Federal statistics in local governments.
"For decades the [U.S.] government has used statistics to carry out policy at the local level. Accordingly, much of the local statistical enterprise has evolved in response to federal statistical requirements. Federal programs provided the original impetus and funding, and the changing forms of federalism have left their stamp on local institutions, attitudes, and statistical practices." The author compares two phases in the development of the federal grant system: 1946-1970, characterized by categorical grants, and 1970 to the present, characterized by block grants and revenue sharing. She also comments on the 1980 census, the significance of public acceptance of its statistics, state and local sources of data, and disparities in local governments' access to census data. (EXCERPT)
Specimens from the lower genital tract of 102 sexually active urban adolescent females were tested for the common sexually transmitted diseases (STDs). The results were correlated with concomitant clinical, demographic, and historic data. 41% (42/102) were infected with one or more of the following organisms: Chlamydia trachomatis (26/102), Trichomonas vaginalis (13/102), Neisseria gonorrhoeae (10/102), yeast (6/102), Condyloma (5/102), and Herpes simplex virus (1/44). Mixed infections were found in 13%. 59% were negative for any infectious agents. The presence of genitourinary symptoms were of no value in predicting an STD. The rate of positive physical findings was significantly higher in the STD-positive group than in the negative group (p=0.03), but 28% of the STD-negative group had positive physical findings, and 50% of the STD-positive group had normal physical findings. A history of genitourinary complaints or presence of physical findings was not predictive of a positive STD culture. Oral contraceptive use of more than 6 months appears to be a risk factor for an STD. No other factors, including the number of sexual partners, were significantly correlated with the presence of an STD. This study supports the need for routine screening of sexually active urban adolescent girls for an STD. (author's)
Menarche and sexuality among a sample of black South African schoolgirls.
Data from a survey of 165 schoolgirls in grades 6-9 in Pretoria, South Africa, were used to assess the impact of cultural background on menarche and sexuality. 110 girls (66%) indicated they had begun to menstruate, and 71 (43%) indicated they had engaged in sexual intercourse. A set of questions on sexual knowledge revealed widespread confusion about changes in fertility (i.e., menopause) that occur with aging. 70% of respondents thought it was necessary to engage in intercourse more than once to become pregnant. Comparison with data from other surveys conducted in South Africa indicates that the age at menarche has decreased over time, suggesting improved living conditions in urban areas. 84% of the urban schoolgirls in this study who were 15 years of age had experienced menstruation; by age 16 years, all subjects were menstruating. 25% of 16 years olds surveyed were sexually active. 76% of study subjects indicated an awareness of birth control, primarily oral contraceptives. When respondents were asked to cite the ideal age at which sexual intercourse should be initiated, the majority identified age 20 years or above. 40% agreed that intercourse should be restricted to purposes of procreation. The combination of the high rate of sexual activity among teenagers in this sample and the limited knowledge of birth control suggests a cause for concern. Understanding of this phenomenon must take into account the cultural context of premarital sexual socialization in South Africa. Traditional Black communities in South Africa expected some form of sex play or sexual intercourse among young people; however, it was always subject to social control and was not supposed to lead to pregnancy. This control has been eroded by urban migration and the consequent challenge to traditional values.
The development of China's population statistics.
China's population statistics began to develop in the 21st century BC. In the 3rd century BC, the system of household registration began. There were comparatively complete records on population figures in 2 AD. However, these statistics were nonsystematic. The figure of 474,800,000 people was pieced together in 1931. After the founding of the People's Republic, China gradually developed complete and accurate population statistics. Today, China procures population statistics through 4 channels: 1) the household register offices at all levels annually tabulate population statistical data sent in from their subordinate units and report the results to the statistics organs at corresponding levels, 2) the nationwide enumeration of the population is conducted in an organized way at a fixed reference time, 3) sampling surveys are conducted to provide information on changes in population, and 4) socioeconomic data is collected. The 1st National Population Census was conducted in 1953, the 2nd in 1964, and the 3rd in 1982. The 3rd has made progress in the following areas: 1) the number of topics expanded from 9 to 19, 2) major methodological improvements were made, 3) the organizational work was meticulously done, 4) all census figures were processed by computers, and 5) it was aided and supported by the United Nations Population Fund, and other UN agencies, and certain countries. China's population statistical work should be strengthened and improved in a number of ways: 1) the system of population statistical indicators should be improved, 2) data of population statistical annual reports need to be improved, and 3) the vast amount of information obtained in the census needs to be thoroughly analyzed.
[Conditions of youth in Latin America]
The definition of youth varies greatly according to the temporal and cultural context. The total world population of youth, defined by the UN as persons aged 15-24 years, was 738 million in 1975 and is expected to reach 1180 million by the year 2000. The Latin American youth population was estimated at 101,438,000 in 1985, of whom 1,854,000 are in the Dominican Republic. The youth population increased by about 80% in the past 20 years in developing countries, and will continue to increase rapidly, exacerbating problems of providing food, education, health, and other services under unfavorable economic circumstances. The social infrastructure all over Latin America has been hard hit by the current economic crisis, which has worsened since 1982. In late 1984 the Latin American external debt reached $350 billion. Its repercussions have included diminished employment opportunities, reduced family incomes, low levels of expenditures for social services, increased prices for food and basic services, and serious social tensions. Poverty and inequalities between social groups have increased, political institutions have been weakened, and the stability of countries has been seriously threatened. To improve the quality of life of youth and promote their development will require specific efforts in the face of this unfavorable economic and social context. Providing for the minimal needs of life, health, economic production, and education of youth calls for reconsideration of the concepts of development and model or image of the type of country which the society aspires to become. The achievement of peace is another goal of the International Year of Youth, 1985. At a time when the reasons f r cooperating are ever more numerous, the causes of friction are proliferating. Each year the world invests over $600 billion in weapons, with even the poorest of countries participating in the race for armaments. In Central America, 800,000 persons have been displaced from their homes and 300,000 are refugees because of armed conflict. Other forms of violence such as accidents also threaten the youth of Latin America. The road to peace in the region contains numerous obstacles which the adult population should seek to overcome. A minimum of 454,230 youth in the Dominican Republic are estimated to live in "extreme poverty", but examples from other countries suggest that youth can contribute significantly to the improvement of conditions.
ERA and the abortion controversy: a case of dissonance reduction.
This study used 1976-82 Center for Political Studies National Election Study Data to assess the dynamics of opinion change toward the Equal Rights Amendment in ratifying and rejecting states in the US. The data suggest that the greater opposition to the ERA in the rejecting states was a reflection of traditionalism in areas such as sex roles, religiosity, attitudes toward abortion, and political conservatism. Rejecting state respondents were significantly more traditionalistic than those from the ratifying states on 14 of 18 indicators of traditionalism examined. By 1976, the ERA had become linked in the public mind with feminism, secularism, nontraditional sex role orientations, liberalized abortion, and civil rights for blacks. There is evidence that many of the more traditionalistic early ERA supporters experienced cognitive dissonance in response to uncertainty and confusion over the amendment's consequences created by the changed political environment in the rejecting states. Many socially conservative supporters of the ERA experienced dissonance in the post-1976 period and re-established equilibrium by changing their conflicting attitudes. By 1982, withdrawal of support for the ERA was virtually complete among anti-abortion whites from rejecting states. These findings lend support to the recommendation that an alternative to a constitutional amendment be sought to secure women's equality, given the identification of the ERA with abortion.
[Comparative changes of exocervical exfoliative cytology in intrauterine device users]
The widespread use of IUDs has led to a series of questions on their possible hazards; however, research in this field is inconclusive. It has been suspected that IUD usage can cause varying degrees of dysplasia in some patients, but up to now most of the research has had conflicting results. Therefore, a study of the modifications of the exocervical epithelium induced by prolonged IUD usage was conducted in Italy on 1000 women who had used the device between 1976-1982. As a control group another 1000 women who had used either another method of contraception or no method at all were used. The age of the patients was restricted to 20-35 years. The sample was fixed with alcohol solution and colored according to the Papanicolaou technique. All of the exocervical epithelium modifications that could have constituted a scaly metaplasia, dyscariosis, mild dysplasia, medium dysplasia, or carcinoma in situ were registered. Out of a total of 1000 IUD users, lesions of various types were found in only 34 cases. There was never a cellular modification from metaplasia or from dyscariosis to dysplasia, while the only case of carcinoma in situ was diagnosed after a deponent cytology for light dysplasia. Out of these 34 cases, 80% of the lesions showed up within the 1st 2 years following the application. This holds true with virtually all types of lesions. The findings show that there is a slight rise in the incidence of lesions in IUD users. According to the results, the scaly metaplasia was 1.3 times greater, dyscariosis 1.4 times greater, and mild dysplasia 3.5 times greater in IUD users than in the control group. There is a slightly greater risk of lesions among IUD users, but this risk does not seem to be enough to advise against their use. However, women who use IUDs should have more frequent regular medical examinations because of the slight increase in risk.
HIV infection in Zaire [letter].
Epidemics develop after a change in the interaction between the causative agent, host, and environment. Urban centers often serve to amplify infectious diseases, as appears to have happened with HIV in various African cities. HIV infection has remained stable and low over 10 years in a remote region in northern Zaire. Low rates of HIV infection have been demonstrated in rural areas of other countries as well. In contrast, studies of stored serum specimens from pregnant women in urban Kinshasa show an increase in the prevalence of HIV infection, from 0.25% in 1970 to 3% in 1980 and 6% currently. Acquired immunodeficiency syndrome (AIDS) has spread most rapidly in areas with intense migration, advanced communications, and disruption of social life. Social change, specially urbanization and population movements, is believed to play a role in the different patterns of disease.
[Migration statistics in the capital of Prague]
A demographic study describes the methods of gathering, processing and publishing migration data throughout Czechoslovakia for the period 1950-1980, and then treats in more detail the availability of information on migration for the capital city, Prague. May 1, 1949 marks the initiation of monitoring Czechoslovak internal migration in accordance with Ministry of Internal Affairs legislation requiring declaration of place of residence and employment, and filing applications for any change in status. The collection agencies, which were local national committees in the smaller communities, and offices of the State Security in the larger communities, forwarded monthly collations of statistical lists of applications for permanent residence to district offices of the State Statistics office, which tabulated this information, organized it by district, and forwarded it to Prague for processing. Although another law in 1952 required another national registration of permanent residence, this time eliminating the local national committees from the process, the latter is the method still used today in compiling the regularly issued and updated source statistical volumes for Czechoslovakia. Mechanical processing was introduced in 1954, and since 1972 the EC 1030 machine in the JSEP series has been used. A table showing change of permanent residence within Prague, according to individual districts, was published in Population Movement in the Czechoslovak Socialist Republic in the Year 1964. Present source volumes also contain information on emigration out of Czechoslovakia based on passport applications.
In order to further the constitutional right of citizens to health protection and to rationalize the use of health resources, the Mexican government in February 1984 decreed that health services for the population not covered by social security systems would be decentralized to the states. The affected health services were those of the Secretariat of Health and Welfare and those of the Program Solidarity through Community Participation (IMSS-COPLAMAR) provided by the Mexican Institute of Social Security (IMSS). The decentralization of both systems would require programmatic coordination of functions in the 1st stage. Ultimately, integration of the 2 systems with the local health services would lead to creation of a single organization offering state health services. Decentralization of the services and their integration into state systems is designed to permit extension of coverage and improvement of quality. Decentralization is to be gradual and orderly to avoid deterioration of quality and to facilitate evaluation. The programmatic coordination of services achieved in 1984 is to be reviewed at the end of the year. Health services are to be decentralized to some states in 1985 and to the remainder in 1986. An operational committee of IMSS-COPLAMAR is to be formed with representatives from the Secretariate of Programming and Budget, Health and Welfare, Urban Development and Ecology, Agrarian Reform, and others to develop, implement, control, and evaluate the decentralization program. Within 90 days of the initiation of the decentralization program, the Federal Executive is to be given the necessary materials, manuals, and instructions for the programmatic coordination of health services.
This document presents the text of health legislation approved in Mexico on December 23, 1986, setting forth ethical issues and professional responsibilities in the area of health research. Health research is conceptualized as activities that contribute to knowledge regarding biological and physiological processes in humans; knowledge of the links between the causes of disease, medical practice, and social structures; prevention and control of health problems; evaluation of the harmful effects of the environment on health; the study of techniques recommended or used for the delivery of health services; and the production of goods for the health sector. Title 1 of these regulations outlines responsibilities of the Secretariat of Health and calls for the establishment of an Inter-Institutional Commission on Health Research. Title II defines ethical aspects of research on human subjects, with separate provisions for research involving minors, incompetent persons, women of childbearing age, pregnant women, women during labor or childbirth, nursing mothers, embryos, stillborn fetuses, and cadavers. In general, research is permissible on human subjects only if it confers health benefits and carries minimal risks. Title III sets forth regulations on research on new prophylactic, diagnostic, therapeutic, and rehabilitative methods, while Title IV concerns the biosafety of research. Clinical research in the field of pharmacology must include 4 phases preceded by full preclinical studies. Finally, Title V of this legislation defines the duties of internal committees in health institutions.
[Prevention of post-abortion complications]
A study was conducted on the effectiveness of vibratory massage of the uterus in preventing post-abortion complications. Observations were made on 303 pregnant women, ages 20-40, admitted to the gynecology clinic for induced abortions. The base group consisted of 168 women who received vibratory massage of the uterus after the abortion; the control group consisted of 135 women not given vibromassage. The base group included 28 (17%) primiparae, 9 (5.3%) parae and 27 (17%) nulliparae; 60 (36%) had each had 3 abortion, and 27 (17%) had had 4 or more; 43 (25.5%) of the women had their fit menstruation by the age of 15 and later; painful menstrual function (algodysmenorrhea) was noted in 44 (26%) of the women; 41 (32%) had sex for the first time at an early age (14-16 yrs). Histories showed chronic inflammation of adnexa for 20 (12.5%) and cervical erosion for 6 (3.5%). Similar data were obtained in the control group. In the base group, 28 of the women were 6-8 weeks pregnant, 92 were 8-10 weeks and 48 were 11-12 weeks, in the control group, the numbers were 44, 56 and 35, respectively. Induced abortions were performed by curettage (126 in the base group, 110 in the control group) and vacuum-aspiration (42 and 25, respectively). Vibromassage of the uterus was performed immediately after the abortions and on the 1st and 2nd days of the post-abortion period. The effect of the vibromassage was evaluated by clinical observation of the women, uterine probing, amount of blood loss, examination of vaginal discharge for microflora, clinical blood analysis, and immediate and late post-operative complications. In the group with abortions preformed by vacuum-aspiration with vibromassage, no heavy blood loss was detected, and the number of women with little or no discharge increased significantly compared to the control group. In the group receiving vibromassage, hematometra was detected in 2.4% of the women, endometritis on 6%, exacerbated chronic inflammation of adnexa in 4%. In the control group, the figures were 6, 13.3 and 17.6%, respectively. In observations for 12-24 months after the abortions, among 100 women who received vibromassage, disturbance of menstrual function was noted in 19.3% and sterility in 8.2%, while in the control group 14.1 and 16.2%, respectively. In the first 6 months after abortion, women not using contraception became pregnant in 7% of the cases, and in 9.1% of the cases among those who received vibromassage. Thus, studies showed that vibratory massage of the uterus, employed immediately after the induced abortion and the next two days of the post-abortion period, has a stimulating effect on the contracting activities of the uterus and contributes to a decrease in immediate and late complications.
[Postpartum contraception (letter)]
The article reviews the methods of contraception that can be recommended after delivery. Oral contraceptives can be used following the 1st menstrual cycle, but should be avoided during breastfeeding. The minipill can be used during breastfeeding, but its limitations should be taken into account. The diaphragm can be prescribed once postdelivery secretions have discontinued. The IUD should be inserted once the uterus has returned to its original position in order to avoid IUD dislocation. Sterilizations is justified at the time of delivery only when the procedure has been discussed with the patient in detail in advance. Laparoscopic sterilization is best done 6-8 weeks after the uterus has returned to its original position.
A framework for the study of proximate determinants of infant mortality in less developed countries.
This paper focuses on the development of a conceptual framework of proximate variables that affect infant mortality. It reviews briefly the frameworks proposed elsewhere and proposes a comprehensive framework of proximate variables that might prove to be more adequate than the existing ones for studying the determinants of infant mortality (both neonatal and post-neonatal) in less developed countries. The usefulness of this framework and the importance of a quasi-anthropological methodology for collecting data on some proximate variables is also discussed. The analytical framework includes 9 proximate variables affecting infant mortality in general. Variables operating at conception include: 1) reproductive health of mother at conception (e.g., nutritional status and other indices of maternal health) and 2) genetic constitution of infant (e.g. reflecting congenital abnormality). Prenatal variables include: 3) prenatal medical care (e.g. immunization of pregnant mother) and 4) prenatal nonmedical care (e.g. nutrition and workload during pregnancy). Factors operating at delivery include: 5) medical care at delivery (e.g. attendance by medical, paramedical, or other personnel) and 6) nonmedical care at delivery (e.g., hygenic and sanitary conditions. Postnatal factors include: 7) postnatal medical care (e.g., immunization of infant, treatment of illness); 8) postnatal nonmedical care (e.g., infant feeding practice); and 9) accidental injury (e.g., fire, flood, boat accident). An important and urgent research task to increase the efficacy of the proximate variables framework here is to develop appropriate indices for measuring them.
INTRAH Glossaire de planification familiale / INTRAH Glossary of family planning terms.
This French-English glossary has been developed for all categories of personnel involved in family planning. It covers terms used in providing family planning education and services, anatomy and physiology of the reproductive systems, counseling, illnesses that might influence the selection of a contraceptive, common sexually transmitted diseases, and a basic understanding of statistical words used in program or service evaluation, administration, and management. The definitions are purposely concise, to provide quick identification of terms. The glossary is aimed at a middle level of comprehension, assuming that the user has had some background in, or orientation to, the health field.
Fertility effects of electrification in northeast Thailand.
A sample survey of 1000 households in the Northeast region of Thailand provided support for the hypothesis that electrification alters the socioeconomic structure of household members, which in turn affects family size norms, intermediate variables, and ultimately, fertility. Specifically, the availability of electricity contributes to the establishment of new agri-centered industries and generates opportunities for employment in both farm and non-farm type occupations. In general, the electrified villages surveyed were more developed than the unelectrified villages. The proportions of electrified villages with roads and family planning centers were 2 times greater than the proportions of unelectrified villages. In addition, electrified villages had twice the proportions of males and females engaged in non-agricultural occupations, a higher mean annual household income, a higher incidence of family planning, and lower fertility levels. Household electrification appears to increase income indirectly by increasing the participation of males and females in non-farm occupations and directly by enabling new income-generating activities such as sewing and craftwork. There are 3 patterns of linkages through which electrification exerts a significant antinatalist effect on fertility: the 1st is through the positive effect of male non-agricultural occupation on family planning, which is inversely related to fertility; the 2nd and 3rd are through the negative effects on male and female non-agricultural occupations on desired family size, which inversely affects the use of family planning methods. Further, children in electrified households have consistently lower rates of participation in both household and economic activities than those in nonelectrified households; the reduced utility of children as labor may have contributed to the lower family size norms found in the former villages. It is concluded that continued development efforts in the area of rural electrification will contribute to a fertility decline in Thailand.
Fertility effects of agricultural irrigation in northeast Thailand.
The authors examine the relationship between agricultural development, specifically agricultural irrigation, and fertility in northeastern Thailand. It is hypothesized that "the availability and utilization of irrigation systems in combination with other development projects alters the social and economic structure of households, which affects norms of family size, the intermediate variables and consequently fertility. Specifically, irrigation contributes to a more effective land use pattern, higher cropping intensity, and increases in farm production, which results in higher household income....The increased income and female labor force participation are then expected to decrease the demand for children, resulting in lower norms of family size, higher practice of family planning and lower fertility." The fieldwork for the study involved 4,500 household interviews conducted in 1980. Mixed results are found, depending on the intermediate variable emphasized and the level of analysis--either village or household--used. (EXCERPT)
Fertility impacts of development programs in Sri Lanka.
The authors assess the impact of three specific development programs in Sri Lanka on selected socioeconomic factors and, in turn, on fertility. The data are from a sample survey conducted in areas where the government's guaranteed agricultural price system, land settlement system, and rural electrification programs are in effect, as well as in areas where no development programs exist. Fertility data are for the years 1977-1981. "In the first section we analyze the impact of development programs upon the socioeconomic status of males and females separately, using multiple regression; and in the second section we utilize path analysis to illustrate the relationships and linkages between development programs, socioeconomic status, family planning and fertility." It is found that "development programs and their different combinations will exert an effect on the socioeconomic structure of a population. The second portion of the hypothesis which states that the socioeconomic structure will affect fertility through family planning is supported for all programs, either through the effect of occupation or income or both variables." (EXCERPT)
This chapter discusses the effects of increases in adolescent sexual behavior on the health of the adolescent, her future reproduction, and the health of her offspring, as well as the health consequences of adolescent pregnancy. This literature review is limited to those consequences of sexual behavior--sexually transmitted diseases, induced abortion, and birth--that are most likely to affect the physical well-being and future reproductive health of the adolescent population. Increases in the rates of sexually transmitted diseases (STDs) have generally paralleled the rise in rates of sexual experience among adolescents during the 1970s. For some infections, such as genital herpes or chlamydial infections, they could continue to climb. The risk of gonorrhea, syphilis, and chlamydial infections is highest among the teenager, particularly when rates are estimated for sexually experienced women. Gonorrhea and chlamydial infections have been implicated in pelvic inflammatory disease and its consequences of infertility and ectopic pregnancy; both have been increasing recently among young black women. Complications following induced abortions are generally lower among adolescents than older women, regardless of the gestation at which the abortion was performed or the method used. Most recent research indicates that the elevated risk of poor pregnancy outcomes among adolescents is most likely explained by a preponderance of risk factors among young mothers. High rates of perinatal and neonatal deaths have been associated with high low birth weight rates among adolescents; however, an elevated risk of postneonatal deaths among the offspring of adolescent mothers appears to be independent of age differences in birth weight. The research on early childhood morbidity is too limited to determine whether this increased risk extends to morbidity as well.
[Demographic and Health Survey in Burundi 1987, preliminary report]
This report constitutes the first result of an agreement between Westinghouse's Institute for Resource Development and the government of Burundi formed in 1986 to 1) investigate the demographic situation of the country and 2) improve Burundi's institutional capacity to conduct demographic surveys and utilize their results in development planning. The report is divided into 2 parts. Part I, on women, contains 6 chapters on 1) country background, 2) survey methodology, 3) sample characteristics, 4) nuptiality and fertility, 5) knowledge and use of contraception, and 6) maternal and child health. Part II analyzes data on husbands and contains chapters on 1) sample characteristics, 2) fertility, and 3) knowledge, attitude, and practice of contraception.
The 11 papers in this volume deal with massive population displacements, a 20th century phenomenon. Some of the displaced go voluntarily, as the search for jobs and a better material standard of living leads them to emigrate from rural areas to cities or across regional and national boundaries. Many are forcibly uprooted, the unhappy consequence of major development projects, because governments decide to redistribute populations, or because of war or political upheaval. 1 theme running through these case studies is the interplay between hosts and newcomers. Lacey and Morgan focus their discussion on the responses of the hosts. Lacey deals with shifts in refugee policies since World War II, while Morgan looks at an earlier period in American history when sentiment against immigrants became politicized. Another theme emphasizes the consequences of the growth of national and international agencies which now provide a major element in the environment with which refugees cope while in transit or on arrival in a new country. Whereas legal and illegal voluntary migrants who make their way to a new country or region usually avoid official agencies and rely upon kin and former neighbors who have already made the transition to ease their introduction to the new locality, refugees find themselves both aided and trammeled by having to deal with the many agencies designed to work with them. The resettlement life cycle is another theme; it includes the processes of uprooting and readjustment. All migrants experience and use different strategies at different phases of this cycle as they cope with stress. Their strategies include drawing together kin and those from the smae localities into communities based on home ties, and the strengthening of such communities through rituals that emphasize continuity with the past. Immigrants within such communities can emerge from the anonymity forced on them by a society that considers them merely members of a category, and they again become indivduals with particular statuses which ensure their personal dignity.
Detection and quantification of maternal risk.
It is estimated that, worldwide, close to half a million women per year die from pregnancy and childbirth. European countries have maternal death rates generally below 20-30/100,000. In contrast, many developing countries experience maternal death rates estimated to be in the range of 500-1000/100,000 or even higher. There is general agreement that the vast majority of maternal wastage is avoidable. The major killers in terms of cause of death are hemorrhage, hypertensive disease, and infection with the underlying conditions antepartum and postpartum bleeding, preeclamptic toxemia, obstructed labor, and abortion. An assessment of increase of risk of maternal death assesses risk factors as follows: 1) very young age and first pregnancy: mild to moderate, 2) older age and grand multiparity: moderate to sever, 3) social factors and associated diseases: variable according to the specific conditions, 4) anemia: mild to moderate, 5) hemorrhage due to placental anomalies or complications of labor: severe, and 6) all other complications of labor: severe. Maternal and fetal (not necessarily neonatal and early infant) outcome are affected by the same variables. The instruments for detecting maternal risks are relatively simple and include proper basic antenatal care and intrapartum care with a view to reduce maternal mortality.
Assessment of reproductive risks in Indonesia: a multi-hospital study.
This study reports on risk factors derived from Maternity Care Monitoring (MCM) in 12 teaching hospitals (beginning in 1976) and 21 smaller hospitals (beginning in 1981) in Indonesia for a total of 116,000 cases. A number of risk factors derived from history, physical examination, and the course of labor have been related to adverse pregnancy outcome. Several risk scoring systems have been developed by combining these factors and reducing their cumulative risk to one summary number. The predictive value of these scoring systems have not yet met expectations. The reason for this ineffectiveness is that especially in developing countries a scoring system has to fulfill the requirement of simplicity and easiness to administer. Secondly, the value assigned to each individual factor is arbitrary. The combined antepartum and intrapartum indices give a much better predictive value than the antepartum index alone. To improve the effectiveness of high risk indices the effect of each individual factor on pregnancy outcome should be studied. Though age and parity clearly affect perinatal mortality, the impact of antenatal visits is seemingly much greater. For instance, perinatal death in the most unfavorable age and parity groups was only 1.7 and 1.5 times higher than in the most favorable age and parity groups, while the perinatal mortality in women with very low hemoglobin levels was 3-9 times higher than the perinatal mortality in women with normal hemoglobin levels. The perinatal mortality in women with no prenatal visits was 4-9 times higher than in women with adequate prenatal visits. However, there is interaction among the risk factors. For example, low hemoglobin level is itself associated with high parity and poor timing. This paper also shows that in Indonesia the smaller hospitals admit more young patients (<20 years), probably because they marry at younger ages in the villages, and that the prevalence of anemia is much higher among them (52%).
Maternal mortality in Menoufia, Egypt, 1981-1983.
This chapter describes the Reproductive Age Mortality Survey (RAMOS), which studies the causes of mortality of married women of reproductive age in Egypt. The site studied was the Menoufia Governorate, where the death registration system is almost complete. 385 maternal deaths were identified in 1981-1985 out of 1691 deaths to women aged 15-49. Reproductive mortality was 45/100,000 married women aged 15-49 and accounts for almost 1/4 of the deaths to married women of reproductive age. It was a leading cause of death, second only to heart disease in magnitude. There were 1.9 maternal deaths for every 1000 live births, and 46 maternal deaths per 100,000 married women 15-49. The majority (241 or 62.6%) of these deaths were direct obstetric deaths, of which hemorrhage was by far the most important cause. Another 26.5% were indirect obstetric deaths of which rheumatic heart disease was the most important cause. The study was one of 2 (the 2nd was in Indonesia) to determine the causes of death to women of reproductive age in developing countries. Patterns of death in the 2 countries were similar.
The risk approach to health care.
The basic idea of the risk approach is that risk is a measure of the need for health care. A characteristic or attribute of a person, or of a community, that is known to be associated with an abnormal risk of developing a problem is called a risk factor. The relationships among risk factors, and between risk factors and outcomes, are complex, since risk factors interact differently in relation to different outcomes. The outcome itself can be a risk factor. The information on risk can only tell whether there is a higher or lower probability that something will happen. While we can estimate how many persons will die in a given population in a given period, we cannot predict which individuals will die. Information on risk does not dictate how health care should be organized; it provides epidemiologic information which, together with social, political, economic, and other criteria, can improve health care. At the individual level, it can be used to develop a referral system of primary and secondary screening. Health resources are limited in all countries. The risk approach is a tool for management which can help us make better decisions.
Country experience in the risk approach project in Malaysia.
This study describes the risk approach to Maternal Child Health (MCH) services in Krian district, Malaysia. The risk approach project has provided an opportunity for the existing health care delivery system to be reorganized into a more systematic structure. Among the main lessons from the project are the following: 1) the baseline study must be simplified and refined. 2) The selection of risk cases resulted in too heavy a caseload for operational management and for the provision of good care. 3) Intensive and continuous training inputs are required at all phases of the undertaking. 4) The referral and feedback system between the health centers and hospital needs to be organized in line with the risk approach concept. 5) The improved detection of risk cases in the community by health personnel has resulted in an increased workload in hospitals, which means that risk cases may not receive appropriate management due to various constraints. 6) Community education posed one of the major difficulties of the project, since the major segments of population groups in the area preferred traditional health systems. 7) One of the initial constraints of the project was that the intervention strategies were formulated and implemented based on existing data and not on specific risk profile data. 8) Basic mortality has been steadily declining in the study are.
Severe malnutrition affects each stage of the reproductive cycle. Poor nutrition status can reduce fertility by delaying the onset of menarche, prolonging postpartum amenorrhea, or initiating early menopause. Malnutrition early in pregnancy can cause fetal abnormalities in experimental animals and has been associated with spinal disorders in human newborns. Malnutrition late in pregnancy is associated with reduced neonatal birthweight and with increased incidence of prematurity. Malnutrition during lactation can lower milk output and bring early cessation of lactation. Multiple cycles of pregnancy and lactation can reduce nutrient reserves of women, leading eventually to a maternal depletion syndrome in which there is a lower birthweight and a lesser increase in milk output with increasing needs of the infant with each successive pregnancy. In the health services of the Middle East and North Africa, the primary health care worker (PHC) who lives in the same community as the potentially malnourished mother would be aware of nutritional needs, practice a simple assessment technique, and give pregnant and lactating women in need a small supplement of locally available foods. The countries of the Middle East and North Africa could greatly benefit from a recognition of the importance of maternal nutrition in total family health, but this requires changes in the current health delivery system.
Pregnancy wastage in high risk pregnancy.
In Pakistan, 95% of all confinements take place at home. The person who assists mothers during pregnancy, delivery, and puerperium is generally a traditional birth attendant, since trained professionals are not available to the majority of the population. In a study conducted in the rural areas of Mianwali, Pakistan, it was found that no prenatal medical check-up of any sort was done in 68.4% of mothers; only a dai, the traditional birth attendant, had been consulted for some antenatal advice in 26.5% of mothers, while a trained professional (a doctor or a lady health visitor) had been consulted by only 3.7% of respondents. In 1.4% of cases a mother-in-law or an elderly woman provided prenatal guidance. In view of the prevailing conditions and lack of health care, the realistic approach should therefore be that the dai, who constitutes the only help available to most women, should be duly recognized and encouraged to give better care to her clients. She should then be referred to the nearest available health unit for provision of needed care. The cost of detection and intervention will remain low, within the means of the people. If sufficient numbers of traditional birth attendants are trained and recruited into the primary health care program, mothers with high risk pregnancy will have a better chance of detection and care in the framework of existing facilities, which are meager.
Health aspects of family planning: the evidence from Africa.
The health of African children and mothers will benefit significantly from family planning by eliminating the risks associated with excessive and unplanned childbearing. Studies in Africa have documented increased health risks with certain patterns of childbearing and family formation. 3 main factors have been identified to be the determinants of these health risks: 1) poor child spacing or short birth interval, 2) high parity, especially grand multiparity and large family size, and 3) poor timing of pregnancies to occur at "risky" maternal ages--under 20 or over 35 years. Birth spacing allows the restoration of the mother's health and safeguards the health of offspring. Children born soon after a previous birth had a greater probability of dying during infancy or early childhood than children separated by longer birth intervals. A short birth interval is notoriously associated with poor child health, including low birth weight, prematurity, and poor resistance to infection. During pregnancy, the biologic resources of a mother are systematically depleted. The relative increase of infant and child mortality with increasing parity persists within each social group. Thousands of African women die every year from causes related to pregnancy, labor, and puerperium, all of which are related to high parity. Health problems for mothers include anemia, toxemia of pregnancy, malpresentation of fetus prolonged labor, Cesarian section delivery, hemorrhage, and sepsis. If teenage wives would just postpone the date for the first pregnancy until they are 20 years or older, they can reap health rewards both for themselves and their children.
Health rationale for family planning.
Evidence from around the world shows that the risk of maternal or infant illness and death in both the industrialized and developing countries is highest in 4 specific types of pregnancy: 1) before 18 years of age, 2) after 35 years of age, 3) after 4 deliveries, and 4) less than 2 years apart. In developing countries, older women usually have more children, so that their pregnancies fall into 2 high risk categories. Reported maternal deaths are about 400/100,000 births in developing countries as a whole, compared with about 10 in the US and the UK. Maternal age and parity have an independent effect in making pregnancy hazardous, but these risks can combine. Short birth intervals lead to high maternal mortality rates. The 4 types of high risk pregnancy that are dangerous to women are also harmful for the children. The obvious mechanism causing poor survival chances is the maternal depletion syndrome. Family planning offers highly effective technology that can, by preventing high risk pregnancies, reduce maternal and child mortality. It is essential to consider the risk of childbearing in contrast to family planning. Childbearing is generally far more dangerous than using oral contraceptives, an IUD, or condoms. Condoms, spermicides, and diaphragms when properly used protect against sexually transmitted diseases and pelvic inflammatory disease. Family planning meets individual and community needs. High levels of induced abortions in much of the world demonstrate women's desire to avoid pregnancy. With the skill and facilities available, both physicians and nonphysicians in the community can deliver family planning to the community safely and effectively.
High risk pregnancy: an undisputed indication for birth control in Islam.
Few people realize that Islam was the first ideology that dealt with contraception with objectivity and compassion for its people. Islam introduced the "no-hardship" rationale for family planning in the 7th century, allowing the issue to be discussed openly in mosques and religious gatherings as well as in texts of jurisprudence from the 8th to the 20th centuries. It has been authenticated in Islamic jurisprudence that the companions of the Prophet Mohammad practiced withdrawal. Warding off health risks to mothers and children from an additional pregnancy is by far the most undisputed indication for contraception in Islamic jurisprudence. Indications for contraceptive use include 1) preservation of woman's beauty to help her husband stay faithful and not think of other women, 2) protection of woman's life from the danger of labor and cesarean section, and 3) to avoid health risks to a suckling child. Abortion is allowed by early and contemporary jurists within the 1st 4 months of gestation. It is neither promoted nor prohibited. Translated versions of Islamic medical texts were used in European medical schools until the 17th century, but the chapters on contraception were omitted in the translated versions. During the Middle Ages, church leaders feared contraception might be an Islamic plot to reduce the Christian population. Ironically, similar accusations are echoed nowadays in the Muslim world.
Family planning from Bucharest to Mexico.
In 1974 the first international government level meeting on population was held in Bucharest. The Conference focused world-wide attention on the importance of population as a factor in socioeconomic development plans. It also achieved the production of a WORLD POPULATION PLAN OF ACTION, much to the surprise of many observers who had been concerned during the whole year about the positions on population being taken by many influential countries and some international experts. The atmosphere in Bucharest differed considerably from that surrounding the 1984 conference in Mexico City. The first meeting had been held largely at the urging of the more industrialized nations, many of them openly stating that the population growth rates of developing countries were frustrating their opportunities for flourishing economically. The Less Developed Countries (LDCs) therefore looked on the conference as an effort to divert attention from major development problems to that of population. The developmentalist camp maintained that development is the best contraceptive. The opposing camp maintained that population, as a variable in development, should be planned and managed. The Mexico International Conference on Population, 1984, was convened largely at the request of the LDCs. It was to review the progress made since 1974, to reschedule and upgrade the recommendations of the WORLD POPULATION PLAN OF ACTION. The LDC debt crisis posed a major development crisis. North-South tensions still existed, yet there was no polarization about development and population. It would appear that in most countries the political acceptance of family planning for health or human rights and welfare reasons can now be taken for granted. Whatever the rationale, the reality is that information and services are not reaching many individuals and couples in need. The issue now is how to provide services in a way that makes them accessible, affordable, and effective.
Family planning programs for the Arab World Region.
The population of the Arab world was estimated, in mid-1983, to exceed 180 million living in over 20 states, and is expected to reach 290 million in the year 2000. The region has one of the highest crude birth rates, and hence a young population structure, a young age at marriage, and a large family size norm. 39,956 Arab women were interviewed under World Fertility Survey auspices between 1979 and 1981. Investments in female education remain the most dependable measure that will delay age at marriage, reduce fertility, contribute to better family health, and generate more economic returns. 22% of the women were unaware of any contraceptive method. The percentage of married women who had ever used a contraceptive method ranged from 1% in Mauritania to 47% in Jordan, 48% in Tunisia, with an aggregate of 23% for the Arab World Region. In the Arab World, child mortality ranged from 78/1000 (Jordan) to 237/1000 (Yemen Arab Republic). Only Egypt, Tunisia, and Morocco support national family planning programs. Political leadership has not expressed awareness of population issues, and efforts must be made to sensitize political leadership to the consequences of population increase. The approach to a national family planning policy and its programs should be based on individual country conditions.
[The Tunisian family planning programme]
A National Office of Family Planning and Population was created in Tunisia in 1973. Since 1984, it has been called the National Office of Family and Population. Its mission is to implement programs promoting the family, its welfare, and the optimal development of its members. The 2 major axes of its action are 1) education and information and 2) services. Information and education aim at enabling the citizen to have a free choice; it is offered in various ways, through the health infrastructure, in the home, at the workplace, in schools, in urban as well as rural areas. It touches on health, moral, and religious aspects of family planning. Training programs have been set up for concerned professional groups. Services have been made widely available in the country, through 22 Regional Centers for Family Planning Education, through hospitals, maternal and child health centers, and dispensaries, as well as through mobile units. A major objective is to integrate family planning activities into all structures within the country. The national office also supports a research and evaluation program on demographic, sociological, and clinical topics. The Ariana Center carries out investigations on contraception and human reproduction. International contacts are maintained, especially in the fields of teaching and research. The program has created an irreversible change in Tunisian society. At least 90% of the population knows about family planning. 41% of the women of reproductive age are protected. The general fertility rate and the natural growth rate are declining. Future efforts will emphasize ways to improve the welfare of the Tunisian family in general.
Prevention of obstetric mortality in high risk pregnancy.
This paper deals with the problem of life threatening maternal complications. Excluding mortality from abortion in the first 2 trimesters, it concentrates on the prevention of the so-called obstetric deaths, involving pregnancies from the 28th week of gestation through the 6th-week postpartum. Of the estimated half million maternal deaths a year, some 300,000 belong to the category of obstetric deaths. This amounts to almost .3% of total births on a global basis and reflects approximately 3 mothers dying per 1000 deliveries. The most frequent direct obstetric causes of maternal death include 1) toxemia, 2) hemorrhage, 3) sepsis/infection, 4) dystocia of labor and delivery, 5) embolism, 6) aggravation of preexisting illnesses such as diabetes and heart diseases, and 7) conditions unrelated to pregnancy such as accidents and anesthesia. To prevent obstetric mortality, cases of high risk pregnancy should be identified as early as possible and put under appropriate medical care. What is needed are 1) accessible facilities that can deal with obstetric emergencies, 2) recognition of the indication for obstetric intervention, and 3) early detection of high risk pregnancy by professional and traditional birth attendants. Early recognition of maternal risk factors would without any doubt offer the best means of preventing or appropriately managing most dangerous conditions during late pregnancy and early childbirth. Accepting as fact that 80% of pregnant women are still assisted antepartum and during confinement by traditional birth attendants (TBAs) in most developing countries, there is at this time no other realistic alternative than to depend on the TBAs for primary obstetric care. TBAs should be integrated fully into the governmental health care system and given more adequate training.
Role of TBAs in improving maternal and neonatal health in Bangladesh: a long-term program need.
Maternal mortality is very high in Bangladesh. The major causes are hemorrhage, eclampsia, postpartum sepsis, septic abortion, and difficult labor, many of which are preventable by improved birth care services. Since more than 95% of births are managed at home by traditional birth attendants (TBAs), training this cadre of service providers is an essential program measure for improving maternal health. The Bangladesh Association for Maternal and Neonatal Health (BAMANEH) is implementing a pilot project of training TBAs for provision of better birth care services. Under the program 60 TBAs selected from 3 different areas covering a total population of 137,873 were given training on better management of childbirth. The training included simple lectures, discussion, and practical demonstrations with visual aids such as flash cards and flip charts. After the course, TBAs referred more complicated childbirth cases (2.9%) to hospitals or maternal and child health centers as compared to earlier action (1.4%) and also managed a relatively smaller proportion of abnormal cases (3.1%) compared to the pretraining phase (8.6%). Before training, the maternal death rate had been 4.8/1000 live births; after training it declined to 1.4. Similarly, the stillbirth rate of 76.9/1000 live births in the pretraining phase declined to 46.2. The frequency of the antenatal visits increased on average from 1.3 to 2.9 per client and the postnatal visits increased from 1 to 2 per client following the course.
United Nations Fund for Population Activities (UNFPA) strategies to reduce pregnancy risks.
Today the UN Fund for Population Activities (UNFPA) is working in 8 main areas: 1) basic data collection, 2) population dynamics, 3) formulation of population policies and programs, 4) implementation of policies and programs, 5) family planning, 6) communication and education, 7) special programs, and 8) multisector activities. UNFPA has always been convinced of the health benefits of family planning or of the negative effects of unregulated fertility on maternal, perinatal, neonatal, infant, and child health. In countries which remain unconvinced of the need for family planning, UNFPA has provided assistance for conducting studies which tend to demonstrate the negative health effects of unregulated fertility. In countries convinced of the need for providing family planning services, on the basis of studies of the type just mentioned or of demographic or socioeconomic evidence, a shift typically occurs in UNFPA assistance patterns toward greater support for family planning service-related activities. Such services may take a variety of forms in accordance with national desires and still be eligible for UNFPA support, so long as all couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children. UNFPA will support both high-risk-only family planning programs and those open to all comers, but movement toward wider availability is always welcomed. Regarding modes of service delivery, UNFPA is willing to support 1) specialized free-standing, nonintegrated family planning programs; 2) family planning integrated with maternal and child health in the context of primary health care; 3) family planning integrated in socioeconomic development programs; 4) community based distribution programs, and 5) commercial marketing programs.
Neglected training priorities for primary health care.
This paper reviews the implications of primary health care as essential health care developed with the full participation of communities in the spirit of self-reliance and self-determination. The reversal of roles between communities and health professionals to accomplish this goal requires that training for a process of professionalization of all health workers replace the traditional top-down pattern of supervision. Neglected priorities in pre-service and in-service training are reviewed. Pre-service instruction requires better coordination among facilities, and in-service training needs to move from academic modes to intrinsic training based on review of management information data by peers of service providers and by community leaders. This process of epidemiologic surveillance and peer review is essential for improved skills but also to develop a consensus on standards of care. The preparation of community leaders, health workers, traditional birth attendants, and medical practitioners has been neglected. It is concluded that training for primary health care can be successful if neglected priorities are emphasized and overall priority is given to communities that have made a decision to provide health care as part of their development program.
Maternity care: its opportunities and limits to improve pregnancy outcome.
Although there is almost universal association between amount of maternity care and reduction in perinatal mortality, there is no proof that this is a casual relationship. Selection bias as to who gets antenatal care and the reduced opportunity of antenatal care for women with short gestations are likely important factors producing the apparent favorable effect of maternity care. Few risk factors, beyond patient characteristics and obstetric history, can predict perinatal mortality without large proportions of false positive or false negative diagnoses. This represents a severe limitation of the risk approach to maternity care. The lack of knowledge of etiology of preterm labor and intrauterine growth retardation limits prospects for influencing these key predictors of perinatal mortality. Few components of routine maternity care have been subjected to study in controlled clinical trials. The few studies that have been conducted raise doubt as to the efficacy of past treatment of pre-eclampsia and nutritional supplements. A markedly increased research effort with emphasis on controlled clinical trials is needed to develop improved predictors of perinatal mortality and effective components of maternity care. The emphasis in this research should be in developing countries where the greatest perinatal mortality occurs. As evidence of the impingement of socioeconomic barriers on maternal and child health are delineated, it will become incumbent on obstetricians to move beyond social obstetrics in an effort to remove these barriers. Both the process of professionalization and the research effort suggested should proceed on an urgent basis if the high costs of maternity care of industrialized nations are to be contained and effective maternity care is to reach the least developed countries, especially those in Africa.
Interventions to improve pregnancy outcome in the Third World.
This paper describes important disorders responsible for high perinatal mortality in the Third World and suggests ways to reduce it. Chorioamnionitis can cause preterm delivery and edema-generated hypoxia. It has also been implicated in premature rupture of membranes and abruptio placentae. Etiologic factors for acute chorioamnionitis are coitus late in pregnancy and zinc deficiency. From these etiologic factors preventive regimens are suggested. The influence of diet and physical work on blood volume expansion, delivery of nutrients and oxygen to the fetus, and fetal growth retardation is discussed. The delivery of nutrients to the fetus in the third trimester as evidenced by declining triceps skinfold thickness seems critical to avoiding fetal growth retardation. The bulk of high cereal foods might produce satiety with intakes suboptimal for fetal growth. Zinc deficiency might also impair appetite and has been implicated in pregnancy-induced hypertension. Without a better understanding of these factors, progress in reducing high mortality in the Third World will be slow.
Fetal growth in relation to maternal nutrition.
There seems little doubt that the mother's state of protein-energy nutrition affects birthweight and intrauterine growth generally. Findings from several studies support the view that differences in fetal growth rates among various populations are more probably due to environmental than genetic factors. However, not all mothers producing poorly grown babies are undernourished, so nutritional rehabilitation measures should be directed only at those who require them. The velocity of triceps skinfold increments during the second trimester is an efficient predictor of groups of mothers who may benefit from nutritional intervention. The positive effect of environmental conditions in general, and maternal nutrition in particular, on intrauterine growth is one more reason against adopting a plethora of intrauterine growth standards, and provides a scientific rationale for establishing a single international standard for fetal growth.
The Nairobi challenge: global directory of women's organizations implementing population strategy.
This directory includes those women's organizations which are 1) exclusively or in part implementing population strategies, or 2) dedicated to improving the status of women. The book is divided by geographic region. Within regions there is a regional summary and 3 listings of organizations: 1) women's organizations in population, 2) population, development, and health organizations, and 3) women's organizations. Each regional section also includes poetry written by women of the region in which it appears and pictures of women of the region in which they appear. The organizational listing includes information on staff size, membership, funding, principal purpose, main activities, population concerns, specific population activities, forward-looking strategies implementations, and obstacles to the implementation of forward-looking strategies. The appendix includes multilateral organizations that have program offices too numerous to list in the regional format. There is an organizational index in the back.
Model protocol for tracking promotional campaigns.
A tracking study was undertaken to investigate the effects of an advertising campaign to promote the DuaLima condom in 3 cities in Indonesia. This study consisted of a pre- and post-test assessment of a trial roll-out of a new product and was conducted during April-August 1986. In initiating this study and designing the instrument, certain assumptions were made regarding the objectives of the research: 1) providing information that would guide the introduction of DuaLima into the critical Jakarta market and, later, into national coverage, 2) establishing year 1 marketing goals for DuaLima, and 3) evaluating the current DuaLima marketing strategy against specific marketing objectives which had been set for the brand. All questions placed on the tracking instrument must be driven by the objectives of the research. It is critical to clarify these objectives prior to developing the survey instrument and and to keep them in mind throughout. The questions developed should be: 1) related directly to the research objectives, 2) phrased in a clear and unambiguous manner, 3) based on obtaining scalar data, 4) directed at the appropriate respondent base through use of filter questions, 5) analyzed with the appropriate respondent base, 6) able to provide for direct comparisons of the test brand against others, and 7) consistent across studies to allow for comparisons across campaigns. Use of the present protocol or parts thereof for future tracking studies will serve to establish an ongoing data base to provide insights across, as well as within, projects. These comparisons will encourage a broader perspective in the analysis of issues related to promoting increased contraception in developing countries. A copy of the tracking study protocol is included in the appendix.
The contraceptive social marketing project in review.
Social Marketing for Change (SOMARC), a 5-year project funded by USAID's Office of Population, was launched in 1984 by the Futures Group, a management and consulting firm in Washington, D.C., for the purpose of 1) designing new Contraceptive Social Marketing Projects (CSM), 2) providing technical assistance to ongoing CSM projects, 3) conducting evaluative studies of selected projects and 4) disseminating technical information to CSM practitioners and family planning policy-makers in developing countries. In 3 1/2 years, the following have been achieved: 1) New CSM projects, established in 13 developing countries, have developed active partnerships with private sector organizations in providing family planning and public health services. 1 major result has been substantial reductions in the retail price of many contraceptives, resulting in a major expansion of contraceptive use in these countries and significant savings to USAID in commodity costs. A microcomputer-based management information system, equally useful to USAID and all CSM practitioners, has been a very important byproduct of the project. 2) The project has provided training and technical assistance in such areas as product distribution, advertising and promotion, program management and management information systems, commodity logistics, market research and strategic planning. 3) A recent analysis has shown that mature CSM programs raise contraceptive prevalence rates by about 20%. Factors identified as influencing private sector participation include the organizations desire for increased market share, access to government officials and their own commitment to project goals. 4) Dissemination strategies of lessons learnt include newsletters in different languages, Occasional Papers reporting the latest CSM techniques and research findings of importance to practitioners, a series of Practical Guides that provide detailed how-to approaches to CSM implementation problems and regional conferences that provide infomation on CSM implementation strategies to participants from different countries. To meet the demands of the future, CSM projects must work even more creatively with the private sector to expand the user population and lessen dependence on government support.
This report reviews a trip to Lagos State, Nigeria, sponsored by the Program for International Training in Health. The purpose of this trip was to conduct 2 training activities: 1) a 2-day orientation workshop for 25 family planning/oral rehydration therapy/community health education (FP/ORT/CHE) supervisors; and 2) a 3-week FP/ORT/CHE refresher workshop and practicum for 14 members of the State Training Team (STT). The objectives of the activities were as follows: 1) 25 supervisors will have demonstrated an understanding of the Ministry of Health (MOH)/INTRAH project and the expanded roles and responsibilities of supervisors and providers. 2) 14 STT members will have upgraded their knowledge in FP/ORT/CHE. 3) 10 STT members will have demonstrated their skills in FP/ORT clinical services. 4) 4 STT members will have demonstrated their skill in FP/ORT/CHE services. The current "economic crunch" in Nigeria creates a favorable atmosphere for the dissemination of the FP message. ORT efforts seem to have been effective in reducing severe dehydration. CHE activities were a very important component of the training for both clinicians and health educators and were effective in increasing client volume.
Voluntary sterilization: policy determination.
The US Agency for International Development (USAID) recognizes that each host nation is free to determine its own policies and practices concerning the provision of voluntary sterilization services, but USAID support for voluntary sterilization program activities can be provided only if countries comply with their guidelines. The guidelines relate to informed consent, ready access to other methods, incentive payments, quality of voluntary sterilization services, sterilization and health services, and country policies. USAID assistance to voluntary sterilization service programs is contingent on satisfactory determination that surgical sterilization procedures are performed only after the individual has voluntarily presented himself or herself at the treatment facility and given his or her informed consent to the sterilization procedure. Where voluntary sterilization services are made available, it is required that other family planning methods also are made readily available at a common location, enabling a choice on the part of the acceptor. No USAID funds can be used to pay potential acceptors of sterilization to induce their acceptance of sterilization. Medical personnel who operate on sterilization patients must be well-trained and qualified in accordance with local medical standards. To the fullest extent possible, voluntary sterilization programs shall be conducted as an integral part of the total health care services of the recipient country and shall be performed with respect to the overall health and well-being of prospective acceptors. USAID needs to take appropriate precautions through consultation with host country officials to minimize the possibility of misunderstandings about potential voluntary sterilization activities.
Some determinants of high and low fertility in four Asian countries.
This research note, combining reports from Bangladesh, Nepal, the Philippines, and Singapore, focuses on explanations of variations in fertility change and contraceptive use and possible policy implications. The range of fertility experiences in Asia is great--from Bangladesh, where both the population growth rate and infant mortality remain high, to Singapore, where earlier policies to control growth were so successful that increased fertility is now encouraged. In Nepal, household practices contribute to differential child care, whereas in the Philippines, the fertility transition is abnormally slow compared with other countries in East and Southeast Asia. In Bangladesh, high family size preferences and even higher fertility rates lead to the inevitable policy implication that the contribution of family planning to any decline in fertility will depend upon the effectiveness with which it meshes a couple's desired family size and sex composition with outcome. In Nepal, the problem of discrimination against children at high birth orders might be resolved by easier access to modern contraceptives. In the Philippines, the relatively high levels of fertility still prevailing suggest that more effective and/or alternative approaches to the delivery of family planning services deserve exploration. In Singapore, where low fertility is the issue, new policies include organizing social activities to provide opportunities for college-graduated men and women to meet; creation of the Social Development Section, to cater to 2ndary-educated women; and an assortment of pronatalist measures.
The war against population: the economics and ideology of world population control.
The author critically examines the assumptions that the world's population is growing too quickly and that rapid population growth has an adverse effect on social and economic development. She consequently rejects the need for population control and for the network of organizations and funding that has evolved in order to assist countries around the world in reducing their rate of population growth. Attention is paid to the role of U.S. foreign aid in population activities, the nature of the sex education movement, and adolescent pregnancy, with the primary focus on the United States. The author concludes that government should not get involved in social planning of this kind and should not attempt to influence the reproductive decisions of individuals.
Ageing populations. The social policy implications.
This is the first in a planned series of volumes published by the Organisation for Economic Co-operation and Development (OECD) concerning the economic and social consequences of demographic aging in OECD member countries. "This detailed statistical analysis of demographic trends in the 24 OECD countries examines the implications for public expenditure on education, health care, pensions and other social areas, and discusses the policy choices facing governments." Data are from official sources. (EXCERPT)
Single mothers and their children: a new American dilemma.
During the past 25 years the proportion of children living in families headed by women has more than doubled from 1 in 10 to 1 in 5. Concern about this trend stems from the fact that these families are much more likely to be poor or to experience sharp drops in income than other families and from a belief (and some evidence) that the children of single parents are less likely to be successful as adults than those who grow up in 2-parent homes. The tradition of providing public assistance to women with children is now being called into question. Although such assistance improves their economic position and enables them to stay home with their children, it also fosters long-term welfare dependence and may encourage or marital instability or out-of-wedlock births. This tension between the desire to provide economic security to such families and the need to stem their growth and dependence on government is the new American dilemma. Has welfare, in fact, caused an increase in the number of single-mother families? Has welfare dependence grown to the point that it morally corrosive to the recipients and fiscally unacceptable to the public? Do other solutions, such as encouraging mothers to work, make sense in light of what is known about their effects on children? The authors conclude that the welfare system has been a minor cause of the growing number of single-mother families, that the majority of mothers on welfare remain dependent on government assistance for a long time, and that this dependence could have harmful effects and is, in any case, increasingly unacceptable in a society where most mothers work and self-reliance is highly valued. They also conclude that a mother's employment is unlikely to have adverse effects on her children and could actually be beneficial. In sum, although they reject the idea that the welfare system has been a major reason for the rising number of women who head families, they nevertheless prefer work over welfare as the solution to the new American dilemma. They go on to note that most women on welfare cannot command high enough wages to lift their families out of poverty even if they work full-time. Thus they believe it will be necessary to supplement the earnings of these women with both increased child support awards could greatly reduce poverty and welfare dependence. The authors end the book with a discussion of their own policy recommendations.
Psychosocial aspects of contraceptive sterilization.
While there have been numerous studies of voluntary sterilization, the knowledge about its antecedents remains disappointing. The research reported here uses data collected from a stratified sample of 610 married couples in Toledo, Ohio, in 1978 and 1985-1986. Chapter 1 introduces the study and reviews the literature. Chapter 2 discusses the study design and survey instruments used. Chapter 3 shows how a couple's decision to have a contraceptive sterilization operation--either a vasectomy or a tubal ligation--varies by a broad series of demographic, socioeconomic, marriage, intercourse, contraception, fertility, fertility control, and social psychological variables. Chapter 4 examines the choice between tubal ligation and vasectomy and the accompanying fears and emotions. Chapter 5 looks at several aspects of dyadic interactions to clarify the process by which couples make a decision on having a contraceptive operation. Chapter 6 reviews the process of negotiating decision making for vasectomy versus tubal ligation. Chapter 7 analyzes the distinguishing characteristics of planners and resisters among those couples who have not yet been sterilized. Chapter 8 looks at the consequences of sterilization in terms of differences between those who chose male or female sterilization as well as its influence on feelings of well being. Chapter 9 examines the consequences for divorced couples.
Urbanization and development: the rural-urban transition in Taiwan.
This volume examines patterns of demographic and economic change in developing nations by focusing on urbanization and migration in Taiwan, and by investigating the linkages between these processes and increases in population size and growth of the economy. Over the last several decades, Taiwan has been transformed from a rural to an urban society and has undergone the demographic transition from high to low birth and death rates. Estimates for the mid-1980s suggest that Taiwan is characterized by a life expectancy of 73 years, infant mortality rates of less than 10/1000 live births, and a total fertility rate of only 1.9 children/woman. Fully 2/3 of its population live in places designated as urban. These demographic indicators place Taiwan among the most developed nations of the world. The economy has shifted over the last several decades from agriculture to industry, from local to international trade, and from relatively simple to more complex economic specialization and diversification. The demographic transformation in Taiwan is usually attributed to the development of an extensive family planning program, and the debate has centered over its role in the fertility decline. In this volume, the authors have documented the central role of another demographic process in the socioeconomic development of Taiwan, migration. Movement from rural areas to urban places was part of the economic development and the demographic revolutions that characterized Taiwan. Using extensive survey data to capture the decision-making process, the authors specify 4 factors that are involved in determining migration: 1) the social and economic bonds at places of origin, 2) residential and job satisfaction at places of destination, 3) awareness of opportunities elsewhere, and 4) the expected costs and benefits of the move. The specification of these migration determinants is the basis for weaving together sociological and economic models and investigating empirically individual- and household-level decisions to move.
This volume is a reprint of the original edition of the author's SOCIAL MOBILITY, supplemented by a chapter titled "Genesis, Multiplication, Mobility, and Diffusion of Sociocultural Phenomena in Space." While the book as a whole deals with a change in the social position of persons and groups in social space, the additional chapter is concerned with the mobility of cultural phenomena in social space. Combined, these works give an essential knowledge of both forms of mobility--social and cultural--that are different from, but supplementary to, each other. The parts of the book include 1) the fluctuation of social stratification, 2) social mobility, 3) the population of different social strata, 4) fundamental causes of stratification and vertical mobility, 5) present day mobile society, 6) the results of social mobility, and 7) an appendix on social and cultural dynamics. The book sums up the main limited and approximate, but real, uniformities in the field of social displacement, mobility, circulation, and diffusion of cultural phenomena. It shows that some general rules exist and that the deflections are special cases and not exceptions.
Immigration and ethnic conflict.
This book reviews the experience of post-industrial countries that have had large-scale movements of population since the 2nd World War, creating ethnically diverse multicultural societies in a context of rapid economic, technological, and social change. The book uses a critical theoretical approach which emphasizes the dynamic nature of the structural changes which have taken place and the interdependence of economic, political, social, and psychological factors. The results of extensive comparative studies of Britain, Canada and Australia are reviewed, with special attention to questions of immigrant adaptation, refugees, racism, unemployment, ethnic nationalism, and social conflict. Traditional views of immigrant assimilation are rejected in favor of 1 which treats immigrants and ethnic minorities as the catalysts of change in a global polity, economy, and society, simultaneously united and divided by satellite communications, nuclear terror, and the world population explosion.
Return to Aztlan: the social process of international migration from Western Mexico.
This book examines Mexican migration to the US. Chapter 1 introduces the study. Chapter 2 presents the rationale for the ethnographic survey, and chapter 3 undertakes a comparative demographic, social, and economic profile of the 4 sample communities--2 rural and 2 urban Mexican communities. Interviews took place in 1982-1983. Chapter 4 examines the historical origins of US migration within each of the 4 communities under study, explaining how and why migration grew from very modest beginnings to become the mass phenomenon it is today. Chapter 5 contains a detailed analysis of current migration patterns within each sample community. Chapter 6 shows how migrants' social networks develop and grow over time and how they gradually support migration on a continuously widening scale. Chapter 7 analyzes the role that US migration plays in the household economy, studying how it is manipulated as part of a larger strategy of survival. Chapter 8 considers the impact of US migration on the socioeconomic organization of Mexican communities. Chapter 9 shifts attention north of the border to analyze the process of US settlement in some detail. Finally, chapter 10 summarizes the insights of the prior chapters by estimating 4 statistical models that measure how different factors determine key events in the migrant career. Chapter 11 briefly capitulates the findings and makes some concluding remarks.
This monograph fills a void in the literature on early parenting and forms a companion for the many writings that now exist on the adolescent mother. It effectively makes the bridge between empirical research findings, evaluations of programs that have been designed to support young fathers, and the identification of resources that are needed by practitioners. Despite the national attention that has been paid in the US in the past decade to the seriousness of early pregnancy and parenting outside of marriage, surprisingly little attention has been paid to the other half of the procreation process, the young fathers. Many writers do not even mention fathers, and others do not feel that fathers are important enough to include in their research designs. There is even a lack of consensus on who is a teenaged father. Research has not been able to isolate the short- or long-term consequences of being a teen father, because age becomes confounded with other salient variables in the literature. The tendency to delay marriage, but no sexual activity, results in pregnancies outside marriage. Adolescents are poor contraceptors because they are young and they think the way youth in all cultures think-immaturely. This book describes several remedial efforts to prevent pregnancy. Delaying initial sexual encounters should be 1 goal. However, it is simplistic to expect that a program of encouraging youth to say "no" will be effective. We need programs to help young men become aware that the little decisions that they make on daily basis may result in lifelong consequences to their lives, the lives of their partners, and most importantly, the lives of their unborn children. The dissemination of AIDS-related educational materials about sexual activity will enable teens to have access to preventive information about contraception. This book presents the results of many important studies and evaluations in everyday language. The vignettes within each chapter poignantly and starkly present the reality of the life of a young man. The book includes references, tested educational materials, sources for curricula materials, and addresses.
International labor migration: a study of the ASEAN countries.
The 2 principal objectives of this study are 1) establish just how international migration features in the Association of Southeast Asian Nations (ASEAN) and 2) to evaluate its importance to their economies. It is generally believed that labor immigration can give rise to several potential benefits. It can relieve unemployment and underemployment. It can be a source of foreign exchange. It can lead to the acquisition of skills, and it can improve material welfare by increasing per capita national income. The potential benefits of labor immigration to firms can also be considerable. It can allow firms to realize economies of scale. It can prevent wage inflation in those industries experiencing labor shortages. It can facilitate investment by ensuring that a new facility can be adequately staffed. It allows countries to adjust their labor supply in accord with the ebb and flow of economic activity, and generally it makes available labor services without the need to finance the formation of the human capital from which those services are derived. The extent to which a country fully realizes the potential benefits of labor export or import depends on many considerations. In relation to labor export, 1 of the aims of this study is to suggest policies to augment potential benefits. The study also draws attention to the cost of labor export and makes suggestions as to how costs might be reduced. Separate chapters consider the Philippines, Thailand, Indonesia, Malaysia, and Singapore. The study commences with the study of the labor exporters--the Philippines, Thailand, and Indonesia. Malaysia is unique among ASEAN countries in that it both imports and exports labor. Some labor is exported to the Middle East, but the majority goes to Singapore, a labor importer. Section VII examines critically the hypotheses concerning the benefits of labor exports and reviews evidence from those country studies which sheds light on the hypotheses. Section VIII concludes the study with a discussion of the international distribution of the gains from international migration. .
This research uses survey data from 3 samples of undocumented aliens from the New York City-Newark, New Jersey areas from 1980-1983 to examine 1) their labor market characteristics, 2) their motivational structure prior to and during their stay in the US, 3) their plans for the future, 4) the entire set of social welfare questions, and 5) the policy implications of the research on areas where advocacy, rather than scientific objectively, has routinely carried. In the absence of reliable information on specific communities of undocumented aliens, the in-depth investigation of legal immigrant communities of the same ethnicity may be an acceptable surrogate measure. The respondents appear to have fled neither abject poverty nor political suppression per se; their motives are much more complex than that. Subjects appear to be almost an elite when compared to the many undocumented communities studied in the Southwest, yet they are close to the profiles of similar communities studied in the Northeast. The samples report extended tenure in the US, success in reuniting their families in the US, and the expectation of staying indefinitely or permanently. The evidence suggests that respondents are successful labor market competitors vis-a-vis both native and legal immigrant groups. The authors found no evidence of the abuse of income transfer programs, although the situation with regard to health services and education is more complex. The currently considered social security card-based identification requirements can be easily met by virtually all of the economically active respondents. Finally, in terms of the contemplated cut-off dates for legalization, a 1980 date would disqualify most of them, while a 1982 date would allow a substantial majority of them to regularize their status.
Theories of fertility decline.
Despite decades of intensive and sophisticated work, we do not know a good deal about the determinants of fertility. The work Bongaarts and others on the proximate determinants of fertility is a major accomplishment in quantifying the effect of the Davis and Blake intermediate variables on fertility. It now provides the challenge of specifying the determinants of the proximate determinants. We know that the large variations between cultures in pre-industrial fertility is immediately due to the variations in breastfeeding practices and age at marriage, but what determines the variation in those is still unknown. The classical list of determinants, such as education, urbanization, and labor force status, have turned out to vary in their relation to fertility from country to country. This may turn out to be more useful information than if they had followed a uniform pattern, especially if we can establish that there are macro determinants that explain their varying relationships. While the failure of these determinants to explain the course of the demographic transition disappointing, it is consistent with the similar lack of relationships for developing countries. There are interesting potentials in the role of ideas and the mental framework, in changing familial structure, in macro variables at the community and other collective levels, especially with reference to the changing economy, in family planning programs, especially as affected by the central capabilities for mobilizing population and resources.
In the US, over 1 million teenage women become pregnant annually. Each year, almost 500,000 teen women have babies; nearly 10,000 of these mothers are under the age of 15. Over half of the families receiving public assistance were begun when the mother was a teenager. In 1985, the US spent more than $16 billion to support families that were begun when the mother was a teenager. This handbook is designed to help readers estimate the cost of teenage childbearing in their own state, city, or town. Section A is an introduction to estimating the public costs of teenage pregnancy. It defines terms, summarizes the Center for Population Option's national study on the costs of teenage childbearing, and discusses the assumptions that were used. Section B addresses collecting the data needed for a study, and provides detailed worksheets and instructions for determining costs for any jurisdiction. A Lotus 1-2-3 program of the worksheets is available separately. Section C offers suggestions for using this data. A glossary and reference section follow.
Sexual, contraceptive, and pregnancy choices: counseling adolescents.
Offering concrete, practical models on how to help adolescents engage in healthy decision making, this book is essential for anyone who works with young people. Its unique feature is that it is written as a guide to be used on a day-to-day basis as the counselor--and client--must cope with new issues. The author examines the complex issues that impact on counselors' effectiveness--attitudes about contraceptive use, pregnancy, sexually transmitted diseases, and AIDS--and, more important, she provides the foundation for resolution. The author's focus is on the "whole" person of the client and the board range of psychological, sociological, and educational variables brought to bear on decision making for contraceptive usage and for pregnancy. The need for sensitivity to each adolescent's background is emphasized and intervention alternatives are fully described.
FPIA: 1987-1989: a strategic plan. (progress and update).
Family Planning International Assistance (FPIA), the international division of the Planned Parenthood Federation of America (PPFA), was established in 1971 to respond to family planning assistance needs of non-governmental organizations and government institutions in developing nations. FPIA generally met or surpassed its planned performance in 3 key areas (number of active projects, number of countries with active projects, and number of contraceptive clients). Beginning in the spring of 1987, because of PPFA/FPIA's refusal to accept the Mexico City anti-abortion clause in a new Agency for International Development (AID) cooperative agreement, AID began delaying approvals for those projects with projected end dates beyond 31 December 1987, the end date of the current cooperative agreement. During 1987, FPIA obligated a total of $5,119,343 in subgrant funds, or 75.4% of the planned $6,706,126 objective. The 1987 planned objective was to make 72% of all subgrant obligations in 10 priority countries, but actual obligations to these countries accounted for 66.5% of all project obligations. FPIA surpassed its planned performance in 3 key areas (number of countries receiving FPIA-supplied commodities, distribution of oral contraceptives, and distribution of condoms). The strategic plan called for FPIA to provide a maximum of 1666 days of technical assistance to its subgrantees during 1987; the actual number of days totaled 2167, 30% higher than planned. Selected project development objectives for 1988 have been revised as follows: 1) number of active projects, 125; 2) number of countries with active projects, 34; 3) percentage obligated subgrant funds in 11 priority countries, 73%; and 4)percentage obligated subgrant funds in 3 priority non-bilateral countries, 20%.
The World Health Organization (WHO) sent a mission to Chad on 9-15 November 1982 to 1) identify the essential features of the health and social situation in Chad, 2) determine the immediate and short-term health and social needs of Chad, and 3) identify priority programs for rapid improvement of the health and social situation. The mission noted the disorganization of the national health system and the precarious health conditions of the Chadian population. This situation is the result of the civil war which has ravaged the country since 1979. Chad's formerly sufficiently well-organized health system is at present greatly underutilized due to 1) a deterioration of the existing infrastructure, 2) a shortage of qualified national or foreign personnel, 3) a marked shortage everywhere of materials, equipment, drugs, and vaccines, and 4) the mobility of the local population due to drought and political events. The health and social services are still operating moderately because of the commitments of several Chadian health and social workers and support from international and nongovernmental agencies and religious missions. Water supply and sanitation conditions are alarming. Foreign financial, material, technical, and human support is essential to revive Chadian health and social services. The most urgent actions are to 1) supply the country with essential drugs, 2) revive the expanded program on immunization in densely populated areas, 3) repair premises and equipment in health and social units, 4) strengthen the work of social centers, especially for nutrition and maternal-child health , 5) identify funds to pay for foreign health teams, 6) implement primary health care as soon as possible, 7) award a reasonable number of fellowships for overseas training of the qualified staff Chad needs, 8) make water points serviceable, especially in towns, 9) strengthen public health information and education, 10) strengthen the national health information system, and 11) make the best use of the services of specialized UN agencies and WHO intercountry projects.
Women, work, and fertility, 1900-1986.
This study captures the basic features and complexity of the revolution in women's roles and perceptions in 20th century America, along with the growth of the state and its emergence as a world power. Taking a relatively long time span, the author blends statistics, anecdote, and interpretation to sketch a series of collective experiments by 20th century women to find a new voice and meaning in an advanced industrial society. The commitment to new kinds of work and work settings represents the most fundamental change. While this is no surprise, the author delineates clearly the several factors that went into this new development, including the still-recent reduction of other more traditional work outlets and the competition of men in several "feminine" work sectors. Wider economic developments, such as the rise of the service sector, new material expectations, new personal strivings, and ideologies, all enter the mix. Nor are women workers treated as a single group: the author shows clearly how social stratification differentiated women's responses to work and how, in turn, women's diverse work roles have in some ways heightened social gaps among women and in American society as a whole. 20th century women, however, still juggle work and family commitments. This study shows how, in 3 key time periods in our century, 3 different balancing acts have been attempted. The current equation, in which substantial work roles play off against low fertility, may be the logical end result. The author's depiction of the baby boom era, in which women tried, for good if complex reasons, to combine comparatively high fertility with new work initiatives, forms a compelling argument. The experiment may not be renewed, but understanding it as something more than an anomaly or a strange retreat into domesticity remains vital to our assessment of women's present and future prospects. Without offering a conventional feminist account--in noting the greater complexity of motive and result than some feminists emphasize--the author shares an enthusiasm for women's initiatives and their outcomes, particularly in the work-force gains.
Understanding your body: every woman's guide to a lifetime of health.
This book contains straightforward and comprehensive gynecological information for both women's clinicians and women. It is organized as a reference manual for looking up facts and information on specific problems and is indexed by subject. Reference citations in the text and suggested reading lists guide readers to additional sources. The volume's 49 chapters are divided into 5 general categories: 1) Everyday Aspects of Health Care for Women, 2) Controlling Fertility, 3) Infections, 4) Common Problems, and 5) Surgery.
Women, society, the state, and abortion: a structuralist analysis.
It is widely assumed that abortion policy is one of the most important political issues in the US today, but this assumption may not be wholly accurate. Surveys since 1976 have consistently shown that only a minority of the US public sees abortion as a critical political issue. Nevertheless since 1973, when the Supreme Court in Roe versus Wade legalized abortion nationwide, it has become a very emotional and controversial issue. This study reviews the present policy on abortion, analyzes the consequences of that policy, and presents a history of abortion over the centuries, including its history in the US. This is followed by a review and critique of the literature covering the legal, philosophical, biological, medical, and ethical aspects of the issue. Finally, the book attempts to uncover, through a structural analysis, what may be happening beneath the surface of the present controversy. Interviews with pro-choice representatives revealed that abortion is not any more the main issue among pro-choice activists. The real issue, which is gradually coming to the surface, is the equality and freedom of women. Abortion is 1 important vehicle for achieving equality and freedom. Both pro-life and pro-choice interest groups are pursuing their respective interests through interest-group politics. In the Reagan administration, the pro-life interest group has been in a more favorable position, not only on the abortion issue, but on all the other traditional values involving the family. Resolution of the abortion debate is not likely in the foreseeable future. Abortion is an issue that is embedded in a cluster of other moral issues and values.
Children having children: global perspectives on teenage pregnancy.
This book features ideas in conflict on adolescent pregnancy, including counterpoints, debates, opinions, commentary, and analysis for use in libraries and classrooms. Chapter 1 covers global perspectives on adolescent pregnancy. Chapter 2 on preventing teenage pregnancy considers whether or not sex education has failed. Chapter 3 examines pregnancy among black teenagers and maps out an agenda for social reform. Chapter 4 presents ideas in conflict on teenage pregnancy. Chapter 5 deals with adolescent pregnancy in developed nations. This text is suitable for use in secondary schools.
Financing and delivering health care: a comparative analysis of OECD countries.
This report analyzes health care expenditure, price, and utilization trends in the Organisation for Economic Co-operation and Development (OECD) countries. In 1984, the 780 million citizens of the 24 OECD countries consumed over $800 billion worth of health services, more the $1000 per person. On average almost 80% of all health expenditures are financed by the public sector. Health care expenditures are the 2nd largest social expenditure item in the OECD, accounting for almost 15% of all public spending, and 25% of all social spending. Public expenditures on health account for almost 6% of the gross domestic product, while overall health expenditures are approaching 8%. The health industry is generally one of the largest employers in all OECD countries, and in several countries medical goods and services are a significant element in their international trade. Over the past 20 years health expenditures have increased substantially faster than overall economic growth, resulting in increasing proportions of social resources being devoted to the health sector. Much of this growth has resulted from certain unique structural characteristics that cause external diseconomies and market failure in the production and consumption of health care. Given progress in medical technologies, future demographic change, and potential future financing constraints, governments are increasingly concerned about their ability to provide universal access to necessary services. Difficult financial and ethical questions concerning the reconciliation of needs and costs, the rationing of care, and choices between therapy and death are at the forefront of the policy agendas in all OECD countries. Chapters include 1) introduction and summary, 2) issues in international comparisons, 3) the health systems of OECD countries, 4) measuring the effectiveness of health expenditures, 5) size and growth of the health sector, 6) composition of health spending, 7) cross-country differences in health spending, 8) technology, demographic change, and long-term care, and 9) conclusions for policy.
External labour migration from Turkey and its impact: an evaluation of the literature.
This document reviews the literature on Turkish labor migration abroad, focusing especially on the impact of this migration on Turkish economy and society. Since an excellent annotated bibliography already exists on the subject of labor migration, the authors make no attempt to cover each book, pamphlet, or article separately. Rather, they attempted to compose essays built around a critical appreciation of a few important or paradigmatic contributions under each topic. What is needed is more comprehensive studies on the subject of return migration, taking into account the structural differentiation within Turkish society, its transformation over time, and various aspects of the migration experience. The available studies on returning migrants are limited in scope, restricted to specific localities, and may not be generalized over space and time. In particular, there has been no study of the recent period (post-1980) dealing either with Middle Eastern return migration or with permanent returns from Europe. Obviously, it would be research on these recent phenomena which would have important implications on the formulation of public policy. Research priorities include 1) return migration and 2) micro-transformations (small town, village, family) that stem from migration. In both these areas new conditions that arise from the magnitude of the return flow, and from the changing socioeconomic and ideological context that migrants find themselves in--both in the country of work and the country of return--have to be taken into consideration.
The period of reproductive capacity for the normal woman is the 30 years from age 15 to age 45. Suppose that by common agreement children were born only to women between ages 18 and 35--or, in the developed world, between 20 and 35: in short, a socially defined period of childbearing of 15-17 years in place of the biologically natural period of about 30 years. This would in itself lower maternal mortality by a substantial amount--maybe by as much as 20%. A similar picture emerges with regard to certain medical complications of pregnancy. For example, in developed countries, anemia is higher among younger mothers and toxemia higher among older mothers. In a few developing countries where data are available, the rate of complicated deliveries is higher below age 20 and much higher above age 35. In general, then, maternity is somewhat more difficult at the younger ages and substantially more difficult at the older ages. From the beginning of pregnancy through the 1st year, the new life is more likely to survive with mothers in the middle age band. There is a larger risk to fetal life at the older ages of motherhood and a larger risk to infant life at the younger ages, with a correspondingly smaller risk in the middle years in both cases. Prematurity and low birth weights are particularly high at the younger ages, and congenital abnormalities are more frequent among children of older mothers. There would be large social and psychological benefits for women and children in limiting fertility to ages 18-35. Fertility would also decline. Human reproduction is too closely tied to a whole set of cultural prescriptions to change easily or quickly, but in all probability a good deal of reproduction at the young and old ages is not really wanted.
Statistical abstract of the United States, 1988. 108th edition.
This annual publication summarizes the most current statistics available as of October 1987, on US society, politics, and economy. The emphasis is on national data, although data for regions, states, cities, and metropolitan areas are also included. This edition greatly expands entries for vital statistics, prices, and business enterprise. The sections on geography, government, social insurance, transportation, agriculture, and mining have been reduced. All these changes are due to consideration of the comments received from readers in response to a 1984 questionnaire. New tables have been introduced on the aged, state population projections, 1986 election results for the US House of Representatives, and working life indices.
The aging and population in the twenty-first century: statistics for health policy.
Concern about the inadequacies of statistical information and methodology available for policy decisions for the elderly is widespread. 7 federal agencies that shared this concern--the Veterans Administration and 6 agencies of the US Department of Health and Human Services--joined forces and sponsored a 1984 study by the National Research Council to address these problems. The panel was charged with 3 major responsibilities. 1) It was to determine the data requirements for policy development for health care of the elderly during the next decade; to assess the statistical adequacy of current data sources pertaining to the health care of the elderly; and to identify major shortcomings and recommend appropriate remedies and actions. 2) The panel identified the essential components of a comprehensive program of statistics on the elderly that can be implemented within a decentralized statistical system and that would provide adequate data on aging for all functional areas and recommended changes and procedures that would facilitate integrating data from the various components. 3) The panel determined whether changes or refinements are needed in the statistical methodology used in health policy analysis or in the planning and administration of programs for the elderly and recommended actions or further research. The panel's 3 charges are addressed in separate chapters of the report. 5 general recommendations represent the collection and integration of a number of specific recommendations contained in the book's chapters: 1) Develop and maintain a core group of national longitudinal health surveys to study health transitions and health service needs among the elderly; 2) introduce design changes in other major survey programs to improve their usefulness for studying the health of the elderly, health care expenditures, and quality of care; 3) standardize definitions and instrumentation across data collection and data dissemination activities; 4) improve mechanisms for the broad dissemination of all types of data collected with federal support; and 5) provide an adequate level of support for statistical and forecasting research. These recommendations respond to the most pressing needs for information to meet the overall goals of medical care for the elderly: to enable the elderly to stay healthy and functionally independent as long as possible, to provide access to good medical care of whatever type is appropriate, and to provide care in the least restrictive and most cost-effective and appropriate environment.
The Center for Population Research (CPR) of the National Institute of Child Health and Human Development (NICHD) is responsible for the primary federal extramural effort in population research. CPR, NICHD carries out its programs through the support of research and research training in the biomedical, demographic, and behavioral sciences. Funding is provided through grants and contracts for fundamental biomedical research in the reproductive sciences relevant to the problems of human fertility and infertility; the development of safe and efficacious methods for fertility regulation; the evaluation of the benefits and risks of current contraceptive methods; and demographic and behavioral sciences research on the causes and consequences of population structure and change. This publication is a progress report for 1987 of the 4 branches of the CPR of the NICHD. This includes: 1) the reproductive sciences branch which supports a basic science research base in the reproductive sciences to facilitate the alleviation of human infertility, amelioration or cure of human reproductive diseases and disorders, development of healthy embryos, and discovery of new leads for the development of safe, efficacious, and widely acceptable methods of fertility regulation; 2) the contraceptive development branch which supports clinical trials and laboratory studies in order to develop improved methods of fertility regulation for both men and women that are safe, effective, reversible, and acceptable to various population groups; 3) the contraceptive evaluation branch which supports research on the safety and efficacy of current contraceptive methods over short as well as extended periods of time; and 4) the demographic and behavioral sciences branch which supports research concerned with factors governing variations in the growth, distribution, and characteristics of people and the impact of population changes on the health and well-being of individuals, families, and society as a whole.
Programmes to promote breastfeeding.
This book is a companion volume to HUMAN MILK IN THE MODERN WORLD and is mainly concerned with attempting to draw together some of the experiences of the past 10 years with breastfeeding programs. The book looks initially at relatively small-scale programs, usually in hospitals, initiated by concerned health professionals. Following this, the situation is examined in some countries where breastfeeding has increased apparently with no centrally-planned, coordinated, overall program. Finally, reports are included from certain countries in which larger-scale interdisciplinary programs have been launched. Different components making up breastfeeding programs are discussed by various authorities. These include, 1) the positive and negative influence of the health services, 2) the training of those concerned with assisting mothers to breastfeed, 3) the increasing emphasis on practical management as a major key to success, 4) the continuing need for modification and surveillance of marketing of formulas (advertising and promotion), and 5) legislation and services for breastfeeding mothers employed out of the home. Finally, consideration is given to policy needs and strategies for the development of future programs in different circumstances, within the context of other aspects of maternal and child health policy in the particular area. Even from the often limited, insufficiently evaluated activities described, the main emphases for successful breastfeeding programs are clear, although requiring modification for different circumstances, with special reference to the need for evaluation and with widening the scope of activities to continuing national activities.
Data on childlessness may be utilized to understand the fertility behavior of women. This paper describes the age pattern of childlessness by a mathematical model. The model gives the starting age of fecund married life, which is an important indicator of fertility patterns. The relationship of childlessness with age at 1st marriage, total fertility rate and contraceptive prevalence can also be studied with the help of the proposed model. Age at marriage is often taken to be the beginning age of childbearing. But, in fact, the pace and age pattern of natural fertility is largely characterized by the age at which childbearing starts. This model was developed in India using World Fertility Survey data from 6 countries.
A study of social-psychological factors affecting fertility and family planning acceptance.
With a focus on psychological factors such as satisfaction of basic needs, value orientations and the attitude system as predictors of fertility and contraceptive behavior, this study investigates why some accept and adopt the ideas and means of family planning, while others do not. From a sample of 250 Indian villages a detailed interview schedule was used to collect information regarding the respondents' background characteristics, psychological characteristics and fertility and family planning behavior. Findings suggest that while the socioeconomic characteristics such as place of residence, education, income and socioeconomic status of the individual do have considerable impact on acceptance of family planning and level of fertility, these factors produce their effect mainly through their influence on the psychological factors.
A survey was conducted in Trinidad among mothers with children hospitalized with diarrhea and matched controls (30 in each group) to investigate socioeconomic, dietary, and knowledge attitude-practice factors relating to diarrhea. Anthropometric measurements showed that 10% of children of both groups were below normal limits for weight for length. There were consistent trends to lower birth weight and earlier introduction of bottle feeding among these cases. Over 1/2 the mothers withheld some or all food from the child during an episode of diarrhea, and 1/3 also reduced fluid intake. Both practices need to be strongly discouraged. Immediate measures are needed to protect young children at risk of diarrheal disease in Trinidad and Tobago. Priority should be given by both the public and the medical profession to the following health education practices: protection via the strong encouragement of breastfeeding and discouraging of bottle feeding; and early treatment through provision of oral rehydration therapy in the community to prevent serious dehydration and quickly restore the child's appetite. (author's modified)
Use of rapid survey methodology to determine immunization coverage in rural Burma.
Immunization coverage for diphtheria, pertussis, and tetanus (DPT vaccine), polio (OPT vaccine), and tuberculosis (BCG vaccine) was quickly determined for a population-based sample of 396 children in rural Burma using Rapid Survey Methodology (RSM), a new approach to information gathering using a portable, battery-powered computer and printer, contemporary software, and a recently validated sampling procedure. 5 days after the survey team went into the field, the findings were presented in tables and computerized graphs to the local program manager. Within 10 days of the initial field day, a final 50-page report was issued. Using RSM, health professionals in Burma can now quickly and effectively monitor and evaluate immunization programs at the community level.
Assessment of the nutritional status of preschool Bahraini children.
Anthropometric measurements were made on 392 Bahraini children to detect prevailing patterns of protein caloric malnutrition (PCM) and to study the extent and severity of malnutrition. Nearly 1/3 of the children had PCM according to Gomez classifications, while moderate and severe cases were 4.6% and 0.2%, respectively. Distribution of acute malnutrition by age group showed that children aged 6-24 months were most affected, with the overall rate at 10%. Data also illustrated that 12.2% of the children were overweight. Stunting was most prevalent during the 3rd year (23.5%) and continued through the 5th year of life. PCM represents a public health problem in Bahrain and needs detailed ecological study.
The rural Alabama pregnancy and infant health program.
Infant mortality in the state of Alabama is among the highest in the nation and its breakdown among subgroups shows that the rate for nonwhite infants is more than 60% higher than for white infants. In an attempt to improve perinatal outcomes, the Rural Alabama Pregnancy and Infant Health (RAPIH) Program was founded in 1983 to reach out to high-risk, black childbearing women in 3 of Alabama's poorest counties: Greene, Hale and Sumter. The RAPIH Program is part of the larger Child Survival/Fair Start initiative funded by the Ford Foundation and is administered by the federally funded West Alabama Health Services, Inc. (WAHS). About 70% of the population in the service area is black, of whom more than 50% live below the poverty level. The Program is a home-visit program that relies on lay community workers to provide outreach, education, and social support to low-income families. A model visitation program begins at the 20th week of gestation and continues to the child's 2nd birthday. The home-visit services are provided by a group of black laywomen who are mothers recruited from the counties they serve. Prior to assuming their caseload, they participate in a 2 week training program sponsored by WAHS. Role-modeling activities provide active practice in establishing relationships with clients, presenting lessons, and dealing with problems. Prena