the effectiveness of a given contraceptive method depends in large part on the couple's correct use of that method. The manual is simply written and illustrated with charts and line drawings.
Counseling adolescents in reproductive health care settings.
Counseling adolescents in reproductive health care is difficult and requires specialized knowledge and skills. The adolescent client is often in conflict, perhaps in crisis, and needs to make immediate decisions. This handbook was prepared to impart competency in basic counseling techniques and to explain the facts of adolescent psychosexual development. Topics covered by the handbook's chapters are: adolescent development and reproductive health; generic counseling skills (communication and interviewing skills, counselor-client relationship, and structuring the counseling session); counseling the contraceptive client (assessing counseling needs and counseling model); and counseling the pregnant teenager. Counseling is conceptualized as a process that joins learned skills and knowledge with personal qualities and style. Counseling is intended to help people make decisions about issues that emerge in the course of normal development and thus does not emphasize pathology. When adolescents participate in reproductive health care programs, they are making decisions about sexuality, relationships with peers and families, pregnancy, childbirth, and childrearing. These can be overwhelming issues for adolescents because they lack experience with decision making in general and have difficulties identifying their feelings. Counseling responds to feelings, values, and attitudes, thus enabling a decision making process to occur. Although this handbook was prepared for counselors in health care settings, it can be useful to anyone who works with adolescents, including teachers.
The contraceptive behaviors of 107 sexually active black male students (mean age 18.34 years) attending a predominantly Black university were evaluated through a questionnaire distributed in personal health classes. The mean age at 1st sexual intercourse was 12.0 years. The condom was the contraceptive method most often used by subjects (41%), followed by withdrawal (20%), birth control pill (18%), rhythm (3%), douche (2%), and the diaphragm and IUD (1% combined). Overall, 85% of subjects reported using at least some method of contraception. Students ranked the condom as the most effective contraceptive method, followed by foam/jelly, the diaphragm, and rhythm. 57% of respondents reported that previous contraceptive education had had a positive effect on their attitudes. The most frequently cited reasons for contraceptive use at time of last intercourse were: too young to be a father (24%), female partner's insistence (19%), whether or not the female is on the pill (16%), and length of time the partner has been known (11%). On the other hand, the following reasons were cited for nonuse of contraception: it did not enter their mind (27%), sex should be spontaneous (22%), lack of time (17%), reductions in sensation and pleasure (16%), and lack of knowledge about contraception (13%). It is suggested that campus-wide educational activities be organized to increase knowledge about contraception, encourage condom use, publicize available community resources, and make students aware of the threat of acquired immunodeficiency syndrome.
Body weight, systolic and diastolic blood pressure, and plasma renin activity were longitudinally followed in 2 groups of oral contraceptive (OC) acceptors: 10 women who received a combination OC containing 0.150 mg levonorgestrel and 0.030 mg ethinyl estradiol and 10 women who received an OC that combined 0.150 mg desogestrel and 0.030 mg ethinyl estradiol. The study participants were monitored over a 2-year period. Most studies of use of OCs containing 0.050 mg or over of ethinyl estradiol have recorded a gradual rise in blood pressure during the 1st 2 years of use, after which systolic pressure stabilizes while diastolic continues to rise slightly. On the other hand, some studies have found that blood pressure increases are less notable when the OC contains only 0.030 mg estrogen. In this study, all 3 parameters -- body weight, systolic and diastolic blood pressure, and plasma renin activity--remained unchanged throughout the entire study period. In addition, there were no significant differences in results between the 2 different types of combined OCs. It is concluded that both the preparations tested are likely to be safer than OCs containing higher doses of estrogen and progestin.
Both epidemiological and experimental studies conducted by the author clearly indicate that methyl isocyanate (MIC) exposure can have an adverse effect on pregnancy outcome. 9 months after the December 1984 accident in Bhopal, India, in which 3270 families residing adjacent to the Union Carbide pesticide plant were exposed to MIC vapor, a preliminary survey was conducted to assess pregnancy outcomes in these households. 865 of these women indicated they were pregnant at the time of the accident. 44% of these pregnancies did not result in a live birth. Moreover, of the 486 live births, 14% of infants died within 30 days of birth. The rate of pregnancy loss was higher among women who were in their 1st trimester at the time of the accident. Similarly, exposure of pregnant mice to relatively low doses of MIC (9 and 15 ppm) for 3 hours caused complete resorption in more than 75% of the animals; a decrease in fetal and placental weights was noted at doses of 2-15 ppm MIC. There was no evidence of external malformations, although there appeared to be an increased incidence of visceral anomalies. In summary, both sets of data indicate that MIC exerts selective fetal toxicity, the exact mechanism of which remains to be established. For example, it is not clear whether the fetal toxicity is due only to effects on the mother or due to both maternal and fetal effects. The 43% pregnancy loss rate recorded in Bhopal in the post-accident period is 3-4 times higher than the normal incidence of spontaneous abortion.
Oral contraceptives and the hemostatic system.
The effect of oral contraceptives (OCs) on the hemostatic system was compared in 131 OC users and 30 controls. The estrogen doses ranged between 30-50 mcg of ethinyl estradiol or mestranol. Assays reflecting clotting (fibrinopeptide A), platelet activation (platelet factor 4 and beta thromboglobulin), and vascular enthelial damage (fibronectin) were within normal limits and did not differ between cases and controls. On the other hand, plasminogen, prekallikrein, and protein C hemostatic parameters (protective against clotting) were above the normal range in OC users (120% higher) and significantly higher than in matched controls. Further analysis indicated that antithrombin levels were significantly lower in women with a family history of thromboembolism, while fibrinogen and fibronectin levels were significantly higher in obese OC users; however, there were no manifestations of activated hemostasis in either group. Overall, these findings provide no evidence for the claim that OC use is associated with hypercoagulability. However, it is recommended that a family history of thromboembolism should be included among the questions routinely asked before OC use is initiated. It is hoped that future research will improve the ability to detect the small number of OC users who will suffer thromboembolism.
Southeast Asian folklore about pregnancy and parturition.
Since 1975, over 600,000 refugees from Laos, Vietnam, and Cambodia have emigrated to the US, posing a special challenge to the US health care system. To obtain more information on traditional beliefs regarding pregnancy and delivery, 363 Southeast Asian women attending the prenatal clinic at the Phanat Nikhom refugee camp in Thailand in 1984 were interviewed at least twice during their pregnancy. Through the interviews, a list was compiled of customs and beliefs adhered to by at least 75% of respondents. Harmony with nature, dualistic concepts of disease, and pathogenetic metaphor were central features of these beliefs. Pregnant and postpartum women, according to traditional beliefs, must be protected against wind, loss of heat, and poisons. Widely accepted rules about the mother's position during labor (e.g., lying on her side with a pillow) and after delivery (e.g., strict bed rest without a pillow) are directed at controlling the loss of heat, vital fluids, and blood. Southeast Asian women are unwilling to put their infant to the breast until their milk comes in because they believe this will further deplete the mother's vital heat and fluids at a vulnerable time. The mother must only consume foods that are classified as not or warm. These beliefs account for the reluctance on the part of Indochinese women to accept common Western obstetrical practices such as pelvic examination, dietary manipulation for gestational diabetes, and frequent venipuncture for laboratory analyses. The Indochinese refugee woman's reticence and respect for authority can interfere with physician-patient communication, further exacerbating the situation. Given the large number of Indochinese refugees in the US, it is important for Western-trained health care personnel to familiarize themselves with the belief systems of Southeast Asian cultures.
Individual migration as a family strategy: young women in the Philippines.
Women from the Philippines show higher rates of rural-urban migration than men; moreover, Philippinas are more likely than men to migrate as teenagers, well before marriage. Data from 2 surveys--the National Demographic Survey conducted in 1973 and the Status of Women Survey conducted in 1076--suggest that the decision to migrate and migration patterns are generally determined by family resources and needs rather than by individual factors. Half of the female residents of Manila have migrated from rural areas, and the majority of these women arrived in the city at ages 15-24 years. A path analysis indicated that the 2 family variables that most predict female migration between the ages of 15 and 24 years are the prestige of father's occupation (negative effect) and the number of siblings (positive effect). Even after controlling for birthplace and education, relatively more young female migrants are found in wage occupations than self-employment or family services. The types of occupations held by women in Metro Manila are further contingent on migration status, with migrants more likely to be employed in nonprofessional, low paying service jobs. To compensate for their relatively low wages, migrant women work longer hours than their non-migrant counterparts (47-51 hours/week compared with 44 hours/week, respectively). In general, a family will send a migrant if there is a need for additional or more steady income, if the expectation that migration will confer economic benefits is reasonably high, and if the opportunity costs associated with migration are low. In the Philippines, daughters seem to be preferred over sons as migrants for several factors, including a higher valuation of the work of sons at home on the farm or in rural craft manufacturing, the nonseasonality of female urban employment, and the greater likelihood that daughters will share their earnings with family.
Looking beyond oral rehydration therapy.
Oral rehydration therapy (ORT) is a simple, effective, and cost-effective means of increasing child survival in developing countries; however, any lasting impact on diarrheal diseases requires preventive measures as well as treatment. Programs that have be found to decrease the incidence of childhood diarrhea include breastfeeding promotion, immunization against measles, improvements in the water supply, and education about the importance of hand washing. Many developing countries need not only preventive programs, but also an adequate infrastructure for delivering primary health care. Given the increase in the number of urban shanty towns and the accompanying unsanitary living conditions, an innovative approach to urban primary health care is a priority. Moreover, any crash programs of health education in the mass media must be coordinated with other activities in health so that the message can be reinforced. Since most countries have a better infrastructure in education than in health, school teachers and school children are often a more effective means of changing behavior in traditional communities than the mass media.
Age estimation from the number of teeth erupted.
Accurate determination of age is essential for demographic analysis but often difficult to obtain, particularly in developing countries. A tendency to overestimate the age of young children results in excess proportions in the 5-9 year age group and a relative deficit of population at 0-4 years. It is argued that the eruption of the deciduous teeth offers an excellent independent measurement of age because it is immune to social and economic influences and displays a relatively small variance. To work from a knowledge of age of eruption of teeth to an estimate of age based on number of teeth erupted, it is necessary to express the probability of being between the eruption of the nth tooth and the (n+1) th tooth as a function of age and find the age which maximized this function or each "n" between 0 and 10. The shape of the distribution of number of teeth by age changes with age, being positively skewed in the early ages by early starters and negatively skewed at later ages by the late finishers. The methods developed in this study produced 10 sets of age estimates, and investigators can select the alternative that corresponds most closely to the race of the population under study. From the chosen age table, an age estimate for a child with a particular number of teeth, and an age distribution for a number of children with that number of teeth, can be read quite simply. Although African populations show a faster growth pattern than Asian and European populations in terms of teeth eruption, the general similarity of the pattern of development is clear and the differences may not be significant.
The results of a survey conducted of projects funded by Family Planning International Assistance (FPIA) indicate that, during 1986, FPIA was involved in over 100 projects in 34 countries that provided contraceptive services to more than 1.5 million clients. FPIA-assisted projects in Asia and the Pacific accounted for 39% of the caseload, followed by Latin America with 32% and Africa with 29%. Although the number of clients served increased by 8% between 1985 and 1986, the number served in Africa increased by 78% in this time. The types of contraceptives selected by new clients in 1986 were: oral contraceptives, 45% condoms, 21% sterilization, 15%, and IUD, 9%. 11 projects in 6 countries reported providing natural family planning services. 24 projects in 12 countries performed 88,273 voluntary sterilizations; only 8% of these procedures were vasectomies. The cost to FPIA per client provided with contraception was US$4.93 compared to $5.64 in 1985. The lowest cost per client was in Africa ($4.36), where there is a large-scale income-generating contraceptive distribution project. In addition to the provision of family planning services, FPIA trained 26,341 individuals associated with 72 projects. Since 1971, FPIA has provided more than 230 million cycles of oral contraceptives, almost 1 billion condoms, and over 11 million IUDs to 3100 institutions in over 100 countries.
A survey of 1016 children under 5 years of age, randomly sampled, was carried out in Sao Paulo, Brazil, with a view to studying the epidemiology of health conditions. In this survey, the prevalence and duration of breastfeeding was especially noted. Although the majority of infants were initially breastfed (92.8%), less than 1/2 were still being nursed at 4 months, only 18.8% at 12 months, and 10.7% at 24 months. The median duration of breastfeeding for the city of Sao Paulo was estimated to be 109.25 days. As far as exclusive breastfeeding is concerned, the median duration decreased 62.85 days. When the sample was stratified according to socioeconomic status, the breastfeeding rates (total or exclusive, as medians) are higher on the highest socioeconomic level, an unusual situation in developing countries. The comparison of data from the 1984/85 survey with that from the 1973/74 and 1981 surveys shows an evident trend towards breastfeeding and in San Paulo. This trend is similar to that seen in developed countries during the 1970s, especially for those in the highest socioeconomic bracket and documented for other great urban conglomerates of the 3rd world. Although the trend can be considered incipient since many infants are still weaned early, it seems that this trend toward bottlefeeding in urban communities in the 3rd world is not irreversible. (author's modified) (summary in ENG)
To determine the extent of husband's opposition as a barrier to contraceptive use among women in Bangladesh, 58 focus group discussions were conducted in 23 villages in the Matlab upazila in 1986. The sessions were held both in villages in which the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) maternal-child health program was operative (treatment areas) and not operative (comparison areas). Despite the persistence of a patriarchal social structure in Bangladesh, the group discussions revealed much husband-wife joint decision making in family planning and, occasionally, a woman's decision to use contraception (usually an injectable method) without the knowledge of her husband. The breakdown of joint families dominated by the mother-in-law appears to have enhanced intimacy between husbands and wives, facilitating mutual decision making. ALthough women in these groups did not differ from men in terms of the number of children desired, women were more likely to advocate longer intervals between marriage and the 1st birth and between subsequent births. Where opposition to family planning was voiced by husbands, it was due to concerns about the monetary costs of contraceptive side effects than to a difference in attitudes about family size. Although not quantified, opposition to contraception among men seemed to be greater in the comparison than treatment areas and there were more cases of gradual conversion to the wife's point of view in group discussions in the treatment areas. This trend appears attributable to 3 attributes of the treatment areas: 1) the higher level of knowledge of contraception women in the treatment areas developed through their contact with trained workers, enabling them to refute many of their husbands' claims; 2) follow-up services for contraceptive side effects, making them less severe; and 3) the higher status of women in treatment villages resulting from the visibility of female program workers.
A prospective study was conducted in New Zealand to assess fertility and pregnancy outcome after the removal of copper IUDs. Over a 4-year period, there were 887 IUD removals for reason of desiring pregnancy and 164 IUD removals due to complications of the device available for analysis. The sample included 375 (36%) nulligravidae and 676 (64%) gravidae. The majority of the complicated removals were for pain and/or bleeding. By the end of the 4-year study period, 92% of the nulligravidae and 96% of the gravid women had conceived. Of the 97 women who failed to conceive within this time, the cause was know for 22 (24%) and included ovulatory failure, low sperm count, blocked fallopian tube, and endometriosis. Analysis of women who had had the IUD in place for 2 years or more revealed no significant reduction in fertility or increase in ectopic pregnancy at 2 years, but there significant increase in miscarriage rates among gravid women who were longterm IUD users. In addition, at 1 year, there were no significant differences between women who had their IUD removed to conceive and those who had the device removed because of complications in terms of fertility, ectopic pregnancy, miscarriage, or preterm delivery rates. These results provide further support to the assertion that IUD use does not impair future fertility. The majority of the conceptions in this study (61%) occurred during the 1st 3 months after IUD removal.
A twin study of the psychiatric side effects of oral contraceptives.
To investigate the etiologic role of genetic factors in oral contraceptive (OC)-related depression and irritability, 715 monozygotic and 416 dizygotic twin pairs concordant for OC use were questioned. For all 6 side effects surveyed (weight gain, nausea, irregular cycles, edema, depression, and irritability), the tetrachoric correlation was higher in monozygotic than dizygotic twins. Biometrical genetic analysis indicated that liability to OC-related depression was clearly influenced by genetic but not familial-environmental factors; similar, but less definitive results were obtained for OC-related irritability. Multivariate genetic analysis indicated that both the genetic and individual-specific environmental factors that influenced susceptibility to OC-related depression and irritability were largely distinct from those that influence baseline levels of psychiatric symptoms. That is, the genes that influence liability to these side effects appear to differ from those that are etiologically important in baseline psychiatric symptomatology. Psychiatric side effects are among the most commonly reported problems associated with OC use.
Women who regret their sterilization: developmental considerations.
Retrospectively collected interview data from 26 women requesting reversal of sterilization at a New Zealand hospital suggest some women seek sterilization as a solution to problems that are not contraceptive in nature, leading to regret at a later point. The average age at sterilization in this sample was 24.6 years, while the average age at time of psychosocial assessment for this study was 30.9 years. The women had 1-5 living children (average of 2.8). 23 women indicate they had been suffering from significant anxiety or depressive symptoms at the stage of their lives when they were sterilized, and 12 reported they were being physically abused by their husband. Major life events such as pregnancy or bereavement preceding sterilization featured frequently in the histories of these women. For most subjects, sexuality had been an problematic area in adolescence, resulting in unwanted pregnancies and unplanned marriages. The decision to be sterilized tended to occur in response to intrapsychic and interpersonal stresses that had little relationship to fertility, but rather reflected immature ways of coping with conflicts about autonomy, self-esteem, and dependency. A recurring process was noted in the case studies of these 26 women in which the sterilization procedure was followed by the termination of a destructive marriage and a newfound ability to cope with single parenting and the responsibilities of adult life. This in turn generated an ability to establish more healthy intimate relationships and a re-evaluation of their ability to handle more children. The majority of subjects were in a new marital relationship at the time of their request for sterilization reversal. Only 2 of the women felt they had received adequate counseling at the time of their request for sterilization. Better understanding of female psychosocial development should reduce the frequency with which some women seek an inappropriate surgical solution to a psychosocial problem.
The health guides scheme in Belgaum and Gulbarga districts: an evaluation.
A primary health care (PHC) program in India, the Health Guides Scheme, utilizing volunteer workers selected by and from individual communities and trained in a government health institution, was studied in the Belgaum and Gulbarga districts of Bangladore. From each of 10 PHC facilities, 10 health guides working in 10 different villages were interviewed and information was collected with the help of a questionnaire. Using further questionnaires, 4 community members from each of the 10 villages and 5 or 6 health personnel working in the PHC area were also interviewed. The age criterion (30 years) for engaging guides seemed not to be practicable, and the study revealed that there were only 11 women out of the 102 total guides interviewed. 92 of the 102 guides were found having middle school education or above. Review committees were found to be totally absent, while proper selection process for guides was found to be fulfilled in nearly 75% of villages studied. The Health Guides Scheme seems to have created a favorable impact on communities and should be extended. Training periods should be increased, and types and quantities of medicines used should be examined and suitably changed.
Fertility and family planning in the Dakshina Kannada district, Karnataka, India.
A study was conducted in the Dakshina Kannada district of Karnataka, India, to investigate birth rates, proportions of couples with wives of child-bearing age practicing family planning, and reasons for nonacceptance of family planning. The study covered 3001 households in both rural and urban areas. The district birth rate in the year preceding the survey was found to be 23/1000 population per year, substantially lower than in surrouding districts. Social, economic and cultural conditions in the district are conducive to the acceptance of family planning and low birth rate. 46% of the eligible couples are practicing family planning. Reasons for non-acceptance of family planning are not rigid, and with more effort it should be possible to attain and surpass a couple protection rate of 60% by 1996.
The cost of children in Egypt.
In order to assess the cost of children throughout Egypt, in this case the direct maintenance costs of goods and services used until the child is self-supporting, a population sample representative of Egypt's total population in terms of socioeconomic status, occupation and geographical distribution was investigated. Food expenditures increase with the number of children in the household and with the rise in socioeconomic status. Educational expenses increase in a similar manner. There is positive correlation between the educational level of parents and their contribution to their children's education expenditures. The average amount spent on clothing per child declines the family size increases, especially within low socioeconomic groups. A rise in socioeconomic status or an increase in the number of children results in only a small increase in funds allocated for recreation. Results indicate that in rural societies the costs of children are small, but in urban and industrial workers' residence areas additional children result in additional spending.
An overview of the development of studies on fertility.
Statistics show that fertility in Arab countries is still high compared with prevailing rates in developed countries and the levels attained in some developing countries during the past decade. Most fertility studies in the Arab world have been functional, descriptive and analytical. They have not attempted to develop theories on fertility and its determinants that would reflect current situations. Efforts are being made at both the individual and institutional levels to encourage theoretical research. Family planning still dominates Arab fertility studies, but it is necessary to cover other concepts such as the supply of children, the demand for children, and the determinants which pertain to both the individual and the surroundings affecting these concepts. Sources of information on fertility in the Arab world need to be collected, confined to a research center or university within the Arab world, and made available to Arab researchers. Studies on various Arab societies, designed by Arab researchers, need to be undertaken.
Childbearing indices in the Arab world.
Patterns and tempo of entry into marriage and motherhood, birth spacing, and exit from the childbearing process play significant roles in the realization of societal level fertility. Childbearing models using quantum measures of period fertility, namely, age-specific fertility rates, to develop projected temporal indices of the childbearing process have been extended to 16 Arab countries representing over 90% of the population of the Arab world. Comparisons of 2 Arabian Gulf countries revealed diverse levels and patterns reflecting the populations' backgrounds, levels of societal development, and the stage of demographic transition. Results for Arab countries and national populations indicated younger projected ages at 1st birth, older projected ages at last birth, longer projected reproductive spans, and shorter projected birth spacing than expatriate populations. It is suggested that reproductive span is the best predictor of fertility, as well as of mortality and socioeconomic factors, at the societal level. Countries in which childbearing is initiated at earlier ages also show termination of childbearing at later ages and thus tend to have relatively higher fertility and mortality levels, poorer health conditions, and unfavorable social environments.
Natural family planning: a review and assessment.
This article describes 3 new Natural Family Planning (NFP) methods which have taken the place of the calender rhythm method and reviews the relevant literature. 1) The basal body temperature (BBT) method relies on the woman's body temperature (BT) which reflects variations in the progesterone levels during the menstrual cycle. It requires longer periods of abstinence than the other NFP methods because of the uncertainties of determining the timing of ovulation using BT. 2) The cervical mucus method, based on changes in the quality and quantity of cervical mucus perceived by women, uses their relation to the estrogen level to predict the timing of ovulation. It is relatively easy to learn and is the only NFP method that applies to women of all reproductive categories. 3) The symptothermal method combines the use of mucous symptoms, the BBT, and 2ndary signs associated with ovulation such as cervical changes, abdominal pain, intermenstrual bleeding and breast tenderness in its ovulation prediction. A major problem is that different signals of ovulation can sometimes be in conflict. NFP is an educational approach rather than a special technology. Training of teachers is of critical importance. Instruction in group setting is the effective approach. Self-instructional methods of training are inadequate; its users need greater motivation than artificial method users and a shared, cooperative approach to family planning by partners is very important. Useful literature on the physiologic basis and psychological impact of NFP are now available for family planning counselors and other health care professionals to assist the continuing growth of both public and private sector NFP programs around the world. While the need exists for systematic research efforts concerning NFP, preliminary conclusions indicate that the effectiveness of NFP methods is not as poor as often assumed but that instructional techniques and organization of NFP need further improvement.
Breastfeeding pattern and the duration of lactational amenorrhea in urban Chilean women.
The influence of the breastfeeding pattern and several clinical variables upon the duration of postpartum amenorrhea was assessed in a group of healthy women selected for having had a normal pregnancy and delivery and being highly motivated for prolonged breastfeeding on demand. 676 women who were fully nursing at the 2nd month postpartum entered the study. Supplements were administered to 11% and 48% of the infants by the end of the 3rd and 6th month, respectively. The 1st bleeding was experienced before the end of the 6th month postpartum by 57% of the cases. Supplementation had a strong negative influence while nursing frequency had a significant positive influence upon the length of amenorrhea. Notwithstanding, a frequency of 8+ suckling episodes/24 hours could not maintain amenorrhea in around 1/2 of the subjects. Age and parity had a moderate negative influence upon the risk of experiencing the 1st postpartum bleeding. Maternal weight and ponderal index, infant sex, birth weight and growth rate showed no significant influence upon the length of amenorrhea. In this urban population selected for having the highest motivation and best breastfeeding performance, the association of breastfeeding with amenorrhea was weak in comparison with what has been described for other populations. The risk of experiencing the 1st bleeding was reduced while fully breastfeeding with a high number of nursing episodes per day and night, particularly in older women with higher parity. But even in such situation 25% and 50% of the women had started to cycle by the end of the 5th and 8th postpartum month. (author's modified)
Overview of the health of women and children.
The health of women and children reflects a combination of biological, behavioral, social, ecological and historical factors and is dependent on political will and a minimum level of available resources. Great progress has been made in the past decade, but inequities persist as many improvements have not reached large groups of women and children. Of the 4 billion global inhabitants, 2 billion are women and children living in developing countries, where 110 million of the 130 million global births each year take place. Infectious and parasitic diseases, malnutrition, and high infant and maternal mortality are major causes of death in these nations. This overview presents comprehensive discussions of maternal mortality and morbidity, fertility and family planning, longterm reproductive morbidity, perinatal mortality and morbidity, infant mortality and morbidity, breastfeeding and nutritional status of children. Adolescent health and pregnancy are addressed. A detailed discussion of the implications for health care systems of the health needs of women and children addresses performance of existing programs and makes recommendations for future improvements. Despite improvements in literacy, food production and women's status, there has been a worsening in unemployment, the literacy gap between the sexes, and the inequitable distribution of food between different areas. Economic constraints are a major limitation on the delivery of health care. Nevertheless, some countries have made impressive, innovative approaches to providing health care to underserved areas. The key to achieving health goals will be enlightened political commitment and leadership, and efficient managerial practices.
The effects of family formation patterns on perinatal health.
As disease patterns change in developing countries, perinatal health is being given increasing priority. The pattern of family formation is a critical factor affecting perinatal health. The main components of family formation patterns are maternal age, timing of births and total number of births. Perinatal mortality is the highest at any time of life, and perinatal factors are major components of infant and childhood mortality. Increasing maternal age is a risk for perinatal mortality due to congenital malformations, late fetal death, and dysfunctional labor, with risk increasing progressively after age 35. In 320,762 births in New York City from 1976-78, mothers aged 35-39 and over 40 had a relative risk of late fetal death 2.4 and 4.2 times mothers aged 25 to 29. Increased perinatal mortality among adolescent mothers may be due to social disadvantages and short birth intervals of mothers in this age group. Perinatal mortality is highest for the 1st birth, lowest for the 2nd and 3rd, and increases from the 4th birth onward. This pattern has been observed in all countries and age groups studied. Many authors dispute this, arguing that mortality decreases as parity goes up, and that observed increased mortality is due to reproductive compensation and other artifacts. The large Mexican Fertility Survey 1976-77 supports this latter view, as does data from the World Fertility Survey. When controlled for birth interval, parity did not increase mortality. While birth intervals are strongly associated with perinatal mortality, confounding variables such as length of gestation, anovulatory effects of breastfeeding and reproductive status may affect the data. If this strong association is valid, it probably is not causal. Since multiple causes exist for perinatal mortality, it is not surprising that the link to single risk factors is weak. Still, it appears that little can be gained by changing family formation patterns.
Does prolonged breastfeeding adversely affect a child's nutritional status?
In 202 children who visited a children's hospital in the city of Accra, Ghana, breastfeeding beyond the age of 19 months was found to be associated with malnutrition. The effect of weaning on food intake was then studied in 15 breastfed malnourished children in a rural community. Before weaning, protein and energy intakes of all the malnourished children were about 1/2 those of 5 normal children. 10 of the malnourished children were weaned, and their intakes rose to the levels of the normal children; the 5 who continued breastfeeding maintained their low intakes. These results indicate that prolonged breastfeeding can reduce total food intake and thus predispose to malnutrition. They also suggest that in Ghana and other developing countries the proper weaning age may be about 18 months. It is suggested that, when breastfed children who are over 12 months old show reluctance to take supplementary foods, they should be weaned completely to enhance their food intake. It is also suggested that, in Ghana, breastfed children who eat well may be weaned at about 18 months without adverse effects on their health. However, in view of the major advantages of long-term breastfeeding, as well as the disadvantages, more work will have to be done to substantiate these observations.
Acquired immuno-deficiency syndrome (AIDS): its implications for women and children.
While 53,121 cases of Acquired Immunodeficiency Syndrome (AIDS) were reported to the WHO by July 1, 1987, the WHO estimates that at that time there were at least 100,000 AIDS cases and 5 to 10 million people infected with HIV worldwide. 7 to 9% of cases are in women, and the % is expected to increase as heterosexual transmission increases. In Africa, where heterosexual spread is more prevalent, the proportion of female cases is much higher. AIDS in children is uncommon, but is expected to increase. Modes of HIV transmission have been well described. Perinatal transmission is the main route of transmission to children, but blood transfusions and medical use of unsterile needles are of concern in Africa. In the US, 80% of children with AIDS have HIV positive mothers, and in developing countries rates from 61 to 76% have been reported. Neonatal AIDS cannot be accurately diagnosed until 9 to 12 months, when maternal antibodies are gone. HIV is present in breastmilk, and the risk of transmission is unknown. Pregnancy has been reported to accelerate disease progression of AIDS, but data are insufficient to be certain. Disease progression in children is more rapid. While condoms are effective in reducing the risk of transmission, they do not completely prevent it. The effect of other contraceptives on transmission is unknown. An increased risk of HIV transmission from use of contraception has been postulated, particularly for IUDs which cause inflammation that could increase susceptibility of the female genital tract. AIDS is expected to affect family planning programs by increasing interest in education and affecting the method of contraception chosen. Maternal-child health programs and family planning programs can and should become involved in preventing HIV transmission.
Direct effects of family planning on adolescent health.
The relatively low morbidity and mortality of adolescents may mask the health needs that exist, especially for family planning. Maternal mortality in those under age 19 is higher in developing and developed countries. A survey in India found that for each maternal death, there were 16.5 illnesses related to pregnancy and childbirth. Pre-eclampsia and iron deficiency anemia are particular risks for young mothers. Antenatal care can greatly reduce these risks, but the young mothers must appreciate the need for it, and it must be easily accessible. Abortion carries many risks for adolescents; decreasing the number of adolescent pregnancies is an important health goal. Reducing adolescent pregnancies should also reduce infant and child morbidity and mortality. Adolescents bear a disproportionate number of the increasing rate of STDs. From 1956 to 1982, the incidence of syphilis in 15 to 19 year olds increased from 10.7/100,000 to 23.1/100,000, and gonorrhea cases from 415.7/100,000 to 1200.2/100,000. Long term sequelae can have serious repurcussions on a woman's later fertility. Counseling and education are essential to improving adolescent health. Young people in many countries live in an environment filled with sexual imagery in advertising and television that conveys nothing on sexual responsibility. In many societies, adolescents may work and live on their own at an early age, with no responsible adults to rely on. Prescribing contraceptives to adolescents poses many problems. Many adolescents will not use them reliably or properly. Their are cultural and ethical constraints to providing contraception to unmarried adolescents that remain unresolved. The most urgent need is for better communication between adults and adolescents to prevent problems before they arise. Participation of young people in the planning and implementation of such programs and policies will help maximize their effectiveness.
The maternal depletion syndrome: clinical diagnosis or eco-demographic condition?
The "maternal depletion syndrome" refers to the combination of several factors that negatively affect women's health in difficult living conditions. Repeated pregnancies, close spacing and extended periods of breastfeeding have deleterious effects on women's nutrition resulting in later reproductive difficulties (e.g. low birth weight, fetal wastage, infant mortality). The evidence for this clinical syndrome is unclear, with conflicting conclusions in different published reports. Several studies show high incidence of low birth weight and anemia with younger mothers rather than in older multiparous women. The World Health Organization (WHO) study of Family Formation Patterns and Health presents the most data in this area. It found weight increasing with parity, and no effect of parity on anemia. They concluded that evidence did not support the existence of this syndrome. An exhaustive search of the world literature published in 1987 did not support maternal depletion either. Poor prepregnancy nutritional status was found to be a major factor affecting birth weight, but was not found to be related to previous reproductive events. A 1986 study in rural Uganda was the most explicit examination of this hypothesis. It found no cumulative nutritional depletion after extensive periods of pregnancy and lactation. Early pregnancy was significant for its affect on the adolescent growth spurt, thus affecting future maternal size. Thus, cumulative nutritional depletion due to high parity and extensive breastfeeding is not supported by existing evidence. Socioeconomic status and maternal work are probably more important determinants of nutritional status.
Utilization of health facilities for child illness in Ethiopia, 1983.
This research note focusses on the patterns of use of both modern and traditional health services when children are sick. Many of the patterns of use are analyzed separately for boys and girls. Among all sick children under age 6 about 33 and 34% of males and females, respectively, received treatment from at least 1 of the facilities. Male children who suffer from abdominal diseases at infancy are more likely to be users of medical facilities than females because male infants were more severely sick than females. Differentials in overall child morbidity according to age have been observed, levels being higher for infants and toddlers than children of older ages. However, no sex differences were found either in morbidity or in health care practices. Children whose mothers are literate have higher reported morbidity than children of illiterate mothers. However, regarding access to sanitary facilities, better conditions exist among children of literate mothers than among those of illiterate mothers. More than 40% of children whose mothers were sick were also sick themselves, but only 21% of children whose mothers were not sick, or about 1/2 of the above group, were sick. The policy implications from the findings presented here are that the Government's Primary Health Care program, while concentrating on expanding health services to the rural areas, needs also to consider ensuring that the cost of treatment and medicines are within reach of the population, otherwise the newly developed modern health services may remain underutilized.
Expanded programme on immunization.
The Expanded Programme on Immunization (EPI) was established in 1974 to develop and expand immunization programs throughout the world. In 1977, the goal was set to make immunization against diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis available to every child in the world by 1990. Problems encountered by the Program have included: lack of public and governmental awareness of the scope and seriousness of the target diseases; ineffective program management; inadequate equipment and skills for vaccine storage and handling; and insufficient means for monitoring program impact as reflected by increasing immunization coverage levels and decreasing incidence of the target diseases. When the EPI was initiated in 1974, fewer than 5% of children in developing countries were receiving a 3rd dose of DPT and poliomyelitis vaccines in their 1st year of life. These coverage levels have now surpassed 50% in developing countries, and millions of cases of the target disease have been prevented. Over 700,000 measles deaths were prevented by immunization in developing countries in 1987, and an increasing number of neonatal tetanus deaths is now being prevented by maternal immunization and improved childbirth conditions. Poliomyelitis immunization efforts have been so successful that the Pan American Health Organization is leading a drive to eradicate poliomyelitis from the Americas by 1990. The successes of the Program represent a major public health achievement, but much remains to be done. Measles still kills nearly 2 million children each year, neonatal tetanus kills some 800,000 newborns, and pertussis nearly 600,000 children. 250,000 cases of paralytic poliomyelitis still occur annually. The major challenges now facing the EPI are accelerating and sustaining national immunization efforts. (Summaries in ENG, FRE)
Control of diarrhoeal diseases.
This article traces the history of the worldwide struggle to control diarrheal diseases. When the 7th pandemic of cholera began in 1961, WHO responded with a greatly expanded program of activities which included cooperation with countries in training and control efforts, and research on treatment and prevention. In 1970, when the cholera pandemic spread to Africa, the emergency assistance program was reactivated, with increasing attention to the provision of appropriate treatment, especially oral rehydration therapy. Another public health problem of importance during the 1970s was the increase in antibiotic resistance of enteric bacteria. The demonstration of the effectiveness of a single formulation of oral rehydration salts (ORS) in the treatment of all diarrheas was instrumental in convincing public health administrators that diarrheal diseases control should become an essential component of primary health care and led to the creation of a global Diarrheal Diseases Control program. The Program, which has the objective of reducing childhood mortality and morbidity due to diarrheal diseases and their associated ill effects, especially malnutrition, consists of 2 main components: a health services and control component and research component. If the targets set by the Program for 1989 can be attained, it is expected that by then at least 1.5 million childhood deaths due to diarrhea will be prevented annually. (Summaries in ENG, FRE)
Unwanted pregnancies and unwanted fertility: conceptual variations.
In order to explore variations in the % of births associated with different definitions of pregnancy unwantedness and unwanted fertility, several approaches to the concept were examined in a single research project involving a study of parental underinvestment in the Philippines. 1 method was to pose a direct question regarding each pregnancy that resulted in a live birth. The 2nd approach follows the more classic definition of unwanted fertility. The 3rd approach attempts to take into account parental sex preferences for offspring. An underinvestment scale was used to explore a possible relationship between unwantedness and failure on the part of parents to provide adequate affection, stimulation, and care. Findings did not support the expectation that parents would underinvest in an unwanted child. Regardless of the way unwantedness was defined, the unwanted child did not emerge consistently as the battered child or the neglected child. Whereas a mistimed pregnancy, an undesired pregnancy, or excess fertility may be contributing factors to mistreatment of a child, there are probably a number of factors in the economic and social environment that influence care and affection provided for a child. Several other interpretations might be provided for the finding that unwantedness and underinvestment were not associated. Findings on parental behavior toward a child were not independently validated. It is possible that the parent failed to recognize, or admit, differential treatment of siblings. Or, the Philippine culture may render underinvestment in a particular child as unacceptable. The concept of underinvestment needs further testing in various cultural settings as an approach to clearer conceptualization of unwanted pregnancies and unwanted fertility.
Spousal agreement on the value of children and fertility behavior.
This study explores the relationship between the level of spousal agreement on the value of children and fertility behavior. Interviews with 441 once married couples from a probability sample in Robeson County, North Carolina, provide the data for testing in hypothesized relationships. The results of the analysis demonstrated significant relationships between the level of agreement and live births, family size expectations, and fertility planning. Furthermore, the effects of duration of marriage and wife's education did not significantly alter the observed relationships. The results provide support for the contention that fertility and family research should feature the marital diad as the unit of analysis. Nevertheless, studies that compare the predictive ability of individual and couple measures are needed to more fully understand the dynamics of family formation. Another suggestion for future consideration is to disaggregate the composite value of children into its constituent values to determine if there is a greater amount of agreement/disagreement among husbands and wives on a particular value. This would also permit an assessment of whether agreement/disagreement on particular values are more salient for specific fertility behaviors. In addition, scales such as the one utilized in this study measure only the degree of a value and do not deal adequately with the question of the intensity with which values are held.
Public perceptions of the ideal number of children for contemporary families.
This research examines perceptions of the ideal size for contemporary families and beliefs regarding factors that have contributed to families' decisions to have fewer children in the US. Findings reveal that the 2 child family is the overwheming standard chosen by respondents, and that this preference holds for virtually all demographic categories. Most respondents did not view a decline in the interest in children as responsible for the reduction in family size. This sample concluded, instead, that the pragmatic issues of economic costs of children along with increased labor force participation among women constrain families to smaller numbers of children. The shifts, then, appear to be a reflection of changes in the economic circumstances of families, and developments in birth control technology, making achievement of desired family size more likely than ever before. This interpretation is consistent with macroeconomic theories of fertility and leaves open the possibiity that changes in structural components might result in changes in individual level decisions. Finally, it is the apparent view of the respondents that several social factors in combination have brought about the reduction in family size in the last 2 decades. Expense of children, wives in the work field, better birth control, and being too worried about the future were all considered important factors.
In Israel, 40 primigravid women due to undergo 1st trimester termination of pregnancy were randomly selected for intracervical application of 1 mg prostaglandin E2 in gel or gel only as placebo. In the PGE2-gel group, a marked dilatation of the cervical canal was obtained, with post-gel treatment mean Hegar dilatation of 11.18 mm in that group, compared to 4.4 mm in the control group (P 0.001). Moreover, 16 (80%) patients in the PGE2-gel group had a complete abortion, 1 (5%) patient had an incomplete abortion, and in the remaining 3 (15%) patients, fetal demise was observed. The mean induction-abortion interval in this group was 7.5 h. In the placebo group, none of the above effects were observed. The only side effect noted was vomiting, which occurred in 5 (25%) of the patients in the PGE2-gel group. Termination of pregnancy was found to be easier in the PGE2-gel group, compared to the placebo group. Major complications such as tear of the cervix or perforation of the uterus were not recorded in the 2 groups. On examination of the patients 4 weeks later, none of them showed any signs of pelvic inflammatory disease, but 1 patient in the placebo group complained of irregular bleeding and needed recuretage. In the present study patients were hospitalized, but the proceedure can be adapted to an out-patient setting with application of the drug in the early morning and termination by afternoon.
Clinical experiences with the Spring Coil intrauterine device: a ten-year follow-up study.
In a 10-year follow-up study in Hungary analyzing 1080 cases and 29,138 cumulative woman-months of use, the clinical experiences of the Spring Coil IUD are evaluated using the life table technique. The net cumulative pertinent termination rates calculated for 100 women at the end of the 10th year were as follows: pregnancy 1.2; expulsion 32.5; bleeding/pain removal 31.6; removal for other medical reasons 6.2. The results support the concept that in problem and symptom-free cases, routine IUD removal is not necessary. Rates of the 2 most unfavorable events (expulsion and bleeding/pain removals) definitely decreased from the 2nd year. After the 12th month, the figures are rather characteristics for the device itself, as the difficult insertion technique (and its consequences) will not distort them anymore (the devices inserted incorrectly, have already been expelled or removed by this time.) The high annual continuation rates at the later years also indicate that, from the 3rd year, the risk of terminations does not increase in parallel with the duration of IUD use.
Adapting the safe motherhood initiative to Indonesian society.
Safe motherhood initiatives being pursued in Indonesia may be on the wrong track. This paper says nothing to challenge the data on maternal mortality assembled to date, nor does it seriously question the analysis of maternal and infant morbidity and mortality presented in various conference documents. Instead, it focuses on 2 related problems. 1st, is the tendency of "Safe Motherhood" interventions to be seen in terms of explicit top-down delivery of services from trained professionals to recipient mothers, with a heavy emphasis on clinic oriented, though community-based, ante-natal care. 2nd, there is little attempt to understand the traditions and meanings of childbirth, and in particular, no acknowledgement of the roles and responsibilities of fathers, families, and friends in the protection of mothers and the newborn. There is something fundamentally wrong with much discussion of "Safe Motherhood" that needs to be fixed quickly. Recommendations involve measures to locate maternal health services more firmly in the home and community. Specific responsibilities and roles for the mother, father, traditional healers, and community leaders are the basis for such an approach. These are acknowledged as the primary responsibilities in primary health care, and all professional staff are defined in terms of their supportive and referral roles. Recommendations include the involvement of family members, the training of traditional attendants, the mobilization of community resources to care for emergencies, the retraining of professionals, and the development of adequate statistics on problems of childbirth.
Women using media for social change.
This volume contains 2 International Women's Tribune Centre (IWTC) newsletters, produced between 1981 and 1983, both of which present some of the major issues related to women and the media worldwide. Each issue includes specific examples of how women in different parts of the world are using a variety of media methods, tools, and strategies to tackle the enormous tasks of disseminating information by, for, and about women and their involvement in community issues. Each contains resource listings on organizations and media materials. A listing in included of approximately 200 women's periodicals from around the world that has been added as a further networking tool. Women's actions around the world to create their own media, including women-produced magazines, radio shows, videos, and newsletters, have been among the more important initiatives of the Decade for Women (1976-1985). As a producer and disseminator of newsletters, slide-tapes, and many forms of media by, for, and about women, IWTC is closely connected to this growing network of groups and individuals worldwide who are creating "alternative" media, making and using media that supports social change and allows the voices of those who have been invisible to be heard. These newsletters have been revised and updated in places to assure their continued relevance.
Risks factors for infection with human immunodeficiency virus among Europeans expatriates in Africa.
The pattern of cases of AIDS in Belgium suggests that Europeans infected with human immunodeficiency virus (HIV) acquired the infection in Africa. The prevalence of infection was assessed in Belgian advisers and European expatriates and risk factors for infection defined in a case-control study of expatriate men. 15 (1.1%) of 1401 Belgian advisers working in Africa and 41 (0.9%) of 4564 European expatriates living in Africa, were positive for antibody to HIV in a voluntary screening program in Belgium. Among subjects with antibody to HIV the ratio of men to women was 3:1. These subjects did not have a history of intravenous drug abuse or blood transfusion and only 1 was homosexual. In a case-control study of 33 expatriate men who had antibody to HIV and 119 controls the men with antibody reported significantly more female sexual partners, who were more commonly local; and significantly more sexual contact with prostitutes in Africa. They had a significantly higher prevalence of history of sexually transmitted disease and had received significantly more injections by unqualified staff in Africa during the previous 5 years. No specific sexual practices were associated with having antibody to HIV. After multivariate analysis sexual contact with local women (adjusted odds ratio 10.8 (1.6 to 71.9), and injections by unqualified staff (adjusted odds ratio 13.5 (3.7 to 49.8) remained independent risk factors for infection. European expatriates in Africa were at increased risk from infection with HIV and were a means of introducing HIV into the heterosexual population in Europe. Transmission from women to men by vaginal intercourse seemed to be the most probable route of infection. (author's)
Society for Education Welfare and Action [SEWA]--rural.
This publication describes the Society for Education Welfare and Action (SEWA)-Rural experiment in health management in India. The founding group was particularly sensitive to the need to involve people in their own development. Despite this, for strategic reasons, a deliberate decision was taken to start the project with curative health services which the group believed should precede and form an integral part of preventive health services. Once trust in the community was established, SEWA-Rural decided to move on to its broader health mandate. The Community Health Project was launched in the 2nd year of operations. It entailed a basic move from the traditional hospital-based curative services to village-based community health services. Within a few months, the health status and awareness of the community began to show improvement. This was convincing enough evidence to consider expanding the program. Under a new arrangement with the government, SEWA-Rural's responsibilities underwent a 3 dimensional increase in terms of services provided and the area served. The 5-year plan adopted the following as its long-term demographic objectives: 1) bring the infant mortality rate down by 40%; 2) reduce the crude death rate by 5%, 3) lower the crude birth rate by 15; and 4) reduce malnutrition of children under 6 years of age by 25%. On the whole, SEWA-Rural is bringing about a silent but highly visible health and socioeconomic transformation.
Poor, powerless and pregnant: country rankings of the status of women [wallchart].
This wall chart of the country rankings of the status of women was produced by the Population Crisis Committee (PCC). The PCC is a private, non-profit organization founded in 1965 which advocates voluntary family planning and other actions needed to solve world population problems. This chart statistically rates the status of women in 99 countries. Measurements of women's well-being and the gender gap between men's and women's status combine to provide a ranking--in a single figure--of the differences in women's condition between countries. Each country score is compiled by adding 20 measures of women's status related to the categories of 1) health, 2) marriage and children, 3) education, 4) employment, and 5) social equality. In each category, 3 measures are related to women's general well-being and the 4th gauges the gender gap. Each of the 20 measures has a maximum of 5 points, 5 indicating the highest status. The maximum possible score is 100, 75 for women's status and 25 for gender gap. Each country's status is then visually plotted on a world map according to a color scheme relating to women's status.
The purpose of this workshop was to train a 14-member Lagos State Training Team: 4 as community health education trainers and 10 as clinical skills trainers in family planning/oral rehydration therapy service provision. 2 curricula were developed for the separate programs. The major findings, conclusions, and recommendations of the workshop included: 1) a supportive, responsive administrative structure contributed to the successful conduct of the workshop, 2) an integrated training team (combining local and external trainers) is an excellent training model worthy of replication, 3) state training team members' role changes which occurred within a 2 month time frame did not allow the members the opportunity to: a) independently practice at each role change level, and b) fully internalize new knowledge, skills and role behavior, 4) continuity and training quality assurance within the clinical skills training team membership needs to be addressed with the designation of a team leader and the ultimate designation of a permanent clinical skills training team, 5) a minimum of 4 weeks training time is essential for a quality training session when a core family planning/oral rehydration therapy curricula is expected as a training product, 6) family planning/oral rehydration clinical practice standards are needed in Lagos State, and 7) a 3-year project management plan focusing on a phased approach to coordinating family planning/oral rehydration therapy training activities and service delivery integration and expansion is needed in Lagos State.
A trip sponsored by the Program for International Training in Health (INTRAH) was taken to Lagos State, Nigeria, to provide technical assistance to 4 state training team members during the training of 20 community health educational service (CHE) family planning/oral rehydration therapy (FP/ORT) service delivery providers. Major findings are that the Lagos State CHE FP/ORT trainers are competent to conduct CHE FP/ORT training to meet Lagos State service delivery needs. The Kwara State cotrainer is appropriately experienced to conduct effective FP/ORT training outside her home state and can be confidently considered for future Nigerian training assignments. Furthermore, the CHE FP/ORT curriculum is a viable and effective training curriculum for Lagos State needs. Additionally, participants report, and trainers concur, that there is strong preliminary evidence to suggest that CHE FP/ORT activities will markedly increase new client turnout at FP/ORT clinics in the state. Consequently, it is anticipated that Lagos State CHE and clinical trainings will be increased by Lagos State Project officials should INTRAH agree to such proposals.
[Fertility and mortality in Brazil, 1970-1980]
Brass's technique is applied to census data to estimate urban and rural fertility and mortality in Brazil as a whole, in the federal states, in the 5 large geographic regions, and in 10 regions defined in the 1970 census. Data are presented separately for men and women. (ANNOTATION)
Years of potential life lost (YPLL) before age 65 in Italy.
"The Italian death rates and years of potential life lost (YPLL) for all causes and for 12 selected aggregations of causes are reported for 1979 and 1983, with the latter compared to United States data. Cancer is the leading cause of YPLL in Italy (23.8 per cent of total YPLL), followed by unintentional injuries (16.3 per cent) and heart disease (11.2 per cent). Rates of YPLL for all causes decreased 12.0 per cent from 1979 to 1983, the strongest declines in absolute terms being observed for prematurity and unintentional injuries, and in percentage decline for pneumonia and influenza, and infectious diseases; during the same period, YPLL for diabetes increased. The rates of YPLL are higher for males than for females (rate ratio=1.9) especially for causes related to lifestyle factors. Premature mortality is lower in Italy than in the U.S.A., because of the striking difference in mortality from injuries and heart diseases." (EXCERPT)
[ABEP, the first decade: advances, omissions, prospects]
This report describes the activities of the Brazilian Association for Population Studies (ABEP) during the first 10 years of its existence, from 1978 to 1988. Separate sections are included on fertility, mortality, internal migration, and the labor force. An overall analysis of the Association's publications, conferences and subjects and regions studied is also included. (ANNOTATION)
The dynamics of urban population.
The relative roles of natural increase and migration in determining the long-term dynamics of an urban population are considered. "Rogers' model is used to represent the simultaneous growth of a multiregional population. Exploiting the mathematical structure of the resulting system of difference equations, a perturbation theory for demographic models [is] outlined. This theory provides useful tools for analysing the sensitivity of stable population distribution and rate of growth to changes in the fundamental demographic parameters. With respect to the conventional approach to sensitivity analysis, it does not require the sometimes cumbersome calculation of matrix derivatives." A numerical example is given to demonstrate the method. (SUMMARY IN FRE AND ITA) (EXCERPT)
[The application of data sampling to population censuses in Brazil]
The data sampling methods used in recent censuses in Brazil, including the 1980 census, are reviewed and compared with the sampling methods used in the United States, Canada, and Argentina. (SUMMARY IN ENG) (ANNOTATION)
The authors test the proportional mortality ratio developed by Swaroop and Uemura for those aged 50 and over using data for 34 countries for selected years from 1950 to 1980. They conclude that better discriminatory power between developed and developing countries can be obtained by using the proportional mortality ratio for those aged 75 and over. (SUMMARY IN ENG) (ANNOTATION)
[An attempt to describe the population history of Zaire]
Population trends in Zaire since 1880 are analyzed. Consideration is given to regional and subregional differences in population development from 1938 to 1984. Data are from a variety of official sources, including the 1984 census. (ANNOTATION)
The authors apply the Lost Years of Life Rate (LYLR) developed by Haenszel in 1950 to data from various countries, and more specifically to data from the state of Sao Paulo, Brazil. They conclude that the LYLR is in many cases a more useful indicator of the health level of a population than is the Standardized Mortality Ratio. (SUMMARY IN ENG) (ANNOTATION)
[Institutions of youth promotion and services in La Paz, Bolivia: an analytical-descriptive study]
This work presents the results of an evaluation of 30 institutions in La Paz, Bolivia, which offer recreational, nonformal educational, training, and sports programs to young people. The 1st chapter provides theoretical background on the psychological, social, and sexual problems and tasks of adolescents in modern societies. The 2nd chapter briefly discusses the roles of the family, friendships, and organizations in the development of adolescents, and briefly describes the goals, programs, and financing of 17 of the 20 organizations studied. 21 of the 30 had formal legal status. 16 of the organizations were public and 13 were private. 7 were national in scope and 15 had international ties. 2 were for women only, 23 were for both sexes, and 5 included children. The primary program objectives were educational in 11 cases, cultural in 8, and sports and religious in 5 cases each. 24 of the organizations reported that they fulfilled their objectives and 5 that they possibly did so. 9 of the organizations had vertical patterns of authority, 16 had horizontal, and 5 had other types. 26 reported that their personnel were qualified. 21 were financed by member contributions, 5 by donations, and 1 by parental contributions. 21 reported that attendance was normal and 5 that there was little participation or interest among members. None of the organizations provided more than very superficial sex education programs, although 26 organizations indicated their belief that sex education is important. 12 of the organizations had professionals on their staffs and 17 had volunteers only. 19 reported they had sufficient manpower and 2 that they did not. The material resources of the organizations were scarce; only 6 had their own meeting places. 15 relied on financing by members, 8 had governmental help or received donations from nonmembers, and 4 had international assistance.
[A tentative discussion on family planning problems in Xinjiang's minorities]
The Uighur Autonomous region in Xinjiang includes a number of minority groups such as the Uighur, Kazakh and Hui. The question of how to implement family planning in minority areas if of utmost importance. In February 1982, the State Council decreed that family planning policy for minority groups could justifiably be more lax than for the Han people, who comprise a majority of Chinese population. Instead of advocating 1 child per couple, as is the current national policy, urban minority groups are permitted 2 (with exceptions, 3) children per couple and rural villagers are permitted 3 (with exceptions, 4) children. The 1982 National Census showed that the natural rate of growth for Xinjiang was 13.63/1000 (compared to the national rate of 11.45/1000) with individual minority growth rates as high as 20.11/1000. The area's gross output value cannot keep up with this population increase. Over half of Xinjiang's minorities are of the Islamic faith, which teaches that births are not self-willed. It is crucial to inculcate in them that births can indeed be planned. Also, their custom of early marriage (age 15 for girls and 16 for boys) which leads to a high fertility rate, must be changed. Although Xinjiang's land mass is great, only 38.4% is arable, so the common belief that its population can grow without limit is fallacious. When family planning was being implemented nationwide, for minorities it was only propagandistic. After the population growth for the majority Han was under control, the minority groups declared family planning programs would also benefit them. Symposiums were held contraceptive use became voluntary among many women. The birth rate fell from 22.5/1000 in 1981 to 14.09/1000 in 1985. Family planning also received approval from religious leaders. But because population distribution and growth are uneven in Xinjiang, family planning policy must reflect these differences.
[Premarriage education in family planning should begin in puberty]
The work of disseminating family planning information must begin at puberty in order to provide a sound foundation for future family planning education. Premarital education that begins at puberty should emphasize decreasing the number of early marriages, planning for only 1 child, and superior births. The Chinese Family Planning Association held a special seminar in November 1986, in Taicang County, Jiangsu Province, to study sex education. Some observations by individual participants are included below and do not represent the viewpoints of the Conference. Education at puberty concerns 2 primary areas: knowledge about sex, and morals concerning sex. At this age, physical changes are met by immature minds. Adolescents are not informed about the sexes; nor do they understand self control. Families and teachers must help them comprehend physical desire and relationships. The first step in educating adolescents is to eradicate feudal attitudes that make sex a taboo subject and that equate it with obscenity. Sex education is scientific and must be disseminated as such. If proper objective information is not provided, adolescents will acquire the wrong, and sometimes detrimental, information from peers. Early marriage, abortions by unwed mothers and sex crimes can be prevented by proper education. In those schools, particularly in Shanghai, which have sex education, the reception has been positive among teachers and students. Although sex education is crucial to educating adolescents, it should not be confined to this age group. Engaged couples and newlyweds also need such information.
The epidemiology of cervical neoplasia.
Data from northern Italy are interpreted, along with indications from the literature, to examine the role of risk factors in development of invasive and preinvasive cervical cancer. This case-control data included 183 cases of histologically confirmed cervical neoplasia in women aged 19-71. Mortality has fallen since the 1950s, starting with younger age groups, but since the 1970s, this trend has flattened out, again, starting with younger age groups. Probably changes in life-style as well as less rigorous Pap smear testing are responsible. This study found that risk of moderate dysplasia is a function of time since last smear, but that of invasive cancer depends on the number of smears, suggesting that squamous carcinoma evolves from dysplastic lesions. Both pre-invasive and invasive cancer were positively related to number of sexual partners and age at 1st intercourse. Intraepithelial neoplasia was strongly associated with Condylomata acuminata (genital warts), and trichomoniasis, and (not significantly) with Herpes genitalis and salpingitis. Invasive cancer was not related to any venereal diseases. The risk of intraepithelial neoplasia was elevated within 20 years after starting smoking, but did not increase afterward. In contrast, the risk of cervical cancer was not increased for the first 20 years of smoking, but increased steadily thereafter, to 3-fold after 40 years of smoking. Beta-carotene intake (reflected by vegetable consumption) had a powerful negative association with invasive cervical cancer. No such relationship was apparent with retinol (preformed vitamin A, indicated by dairy and meat consumption).
Is breast feeding the solution to the infant nutrition problem in underdeveloped countries?
133 children from birth to 1 year of age and living in the squatter settlement of Paranoa, 25 kilometers from Brasilia, were studied to investigate the value of breast milk as a solution to the infant nutrition problem. Data were obtained on socioeconomic and sanitary conditions, diet during the last 24 hours, and health status. A random subsample of 95 children was used for the anthropometric study. The infants mothers were interviewed in their homes by 2 nurses previously trained to use a standardized technique. The questionnaire used included both open and closed questions and had been previously validated in a pilot study. The 95 infants of the subsample were weighed and measured between 9 am and 5 pm by the same 2 nurses at a station established in each neighborhood. 15% of the sample was being fed exclusively breast milk, 44.4% breast milk plus cow's milk, and 40.6% only cow's milk. The most common feeding practice in infants 6 months of age or less was breast milk mixed with cow's milk, followed by cow's milk only and breast milk only. For infants of more than 6 months of age, cow's milk only was the most common feeding practice, followed by breast milk with cow's milk and breast milk alone. Some children as old as 12 months were still breastfeeding. The food eaten by the infants studied came from 5 categories: breast milk or cow's milk, cereals and cereal derivates; beans and bean broth; various kinds of tea; and occasionally some kind of meat, fruit, or vegetables. Among the 95 infants for whom anthropometric data were available, 63.2% were eutrophic and 36.8% undernourished, 27.4% of these suffering from 1st degree malnutrition and 9.5% from 2nd and 3rd degree malnutrition, according to Gomez' classification. There were similar percentages of undernourished children among breastfed infants (33.3%) and infants fed breast milk plus cow's milk (30.4%). The largest percentage of undernourished infants (47.1%) was found among those fed only cow's milk. More undernourished infants were boys (65.5%). The prevalence of malnutrition was greater in infants older than 6 months (24 in 47) than in younger infants (11 in 46). Artificial feeding was the commonest practice among undernourished infants of 6-12 months. There was a general decline in weight for age from the 1st to the 2nd month. Using Waterlow's classifications, the combined malnutrition of weight for age and height for age together was 1.0%.
Early treatment with erythromycin of Campylobacter jejuni-associated dysentery in children.
To evaluate the efficacy of early treatment with erythromycin on the duration of fecal excretion and of diarrhea associated with Campylobacter jejuni, 170 patients, ages 3-60 months, were randomly assigned in a double-blind fashion to receive either erythromycin ethyl succinate or placebo immediately after being seen at Cayetano Heredia Hospital because of acute dysentery. The groups' pretreatment characteristics were comparable. Of the 30 patients with stools positive for C. jejuni, 12 were in the placebo group and 16 in the treatment group. After 2 days of treatment, none of the patients in the placebo group and 36% of those in the erythromycin group had normal stools (P 0.05). After 5 days of treatment, 50% of the patients in the placebo group and 93% of those in the erythromycin group had normal stools (P 0.02). Fecal excretion of the organism continued significantly longer in the placebo group (P 0.01). There were no treatment failures in the treatment group compared with 5 (42%) in the placebo group (P 0.01). Thus, early administration of erythromycin significantly reduced the duration of both diarrhea and fecal excretion of the organism in infants and children with acute dysentery associated with C. jejuni. (author's)
The Expanded Program on Immunization (EPI), which seeks to provide immunization against 6 major childhood diseases for all the world's children by 1990, is a stepping stone toward the broader target of providing health for all by the year 2000. Theoretically, the immunization program should not require investments in new or complex medical technologies. There should be application on a larger scale of already available knowledge and technologies. Programming strategies should promote delivery of immunization services to those at greatest risk of contracting the target diseases--children under 1 year of age and pregnant women--as an integral part of the primary health care system. To increase program efficiency, infants and pregnant women can be simultaneously vaccinated against several diseases at a single visit. Program evaluation is the fundamental means of improving all facets of program implementation. Immunization coverage statistics are an important index of the performance of the health services in a given country. 2 Latin American countries--Ecuador and Costa Rica--have carried out evaluations of EPI coverage and have used the results to improve service delivery. For example, the Ecuador survey indicated that immunization coverage was higher among 1-4 year olds than among infants. This finding led to a change in focus to concentrate on children under 1 year of age. In general, the coverages obtained in Ecuador and Costa Rica--in the range of 75-95% of eligible children--are considerably higher than those normally achieved in most developing countries. The methodology of evaluating coverage through random sampling is a good example of the application of appropriate technologies in the process of program evaluation and can be applied in other fields such as maternal-child health care.
Barriers to family planning service delivery in indigenous communities in Ecuador.
Barriers to the provision of family planning services to indigenous groups in Ecuador, experienced during an operations research project, were identified. The project included 8 rural "parroquias" -- the smallest administrative unit -- in the provinces of Chimborazo and Imbabura and 6 in the province of Cotopaxi, for a total of 84 villages and 22 parroquias with a population of about 170,000. Each group of parroquias was served by a clinic located in the Cantonal capital, 2 or 3 paid promoters, and 20-30 trained volunteers. The promoter and volunteer played complementary roles. The project design included 2 experiments. The 1st experiment tested the effectiveness of integrated versus nonintegrated services. The design measured the impact of the addition of oral rehydration therapy (ORT) to family planning services and, conversely, the addition of family planning to ORT. The 2nd experiment examined the impact of adding home visiting to family planning service delivery. For the first 6 months of the project, the community-based program in half of the parroquias in each province distributed family planning methods only while the other half distributed ORT only. Home visiting was limited to family planning parroquias. Data were available for the first 5 months of project activity, March-JUly 1987. In the 11 parroquias providing ORT, 34 distributors provided 1326 ORT packets, treating 663 cases of diarrhea during the period. The results compared favorably to the distribution of ORT by Ministry of Health workers in rural areas, indicating success in penetrating indigenous communities with ORT. The results obtained by the family planning program were most modest. 50 distributors provided a total of 35.4 couple-years years of protection (CYP) in 5 months. Promoters recruited 40 new clients during 728 home visits for an acceptance rate of about 5%. Barriers to service delivery can be divided into 2 general categories -- those related to the characteristics of indigenous communities themselves and those related to the characteristics of the family planning program. Community barriers included geographic isolation and the problem of difficult terrain, the political structure of indigenous communities, religious conservatism, the dominance of males, and sexual fears. Program barriers included the limited availability of oral contraceptives (OCs) and a lack of bilingual staff.
[Quantum pharmacological investigations of gossypol and some simple aromatic compounds]
Molecular orbital indices of gossypol, 8-hydroxy quinoline, salicylaldehyde, salicylic acid, o-vanillin, vanillin, 2, 3, 4-trihydroxybenzaldehyde, and guaiacol were calculated by means of Huckel's molecular orbital (HMO) method. It was found that the nucleophilic superdelocalizabilities of maximally positively charged hydroxyl oxygen of these compounds were correlated with their spermatocidal action in rat cauda epididymis. Moreover, as the polyacrylamide gel electrophoresis of healthy human semen treated with the above spermatocidally active compounds shows different protein patterns from those treated with spermatocidally inactive compounds (except guaiacol) and normal semen, there exists in the above compounds fair accordance among the nucleophilic superdelocalizabilities of particular oxygen atoms, the spermatocidal action, and the influence of semen protein motilities. A probable mechanism of the spermatocidal action of the compounds described above was proposed. (author's) (summary in ENG)
Persistence of anti-HIV p24 antibodies in African AIDS patients [letter]
It has been repeatedly observed that after progression of HIV-1 infection to AIDS, antibodies to the viral core protein p24 are not detectable in 50-90% of the patients, whereas antibodies to the envelope glycoproteins gp120 and gp41 continue to be present. However, we found evidence that this phenomenon may be restricted to AIDS patients in the US and Europe. We examined sera from 143 Tanzanians in whom HIV-1 infection was demonstrated by ELISA (Vironostika-Organon Teknika and Abbott HTLV-III EIA recombinant) and immunoblot tests (Biotech-Du Pont de Nemours). 78 of these individuals showed clinical evidence of AIDS, as defined by WHO. 63 people had nothing to suggest the presence of AIDS and belonged to 1 of the following categories: blood-donors (11), pregnant women (20), patients attending outpatient departments of rural hospitals for various reasons (21) and patients admitted for tuberculosis (11). Our immunoblot results did not show major differences between the 2 groups (Table 1). Antibodies to gp41 were found somewhat less frequently among AIDS patients (P 0.05). The incidence of antibodies to p24, however, did not differ significantly between individuals with and without AIDS (P 0.05). These data confirm similar recent observations by Barin, that the serological response, after infection with HIV-1 is not necessarily the same in all parts of the world. (full text)
Trichosanthin is a new abortifacient protein purified from the Chinese drug, Wangua, root tubers of Trichosanthes cucumeroides (Cucurbitaceae). The purification procedure involved acetone fractionation, ammonium sulfate precipitation, ion exchange chromatography on CM-Sepharose, and preparative agarose electrophoresis. Homogeneity of beta-trichosanthin was demonstrated in immunoelectrophoresis, agarose electrophoresis, and SDS-polyacrylamide gel electrophoresis. It had a molecular weight of 28,000 and no cysteine in its molecule. It differed from trichosanthin, a known abortifacient protein isolated from a related Chinese drug, Tianhuafen, root tubers of Trichosanthes kirilowii (Cucurbitaceae), in molecular weight, carbohydrate content, charge, and amino acid composition. Beta-trichosanthin was, however, immunochemically identical to trichosanthin and was about twice as potent as trichosanthin in inducing midterm abortion in mice. (author's)
HIV2 is responsible for AIDS cases in Senegal.
Both human immunodeficiency virus type 2 (HIV2) and human T-lymphotropic virus type IV (HTLV-IV) have been recently isolated in West Africa. Although previous serological surveys have revealed a high prevalence of seropositivity to HTLV-IV in healthy populations in Senegal, there have been no reported cases of HTLV-IV-related acquired immunodeficiency syndrome (AIDS). There have, however, been 2 AIDS cases in Senegal involving individuals with HIV2 infection. In addition, 4 Senegalese patients tested positive for the HIV2 virus in hospitals in the country in the 1 month period of March 15-April 15, 1987. One of these patients is a 50-year-old man with Kaposi's sarcoma; a 2nd is a 33-year-old man with Kaposi's sarcoma. The remaining 2 patients show symptoms of viral encephalitis. Blood samples were 1st rested by ELISA with a negative antigen as a control for specificity against HIV1 and HIV2. The difference, if any, between anti-HIV2 and anti-HTLV-4 seropositivity needs to be clarified.
[Population policy trends in Rwanda]
Rwanda is 1 of the few African countries that recognized the impact of population growth on national development at an early date and made control of demographic growth a principle development goal. The limited availability of land suitable for agriculture and the increasing fertility rate were 2 main elements of this realization. The total fertility rate increased from 7.7 in 1970 to 8.6 at present, while mortality is declining and the prospects of international migration have become almost nonexistent. Thus far, economic growth has been satisfactory and the standard of living of households has not declined, but population growth will lead increasingly to deterioration of land resources and eventually to a declining nutritional status in individual households. The interim emergency development plan in effect from 1966-70 recognized the demographic problem but placed the emphasis on increasing production and improving human resources in the belief that fertility could not be modified in the short run. Encouragement of internal migration and improved demographic data collection were the only strictly demographic goals in the plan. The 2nd development plan noted the inability of agricultural production to satisfy the nutritional needs of the population indefinitely, and clearly defined a demographic policy to encourage birth spacing while placing the greatest stress on increasing agricultural production. The 3rd plan, in effect from 1982-86, noted that the annual rate of population growth was 3.7% rather than 2.6% as assumed in the 2nd plan. Goals of the plan were to stop the acceleration in rates of growth and prepare the infrastructure for a rapid fertility decline in the 4th plan period. Demographic problems increased during the 3rd plan period and led to increasing subdivision of land and increasing problems of employment, education, health, production, and provision of other services. A multidisciplinary council to study population problems and possible solutions was created in 1974, and in 1981 on its recommendation the National Population Office (ONAPO) was created to implement population programs. The main areas of ONAPO activity were in sensitizing the population to sociodemographic problems and overcoming the tabu against discussion of family planning; conducting research to improve knowledge of various aspects of population and their impact on development; providing family planning training and population education at all levels; and determining the best way of integrating family planning services into basic health care. International population conferences have encouraged the government in its efforts. The role of private agencies has recently been increased, and a private family planning organization will soon come into being. Official discourses since 1973 have demonstrated the evolution of thinking about population problems and possible solutions appropriate to the economic and cultural conditions of Rwanda.
[The teacher and family planning]
This book is intended to prepare Mexican teachers for their role in providing family planning information in a positive context of values, interests, and affection. The 3 chapters discuss principles of family planning, methods of family planning, and teaching of family planning. The chapter on principles of family planning contains sections on the teacher in a changing society, sex education and family planning, societal attitudes to sex education, sex and sexuality, education in human sexuality, family planning, the family and family planning, the lack of a correct development of the family in Mexico, problems caused by lack of family planning, objectives of family planning, justification for the national family planning program, the Mexican general population law, National Family Planning Plan, services provided by family planning programs, family planning personnel, main obstacles to family planning programs, and the teacher and family planning. The chapter on family planning methods includes sections on specific fertility control strategies; the physiology of reproduction; contraceptive methods including condoms, diaphragms, spermicides, IUDs, hormonal methods, rhythm, postcoital douching, coitus interruptus, abstinence, prolonged lactation, vasectomy, salpingoplasty, and criteria for method selection. The chapter on teaching family planning contains sections on teaching family planning for the 1st years of life, preschool children, school children, adolescents, young couples desiring to start a family, and parents; planning a family planning education program, and aspects of developing a program: 1) development of a family planning education program in the community 2) recommendations for overcoming obstacles and rumors about family planning, and 3) basic principles of family planning communication. Appendices include a glossary of terms for family planning education program and lists of films and annotated bibliographies of works dealing with human sexuality, family planning, demography, and ecology.
[Evolution of childbearing norms and types of demographic behavior]
"Strict social norms of family size for many centuries maintained high fertility [in the USSR]. The author shows how radical change of family functions along with mortality decline have destroyed this regulatory mechanism and led to [a] decrease in fertility. In the context of social development the changes in reproductive motivation are [outlined] and the main causes of fertility decline are analysed." (SUMMARY IN ENG) (EXCERPT)
[Contraceptive behavior of spouses in urban families]
Contraceptive behavior of spouses living in urban areas of the USSR is analyzed. The distribution of various contraceptive methods and the attitudes of men and women toward their use and acceptability are described. (SUMMARY IN ENG) (ANNOTATION)
[Population growth in the USSR: trends and prospects]
The author discusses trends in the birth rate in the USSR for the country as a whole and for different regions. Causes of the fertility decline in several Union republics are analyzed. The need for cooperation among those working in different branches of the social and natural sciences is noted. (SUMMARY IN ENG) (ANNOTATION)
[The application of sociological methods in the study of population in the USSR]
The authors assess the application of sociological methods in the study of population in the USSR. (SUMMARY IN ENG) (ANNOTATION)
[Fertility in Turkmenian families (results of a pilot study)]
"It is argued that fertility in...Soviet Central Asia has begun to [decline]. It is obvious that within limits of traditional reproductive behavior high fertility is being put under control. The females in rural areas with developing industry now use more and more contraception." (SUMMARY IN ENG) (EXCERPT)
[The popularization of demographic knowledge--an important element in demographic policy]
The contribution of population policy to the development of socioeconomic policy in the USSR is assessed. The need to improve the public's understanding of demographic processes and to promote scientific knowledge is emphasized. (SUMMARY IN ENG) (ANNOTATION)
[Demographic aging of the population]
Trends in demographic aging in the USSR are analyzed, with a focus on the possible socioeconomic consequences. Particular attention is paid to the estimation of the social and economic effects of pensioners' employment and the organizational factors favoring economic activity among the retired population. (SUMMARY IN ENG) (ANNOTATION)
[Factors influencing the reproductive attitudes of spouses]
"Reproductive attitudes of...families and factors affecting them are presented and examined. Factors, divided into three groups--living conditions of the family, socio-demographic and socio-psychological characteristics of the spouses--are analysed as to their relationship with childbearing attitudes. Stratification of the families by their reproductive attitudes allows [the elaboration of] specific policy approaches aimed at fertility elevation." The geographical focus is on the USSR. (SUMMARY IN ENG) (EXCERPT)
[The relationship between matrimonial and reproductive behavior]
"The association between marriage and childbearing patterns at the modern phase of demographic development [in the USSR] is examined. It is shown how the woman's age influences the length of the interval between the wedding and the first birth. The way current marriage patterns affect fertility is characterized." (SUMMARY IN ENG) (EXCERPT)
An attempt is made to combine both qualitative and quantitative approaches to the study of functional types of families. A test for family type is presented posing the question, Who are we? and illustrated using data for 107 Swiss families living in Geneva. (ANNOTATION)
[The population geography of Canada]
Aspects of the population geography of Canada are presented. They include spatial distribution, natural increase, immigration, internal migration, provincial population change, cultural diversity, and population perspectives. (ANNOTATION)
Ethnographic approaches to demographic issues: some experiences from ILO work and studies in Ghana.
The author describes the interdisciplinary approach to data collection and analysis adopted in the course of research being conducted with support from the International Labour Office (ILO). The focus of the research was the relationship between women's roles and demographic issues. Case studies in Egypt and India are described, and recent research in Ghana is outlined. (ANNOTATION)
Spain's demographic modernization, 1800-1930.
This chapter, translated from the original Spanish, describes the demographic changes that occurred in Spain between 1800 and 1930. Consideration is given to regional variations in population growth, the demographic transition, changes in nuptiality, urbanization, and changes in the occupational structure. The author concludes that significant changes in demographic patterns did not occur until after 1900. (ANNOTATION)
The author explores possible ways of developing a qualitative approach to demographic research in developing countries. The primary objectives of such an approach are defined as the improvement of available demographic data and the identification of the role of human reproduction in the overall process of social change. The paper consists primarily of a review of how individual demographers have resolved such issues in specific cases. (ANNOTATION)
[The analysis of family structures: anthropological and demographic approaches]
The author attempts to demonstrate the compatability between anthropological and demographic approaches to the study of the family using examples for Europe as a whole, the Iberian peninsula, and India. The emphasis is on how quantitative and qualitative approaches can successfully be combined. (ANNOTATION)
Admissions of children with measles constituted 8.8% of all admissions to the pediatric medical service of the Korle Bu Teaching Hospital, Accra, over the 10 year period 1973-82. Measles remains endemic in urban Accra as in the towns of other developing nations. The peak of admissions occurred in the age range 7-12 months. Complications were frequent, with a high mortality rate (16.86%). Bronchopneumonia, the most common complication (63.9%) was also the most common cause of death in 51.5% of all cases. Comparative national case mortality rates were, however, surprisingly low and should be accepted with caution. There is an urgent need for intensification of immunization efforts through amalgamation of the preventive and curative services of Ghana, especially for children attending health centers for medical care. Vaccination should be administered before the peak age of admission, preferably at 6 months of age, with a 2nd dose administered as soon after 1 year of age as possible. (author's)
According to an agreement dated November 10, 1986, the Government of Tabasco is committed to support the Secretariat for Health's Smoking Control Program by assuming the following functions: encourage revisions of or additions to legal provisions in force regarding the prevention of smoking and rehabilitation of those suffering from smoking-related diseases; promote cooperation between the public, social, and private sectors; establish a state center for information on smoking; develop and extend public services that provide care to those suffering from diseases linked to smoking; stimulate the formation of self-help groups within the community for the prevention and care of tobacco dependence; foster the participation of antismoking groups in the smoking control program; strengthen the surveillance of compliance with health control measures related to the production and marketing of tobacco; implement smoking control measures in institutions of higher education; encourage academic institutions to develop studies on research methods on problems related to tobacco consumption; undertake epidemiologic studies designed to determine the causal and risk factors and medical and social consequences of cigarette smoking; and undertake studies for the early identification of those at risk of tobacco addiction.
[The decision to undergo tubal ligation]
Gynecologists frequently seek the opinion of a psychiatrist before performing tubal ligations. The case of a 25-year-old childless divorcee whose gynecologist feared that her request for sterilization was actually a sign of depression is described to illustrate different aspects of psychiatric evaluation of women seeking sterilization. The patient's appearance and comportment during the interview, husband, family, attitude toward children, and dreams appeared normal. A traditional psychiatric evaluation shed little light on her reasons for seeking sterilization. A scale developed in the course of a few years of interviewing sterilization candidates to try to achieve a degree of objectivity was applied to the case. The scale requires assessment of the client's motivation, contraceptive usage, self-image, psychosexual development, the economic value of the ligation, and the consequences for the patient's sexual, social, and professional life. The psychiatrist summarizes his detailed findings and states them in comprehensible and practical terms for the sterilization practitioner. In this case, the client was raised rather coldly in a large family of 13 children where she received little attention from her father or mother. Her family background caused her to enter the work force at a very early age and to seek affection from an older man whom she married at 19 after 2 years of living together. She soon realized that he could not fill her need for affection and decided to leave him as he was demanding a child. Her 2nd partner was an alcoholic whom she left for the same reasons. She could not accept the idea of having a child who would be demanding when her own needs were so pressing. Her position was reinforced by her belief that she could not use oral contraceptives because of recurrent infections and that the IUD is unreliable. Deep psychotherapy could probably lower her resistence to motherhood but the client had no motivation for it. There was little reason not to approve the definitive contraception that her past deprivation caused her to desire, even though it would prevent her in the future from fulfilling herself through motherhood. A review of the literature from the past decade on psychological aspects of sterilization indicates that sterilization has no therapeutic effect in the sense of making psychiatric problems disappear. A psychological evaluation should be sought if the candidate is young, feels ambivalent about the sterilization, or feels obligated to undergo sterilization for some reason.
[Urbanization and its consequences for socio-demographic structures in Tunisia]
Comparisons are made between rural and urban populations in Tunisia in terms of selected demographic and social factors using official and other published data for the late 1970s and early 1980s. The focus is on the consequences of imbalances created by Tunisia's urbanization for population composition, health, economic development, and certain social structures. The history of urbanization in Tunisia since the end of the nineteenth century is outlined. Urban and rural populations are compared on the basis of sex distribution, age distribution, mortality, and fertility. The relationships among urbanization and economic development, public health, and family structure are considered.
Third Annual Research Conference, March 29-April 1, 1987: proceedings.
These are the proceedings of the Third Annual Research Conference, held in Baltimore, Maryland, in 1987. These conferences "are intended to provide a forum for presentation and discussion of research relevant to Census Bureau programs, including the work of the American Statistical Association/NSF/Census Research Fellows." The theme of this conference was improving the quality of survey results "and included topics on survey error models, response rates, automated interviewing, automated data editing, confidentiality, and measurement of response error." The proceedings include the selected papers, reviewer comments, and summaries of discussions. (EXCERPT)
"This report presents socioeconomic data for the Black population from the 1980 census for the United States, its regions, divisions, and States, and for selected counties and places." Retrospective data from the 1970 census are also included. (EXCERPT)
"The purpose of the study is to shed light on the causes of the large difference in mortality from ischaemic heart disease (IHD) between East and West Finland. The study is based on the death certificate records on deaths from IHD in 1971-1975 among Finnish men aged 35-64. These records were linked with the records on persons in the 1970 census. Mortality from IHD is analyzed simultaneously by region of birth and region of residence, controlling for several socio-economic and demographic variables, by means of log-linear models. The analysis shows that being born in East Finland and living there both increase the risk of IHD, but that being born in East Finland is a more important risk factor than is living there." (SUMMARY IN FRE) (EXCERPT)
Demographic profile of North West Frontier Province of Pakistan.
Population trends in the North West Frontier Province of Pakistan are analyzed using the latest available census and survey data, including the 1961 and 1972 censuses. The studies divided into five substantive chapters. The introduction includes a review of the available data and its quality. Chapter 2 examines population growth since 1855, population distribution, density, and characteristics. Chapter 3 deals with fertility, mortality, and migration. Chapter 4 presents projections to 1992 and their policy implications, and Chapter 5 contains a summary and conclusions.
[Evaluation of BCG vaccination programmes]
Data from selected Western Pacific countries on morbidity and mortality from tuberculosis in children provide information on the effectiveness of Bacille Calmette-Guerin (BCG) vaccination and illustrate several relatively simple methods of obtaining information from national immunization programs. In Malaysia, where the protective effect of BCG vaccination was estimated at 60%, data were recorded separately for children with and without a BCG scar and the numbers of vaccinated and nonvaccinated persons in the 0-19-year age group were calculated. In Singapore, analysis of notifications of tuberculosis cases in primary and secondary school students suggested that vaccination at birth has a protective effect of over 85% at primary school age and 73% at secondary school age. In Korea, this effect was estimated at 90%. In prospective studies, protection is defined as the difference of the incidence of tuberculosis in the control and the vaccinated groups as a proportion of the incidence in controls. In retrospective evaluations the ratio of vaccinated to nonvaccinated cases is easily determined in persons diagnosed, whereas in prospective studies a population representative of that from which the patients were drawn must be found to allow for comparability.
"Data on age at menarche have been collected, using the status quo method, among 1,246 Tahitian girls attending school. The median age, estimated by probits, is 12.75 SD 1.76. The girls of the rural districts have a higher median age (13.08 SD 1.97) than the girls of Papeete (12.61 SD 1.47). The results were compared with data collected among other girls of Maori or European ancestry in France, New Zealand and Easter Island." (SUMMARY IN FRE AND GER) (EXCERPT)
[Education in the natural method: guide for use with audiovisual]
This guide was prepared to help couples learn how to control pregnancy in a safe and responsible way. The guide is made up of a kit which includes a set of slides with an accompanying tape, a book, and some charts on natural birth control methods. The male and female reproductive systems are explained, as are different ways to determine when a woman is best able to conceive. This birth control method is based on periodical abstinence as a consequence of the observation and interpretation of two main factors: the woman's basal body temperature and changes in her cervical mucus. Various countries have developed small computers which accurately measure basal body temperatures and can determine the most potential days for conception. These instruments can be as small as a thermometer. Natural methods are considered a "way of life" and, if chosen, both partners must fully cooperate in practicing abstinence. This practice requires a good knowledge of the human body, which can be acquired quickly. Such methods are safest for the body since they do not interfere with other body functions. A description of artificial contraceptives includes: the pill, the minipill (progesterone), IUD, vaginal diaphragm, chemical contraceptives and, finally, sterilization. The negative aspect of the latter is irreversibility. Sterilization is the most widely used method in the world, but it has to be considered a definitive solution. A quiz and a list of centers for training in natural methods ends this section. The last part of the book discusses sexuality in the context of morality and responsible love.
[Data organization and automatic elaboration criteria]
The Italian National Institute for Statistical Data (DOXA) has supplied data from questionnaires for this report which has 2 primary objectives: 1) to illustrate what actions have been taken to revise initial data gathered on fertility in Italy and to determine methodology for further studies, while eliminating duplication of effort; and, 2) to clarify the tables in the initial general report. The study resolved the problems of possible sampling errors through the use of a specific language, LS2, in sampling raw data, and allowed a realistic interpretation of each interview conducted by assigning weighted values. The tables are prepared in 5 different groups. Variables on vital statistics and fertility were identified for each group. Some of the tables are crossreferenced. After data had been gathered, 5 different programs were written in Fortran IV, named GROUP 1, GROUP 2, GROUP 3, VARCOM, and TAB. The 1st 4 represent the input of the data generated in LS2. The TAB group gives the variables and prepares the final tables of groups 4 and 5. The system of data organization and automatic generation criteria permits a flexible and rapid gathering of information relating to fertility in Italy.
Global overview: the Expanded Programme on Immunization, Cartagena, Colombia, 14-16 October 1985.
This paper reviews the development of the global Expanded Program on Immunization (EPI) initiative, reports on program progress since the 1984 EPI conference, and identifies actions needed to meet the goal of providing immunization services to all children of the world by 1990. The central EPI strategy to date has been to deliver immunization in consonance with other health services, particularly those aimed at mothers and children. The long-term goal of such efforts is to strengthen the health infrastructure so as to ensure the continuous provision of immunization and other primary health care services. Simply by reinforcing existing health services, a coverage level of 60-70% will be achieved in developing countries by 1990. If universal coverage is to be achieved, external funds will have to be provided to meet operational costs and train national managers. Acceleration of existing efforts constitutes the main EPI priority at present. Specific areas suggested for immediate action include provision of information about immunization at every health contact; a reduction in the drop-out rates between 1st and last immunization; increased attention to the control of measles, poliomyelitis, and neonatal tetanus; improved immunization services to the disadvantaged in urban areas; and, where appropriate, acceleration of the EPI through approaches such as national immunization days. Ongoing actions that need to be pursued include strengthening disease surveillance and outbreak control, reinforcing training and supervision, and pursuing applied research and development. Overall, management capacity within national programs remains the most severe constraint for the EPI.
This training module was designed to provide mid-level managers of immunization programs with the skills needed to allocate resources and plan the distribution of supplies. Careful planning is essential to effective and efficient immunization activities. A lack of planning can lead to problems on the days of vaccination sessions that will have a negative impact on public cooperation and vaccination continuation. The module includes exercises relevant to the following basic steps in planning the allocation of resources and distribution of supplies in a vaccination program: describe the characteristic of the population to be served, identify available resources for vaccination activities, select populations to be served and vaccination strategies to be implemented using available resources, determine whether resources are sufficient to meet the objective, develop and implement a plan to obtain additional resources, obtain additional resources where necessary, consult with higher level managers to modify vaccination coverage objectives, assess whether resources exceed the amount needed, determine the use of extra resources, and develop a plan for distributing supplies. The volume includes flow charts and sample worksheets.
This document describes the new, simplified version of the Vaccine Cold Chain Monitor Card that is being packed with vaccines supplied by WHO and UNICEF. The card, which has 2 monitors that turn blue if the temperature rises, serves as an effective monitor of the cold chain during shipment and gives health workers guidance on whether to use the vaccines they receive. The new monitor card has only 4 windows for registering temperature changes and has the instructions for interpreting the readings on the card. To retain potency, vaccine should be kept at a temperature of 8 C or less at all times. Also provided in this document is information for health workers on how to use the card in routine onforwarding of shipment and action to take in the event of a break in the cold chain; an additional section provides information for vaccine manufacturers and distributors on what to do when packing monitor cards with vaccine despatched and how to store vaccine cards. The cards are available in 5 languages--Arabic, English, French, Portuguese, and Spanish--at a price of 415 Swiss francs/100 cards.
Summary report: UNICEF Cold Chain Survey 1981.
81% of developing countries responding to a 1981 cold chain survey carried out for UNICEF reported that preparations for the Expanded Program on Immunization (EPI) were complete. 64% of the responding countries indicated that Central Store facilities were adequate for the needs of the current national population, but only 28% reported that UNICEF or government purchases for new facilities were in progress. The largest discrepancy was recorded in the African region, where 44% of countries believed that central storage facilities were inadequate and only 31% had purchase orders. Overall, 61% of countries considered Regional Store facilities to be adequate, with a range from 44% in the African Region to 83% in Southeast Asia. The majority of countries of countries reported problems in terms of the quality and availability of power and fuel supplies. The most prominent problem, however, was poor transport for the cold chain, cited by 60% of countries. Specific transport problems mentioned included poor distribution of vehicles, inadequate vehicle maintenance facilities, inappropriate choice of vehicles for peripheral areas, and inefficient utilization of existing transport.
[Fertility in Europe since 1960: convergence or divergence?]
The author surveys fertility trends in Europe since 1960, relying on a variety of official and published sources for selected countries. Trends in cumulative fertility from the 1930s to the 1950s are first discussed. Attention is then given to the decline in fertility in selected European countries during the period 1960-1984. Change over time in fertility outside of marriage in some countries is interpreted as a compensating factor reducing the effect of declining marriage rates on total fertility. Trends in the distribution of families by size, premarital conception, and shifts in contraceptive methods chosen are also discussed. Among the factors outlined in the closing section as contributing to the observed fertility decline are structural variations in the population, progress in contraceptive effectiveness, individual psychological and economic factors, and social factors.
Demographic change, economic growth and social welfare.
"In this paper we examine the economic rationale for concern about the falling rate of growth of Europe's population. Does slow, zero or negative population growth matter from the point of view of its effect on the capacity of the economy to improve social welfare?" It is concluded that "there may be long-term economic effects of demographic change on a stationary Europe's capacity to generate technical progress and to sustain economic growth. There could also be problems in the twenty-first century about financing the state pensions promised to some of the baby boom generation." Alternatives to a deliberate pro-natalist policy solution are discussed. (SUMMARY IN FRE) (EXCERPT)
The author examines population policies undertaken in Europe in pursuit of a variety of demographic goals, with a focus on policies affecting fertility and the family. The recent experiences of selected European countries are described. Among the governmental actions considered are reductions in working hours for employed mothers, subsidized child care, housing allowances, social services for children, and restricting access to contraception. The inadequacy of existing methods to assess population policy effectiveness is discussed. (SUMMARY IN FRE) (ANNOTATION)
Models of marital status and childbearing.
The authors review the microeconomic models of marital status and childbearing that have implictions for female labor supply. The geographic focus is on developed countries, primarily the United States. "Section 2 contains a review for the United States of trends in those demographic variables which are strongly associated with female labor supply: age at first marriage, marital dissolution, age at first birth, the number of children born over the life cycle, and the age pattern of fertility." Section 3 is concerned with demographic models and the empirical regularities in demographic behavior. The microeconomic models that attempt to explain the facts described in Sections 2 and 3 are then considered. "Section 4 explores models of marital status, and in Section 5 the single-period models of lifetime fertility decisions are reviewed. Section 6 is concerned with the efforts of Wolpin (1984), Newman (1985), and Hotz and Miller (1985) to extend the single-period fertility models to dynamic settings with uncertainty." (EXCERPT)
Since 1975, interregional migrations have become less frequent.
Interregional migration in France since 1954 is reviewed, with a focus on the decrease of internal mobility between 1975 and 1982. Age-specific migration rates for several regions are discussed, and graphs of migration rates for the regions are furnished. (ANNOTATION)
Immigration: still the golden door?
A review of current trends in U.S. immigration is presented with the focus on changes in attitudes within the United States toward immigration. Consideration is given to political factors and to the economic effects of immigration. (ANNOTATION)
Opinion poll on population development in the Federal Republic of Germany--Autumn 1984.
The results of a 1984 opinion poll on population trends in the Federal Republic of Germany are summarized. The survey's objective was "to determine which information, ideas, opinions and apprehensions the population has with regard to...present and presumable future population development. This survey comprised [2,500] persons of German nationality aged 18 years and over living in the Federal Republic....The following topics were included in the survey: knowledge and information about...population development in the Federal Republic of Germany, information about family allowances and measures of family policy, marriage behaviour and consensual unions, desire to have children and childlessness, significance of the [family, and] attitude towards the foreign population." (EXCERPT)
Recent changes of nuptiality in the Federal Republic of Germany.
The author describes a method for estimating nuptiality, designed to accommodate changing marriage practices in the Federal Republic of Germany. Tables extracted from the complete nuptiality table and reviewed here provide estimates for marriages and legitimate and illegitimate births, 1966-2010; summary results of nuptiality tables for single German nationals by sex for four time periods; nuptiality tables for singles for three time periods; and the probability of single men and women marrying for three time periods. The tables are constructed, for the most part, for ages 15-65 at five-year intervals.
The projections 1985 of the population of the Federal Republic of Germany.
Projections of the age and sex distributions of the population of the Federal Republic of Germany to the year 2030 are provided separately for Germans and resident foreigners. Population pyramids for the years 1983 and 2030 are compared. Three sets of projections of the age structures of the native German and resident foreign populations are presented, based on three different assumptions concerning the net reproduction rate. (ANNOTATION)
The author describes the construction of a three-generations model, which he uses to explain that a change in net reproduction rates will reach a new balance in the course of three generations. The model is used to illustrate changes in reproduction rates in the Federal Republic of Germany. A population pyramid based on that country's age-specific birth and death rates for 1983 is compared with the population pyramid under stable population assumptions. (ANNOTATION)