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. Prenatal and postnatal visits are conducted in the client's home; during each visit; the home visitor addresses a particular aspect of prenatal care or child health and development. Starting as a teacher, the home visitor eventually develops a partnership with the client in her understanding of and finding solutions for her problems including the use of community resources therefore. In an attempt to increase accessibility to both health and social services in the area, WAHS has purchased several vans to provide transportation to eligible residents. Records indicate that the home-visit group received an average of 5.3 home visits during the prenatal period and an additional 10.4 visits during the child's 1st year of life. As the program gets older, visit frequencies are expected to increase.
Rapid, low-cost data collection methods for A.I.D..
Various methods are used to collect data for the use of USAID managers in designing, implementing and evaluating development projects. Informal methods such as conversations with concerned individuals, reviews of official records, and field visits are quick and inexpensive and they are frequently used in AID as in other bureaucracies. At the other extreme are formal methods developed over the years by social and behavioral researchers which provide accurate information, but often do not justify their time-consuming and expensive characteristic. Between these 2 extremes lie various rapid, low-cost methods characterized by timeliness and relevance of information, ease of supervision and economy. These methods are classified into 5 categories. 1) Key Informant Interviews with a select group of individuals often provide in-depth, inside information and is the least expensive among the 5 methods, but is not designed to provide quantitative information. 2) Focus Group Interviews in group sessions of 8 to 12 carefully selected participants are rapid and economical, helping individuals to overcome inhibitions and participants to stimulate one another but not designed to provide quantitative information. 3) Community Interviews with community representatives in public meetings of 15 or more persons allow direct interaction between the investigator and a large number of people, providing meaningful verbal responses as well as nonverbal behaviors but are subject to manipulation by village leaders and often inhibit open participation. 4) Direct Observation by a team of outside experts is objectivee, rapid and economical but subject to observer bias, unrepresentativeness and inhibited respondent behavior. 5) Informal Surveys using limited number of variables and small, nonprobability sampling procedures provide quantitative data with limited time and resources but are not suitable for complex statistical analysis or for in-depth information. A Scope of Work should be prepared by AID managers to give specific guidance to the contractor collecting data. This should include 1) the background and purpose of the study, 2) the main questions to be answered by the study, 3) the data collection methods most appropriate for the study, 4) a list of specific tasks that will help achieve the purposes of the study, 5) the special skills needed by those who conduct the study, and 6) the study time frame and reporting requirements.
Development assistance and health programs: issues of sustainability.
The purpose of this paper is to generate discussion of the issue of health program sustainability--the ability of developing countries to continue to carry out health project activities and to provide benefits once donor support for a project ends. A fundamental question in a discussion of sustainability is the distinction between sustaining the activities and sustaining the benefits. The issues are explored here through a review of the literature on health programs of the Agency for International Development (AID) and other large donors. This review has identified several program components that seem critical to sustainability: financing, community participation in planning and implementation, host country policy, appropriate program design with respect to breadth of objectives, and program management. Sustainable programs are most likely to result when they are affordable (by the country and the community), when beneficiaries have a role in planning and managing them, when simple but effective management systems are in place, and when program objectives are focused but not limited to a single intervention.
[Report of clinic activities, first quarter, 1988]
Statistics from the 1st trimester of 1988, demonstrate that PROFAMILIA continued to grow with significant increases in many areas of services. There were 35,421 new clinic visits, a 5.4% increase from the same period in 1987. The largest difference was in male sterilization, with a 41.6% increase from 1987. There was a total of 94,174 clinic visits (+3.9%). There were 37,504 visits for IUDs, accounting for 63.8% of the visits for birth control. Female sterilization was the 2nd most common method (12,720 visits; 21.6%). Total cytologies fell by 8.2%, to 41,491. 10,395 pregnancy tests were performed, a 31% increase from 1987. Of the 22,643 visits that were not for birth control, 57.4% were for gynecological problems, 14.2% for general medical visits, 7.6% due to infertility, 6.7% for prenatal visits and 6.5% for urological problems. 17,313 surgical procedures were performed, an 11.1% increase. There was a 41.1% decrease in the sales of oral contraceptives, 19,644 cycles of pills. There was a 16.1% increase in condom sales to 70,814. Data are provided for brand and monthly sales. Oral contraceptive sales rose by 17.1%, to 1,175,272 monthly cycles in the community distribution service. Condom sales in this service rose 11.5%, to 1,244,639. Data for individual brands are provided. Overall, oral contraceptive sales rose 15.2%, with the community distribution service accounting for 98.4% of total sales; condom sales rose 11.7% with 94.6% from the community distribution service. There was a 14.1% increase in the total couple-years of protection (CYP) provided, to 400,968 years. The clinic had a 3.3% increase, the surgical program an 11.1% increase, the over-the-counter program a 16.5% decrease and the community distribution program a 33.2% increase in CYP. Tabulated data and graphs are presented on all topics discussed, broken down by the different centers.
Assessing needs in the health sector after floods and hurricanes.
Over the last decade, hardly a year has gone by in which 1 or more Latin American countries have not been subject to extensive flooding. Because these floods are usually slow in onset and prolonged in duration, confusion and inefficiency have arisen in relief management. The inappropriateness of the timing and nature of relief assistance is in no small part due to the lack of a sound method for assessing needs. Latin American experience reveals that a flood's major effects on health are in 4 main areas: certain communicable diseases, environmental sanitation, food and nutrition, and vectors. Ideally, therefore, the assessment team sent from a central level should comprise an edidemiologist, a sanitary engineer, a nutritionist, and an expert on vector control. This publication is a step toward helping countries to develop the right method for damage and needs assessment and training others in that method. It presents a methodology for selecting the appropriate data from the proper sources. The method is based on the premise that, although each flood has its own peculiarities, there are common key decisions that must be made. Although slow-onset floods are the main subject here, the same approach can be applied generally to hurricanes when the winds usher in torrential rainfall.
In January 1986, the US Department of Defense began screening all active-duty military personnel for antibody to the human immunodeficiency virus type 1 (HIV-1). A total of 1,752,191 persons who remained on active duty as of April 24, 1988, were screened. HIV-1 antibody was confirmed by Western blot in 2,232 (1.3/1000) of these persons. Information from the armed forces' Reportable Disease Data Base was used to determine the demographic distribution of HIV-1-antibody seroprevalence rates. Antibody prevalence by age ranged from 0.1/1000 for those aged 17-19 years to 2.1/1000 for those aged 25-29 years. Blacks were 3.6 times and Hispanics 2.5 times more likely than non-Hispanic whites to have HIV-1 antibody. Although blacks and Hispanics constituted 50.7% of those who were HIV-1 antibody positive, they represented only 23.4% of all active-duty personnel. Seroprevalence was highest in men, unmarried persons, and enlisted personnel. The Centers For Disease Control will continue cooperating with the Department of Defense in monitoring levels and trends of HIV infection active-duty military personnel and military recruit applicants. Surveys in other accessible populations at both low and increased risk of HIV infection are also under way.
The use of anthropometry to assess nutritional status.
Over the past 20 years, there has been substantial progress in the standardization of anthropometry, which is the use of body measurements to asses the nutritional status of individuals and groups. This brief examination of use of anthropometry to assess nutritional status has tried to highlight its possibilities for exploring nutritional status trends over time. Although other methods have been employed for this purpose, including clinical and biochemical techniques, none is as immediately applicable in purely practical terms as anthropometry. Children's development patterns during the 1st years of life, when growth is the most rapid, provide much information about their nutritional history, both immediate and cumulative. An evaluation of this growth provides useful insights into the nutrition and health situation not only of individuals but also of entire population groups. An admitted drawback in the present analysis is the limited availability of data despite the wealth of country information that is known to have been collected nationally and regionally. It nevertheless demonstrates how such data, when used judiciously, can permit the identification of risk groups, contribute to the development of appropriate food and nutrition policies, and serve as a baseline against which change over time can be realistically evaluated. It is hoped that with increased cooperation among those responsible, nationally and internationally, for growth assessment and nutritional epidemiology, both the quantity and quality, and the successful management and application of this information will increase. (Summaries in ENG, FRE)
A case-control study of all perinatal deaths in Leicestershire, England was established in 1976. By 1985, 1342 singleton perinatal deaths had occurred. Deaths were classified in 5 groups: congenitally malformed infants, normally formed stillbirth prior to labor, fresh stillbirth weighing 1000g, early neonatal death weighing 1000g, and fresh stillbirth or early neonatal death weighing 1000g. Overall perinatal mortality declined from 19.4/1000 in 1976-77 to 9.6/1000 in 1983-85. Perinatal mortality among patients of Asian origin was consistently higher than that among European women. Over the 10 year study perinatal mortality for Asian women dropped from 29.5/1000 to 15.7/1000, while for European women it dropped from 16.9/1000 to 7.9/1000. The profile by type of death was similar for Asian and European women. Since 1980, there has been no further decline in the perinatal mortality rate for Asian women, while the rate for European women continued a steady decline. Risk factors differed among the 2 groups of women, although many risk factors for perinatal death were common to both groups. Among Asian women, low social class was not a risk factor, and illegitimacy rarely occurred. Previous infertility increased the risk of perinatal death among Asian women, but not among European women. In 19% of perinatal deaths care was either inadequately provided or taken up. Being the partner of a manual worker carried a relative risk of 2.0 for European women, but was not a risk factor for Asian women. Hypertensive disease during pregnancy carried a greater risk for Asian women than for European women (relative risk of 2.5 vs. 1.2), while the opposite was true for gestational diabetes. The case control design provides a practicable way to evaluate causal risk factors and at the same time provide information to educators and health service planners.
Comparison of mosquito nets, proguanil hydrochloride, and placebo to prevent malaria.
190 students aged 6 to 18 at a boarding school 120 km west of Nairobi in the Rift Valley participated in a comparative trial of malaria prophylaxis. Treatment with a combination of amodiaquine 25 mg/kg over 3 days plus doxycycline 100 mg twice daily for 5 days cleared their blood of Plasmodium falciparum. They were then randomly divided into the following 3 groups matched for age and sex: 1 group slept under mosquito nets; 1 group received 1 or 2 tablets (100 mg each) of proguanil hydrochloride daily according to weight; 1 group received 1 or 2 placebo tablets daily which were the same size and color as the proguanil tablets. Malaria was diagnosed when asexual P. falciparum were seen on blood films and was treated with pyrimethamine-sulphadoxine. At the end of 1 school term 188 of 190 students had completed the study. 1 new infection was found during 3893 days of follow up in the mosquito net group, 8 new infections over 3667 days in the proguanil group, and 35 new infections over 3677 days days in the placebo group, representing a reduction of 97.3% and 77.1% in attack rates for the mosquito net method and for treatment with proguanil respectively. Both provide effective protection from malaria.
Mali's 1987 Demographic and Health Survey of 3200 women aged 15 to 49 and 971 men aged 20 to 55 revealed that only 5% of married women practice contraception. Mali's 8.7 million inhabitants are largely rural, illiterate and poor; 7% of the women and 20% of the men in the survey could read. Mali's high fertility rate (7.1 children/woman) has not changed in 35 years. Malian women prefer large families and only 17% wanted to stop childbearing. 25% of women aged 45 to 49 wanted another child within 2 years. Only 5% of married women use contraception, with abstinence as the most popular method, followed by oral contraceptives. Only 43% of women were familiar with a contraceptive method, only 29% with a modern method. Contraceptive use is related to formal education, with contraceptives used by 13% of those with primary school education, and 53% of those with 2ndary or higher education. Religion and spousal opposition, common obstacles to contraception in many Moslem countries, were cited as obstacles by only 7% and 9% respectively. Desire to become pregnant and lack of information were major reasons for women not to use contraception. Among men, 23% cited religious opposition to contraception, 66% were familiar with a contraceptive method, but only 4% used one. Rhythm and abstinence were the most common methods used by men.
In May 1988, the provincial government of Quebec instituted a payment schedule of new birth allowances. It is explicitly a cash bonus for having children. Parents receive US $500 for the 1st and 2nd children and US $3000 for each additional child paid in 8 tax exempt installments over 2 years. In addition, there are income tax cuts and interest free home loans for parents. Quebec also pays monthly child allowances until age 6 (up to US $500/year). Quebec's 1988 population of 6.6 million is 26% of Canada's population. Quebec is overwhelmingly French, with 80% of Canada's French speakers. Rivalry between French and English speakers is believed to contribute to concern about Quebec's falling fertility. Massive social and economic changes in the 1950s, with transition from a largely agricultural economy to industrialization, led to a decline in total fertility rate from 3.7 lifetime children/woman in 1958 to 1.4 in 1988. Quebec has Canada's lowest total fertility rate and has also experienced significant out-migration due to economic problems. Experience in Czechoslovakia and Romania indicates that incentives produce a temporary upward "bump" in fertility with an eventual return to former levels.
Vitamin A and E status was studied in 5 groups (satisfactory growth, reduced growth, night blindness, Bitot's spots, and corneal xerosis) of rural Indonesian preschool children. All groups except corneal xerosis showed satisfactory weight-height ratios. Initial serum retinol values were 0.35 micromol/L in 34% of all children. After oral administration of 24.4 micromol vitamin A, mean serum retinol values rose from 0.42 to 0.70 micromol/L at 10d. After oral treatment of children with 244 or 314 micromol vitamin A, mean serum retinol remained 0.56 micromol/L for 165d. Of particular note were the low mean initial serum alpha-tocopherol concentrations (6.3 micromol/L) and alpha-tocopherol-total lipid ratios (1.5 micromol/g). Total serum lipids fell in the normal range. Oral administration of 84 micromol vitamin E raised serum alpha-tocopherol and alpha-tocopherol-total lipid ratios by 46 and 44% respectively. Thus, vitamin E inadequacy, which impairs vitamin A absorption and storage, may well contribute to the high incidence of clinical vitamin A deficiency in West Javan children. (author's modified)
Historical study of pregnancy outcomes.
This paper describes a retrospective study covering the period 1972-1980 attempting to estimate the effectiveness of the WIC program from its origins (Special Supplemental food Program for Women, Infants and Children). The study related perinatal outcome and quality of prenatal care between 1972 and 1980 to WIC benefits to pregnant women among 11,154,673 births in 1392 counties in 19 states and the District of Columbia, adjusted for time change and between-county variability. WIC was associated with increased 1st trimester prenatal care (4.1%, p0.001), decreased inadequate prenatal care (-5.0%, p0.001), longer duration of gestation (0.20 d, p0.05), decreased preterm delivery (-9.2%, p0.05) and increased birth weight (23 g, p0.01). After autocorrelation was accounted for, significance levels for birth weight and frequency of preterm delivery were 0.05p0.10. Including counties with incomplete time series data, the estimated effect on birth weight was 23.9 g (p=0.004) and on decreased fetal mortality was -2.3/1000 (p=0.04). Among those with 12 years schooling, whites had a 1.8% reduction in preterm birth (p0.05) and blacks a 2.0% reduction (p0.05). The estimated effect on birth weight for less-educated whites was 46.6 g (p0.001). The predominant effects of WIC were on improved physiologic status of the mother and fetus. (author's modified)
This paper describes the methodology of the 3 contemporary field studies of the National WIC Evaluation, including sample selection; instrumentation; procedures for hiring, training, and supervising field personnel; and data collection, receipt, editing, coding, and processing. It also presents descriptions of the clinics at which women were recruited and of the pregnant women and their children who formed the sample of the cross-sectional study of children. Also discussed are the implications of sample characteristics to drawing inference from these studies. The longitudinal study of pregnant women enrolled a national probability sample of 5205 women 1st certified for WIC and 1358 comparable low-income pregnant women in 174 WIC clinics located in 58 areas in the contiguous 48 states and in 55 prenatal clinics without WIC programs in counties with low program coverage. The women completed 24 hour dietary recalls, histories of food expenditures, health care utilization, health and sociodemographic status, and anthropometric assessment. At late-pregnancy follow-up 3967 WIC and 1043 control women were interviewed and 853 WIC and 762 control women completed 1 week food expenditure diaries. Birth outcome was abstracted (from hospital records) for 3863 WIC and 1058 control women. Anthropometry, dietary intake, health, and use of health services were related to WIC among 2619 random low-income preschoolers. Psychological development was assessed in 526 children aged 4 and 5 years. Control women had higher income, education, and employment status; therefore, WIC program benefits probably were underestimated.
Longitudinal study of pregnant women.
The objectives of the longitudinal study of pregnant women were to address important outcome measures not available in the concomitant historical study and to seek convergent evidence on the effects of the Special Supplemental Food Program for Women, Infants, and Children (WIC) intervention during pregnancy on both the mother and the newborn child for those outcomes addressable in both studies. The major associations with WIC in pregnancy were increased intake of protein, iron, calcium, and vitamin C (4 of 5 targeted nutrients) and of energy, magnesuim, phosphorus, thiamin, riboflavin, niacin, vitamin B6, and vitamin B12; reversal of low weight gain in early pregnancy; smaller fat stores in late pregnancy; reduced frequency of premature rupture of the uterine membranes; larger infant head circumference with no effect on birth weight and length; increased birth weight and head circumference with better program quality; and lower fetal mortality of appreciable but not significant magnitude. Incremental energy intake was comparable to that in most small-scale supplementation trials. There was no evidence of effects on frequency of prenatal care, use of alcohol or tobacco, the intention to breast feed, or the rate of breastfeeding. Maternal alcohol intake was associated with depressed infant head circumference, over and above effects on birth weight and length.
Study of infants and children.
This study addresses the extent to which WIC affected the diet, growth, health care, and, to a limited extent, psychological development of children from birth to age 5 years. The indices used to test program impact were dietary intake, body size (weight, height, head circumference, arm circumference, and skinfold thickness), use of health services (adequacy of immunization and use of well-child care), and, for children aged 4 and 5 years, simple tests of behavior, vocabulary, and memory. The major associations with the Special Supplemental Food Program for WIC in preschool children were better dietary intake associated with current WIC participation, especially for iron, vitamin A, and vitamin C, but there were no increases in energy intake and, after infancy, no residual benefits from past WIC participation; strongest dietary effects among children who were poor, black, or in single-parent or large families (children lost to WIC were as needy as those currently enrolled); shorter stature, suggesting effective targeting (with enrollment in utero there was no parallel deficit in head circumference, which is consistent with results for newborns); better immunization and more frequent regular source of health care but no more frequent use of preventive health services; and better vocabulary with WIC participation begun in utero; better digit memory with entry into the program after the 1st birthday (differences that emerged only after statistical adjustment for sociodemographic factors); and more advantageous child behavior.
The objective of this component of the The National WIC Evaluation was to estimate the effect of the Special Supplemental Food Program for Women, Infants and Children, (WIC), benefits on the food purchases of the family, on both the amounts of money spent and the types of foods purchased. The central focus was on groceries prepared and eaten at home but costs of food purchased and eaten away from home were also estimated. Recalls of monthly family food expenditure, taken before and after maternal WIC benefits, were obtained from 4219 WIC and 785 control women; 1 week expenditure diaries (at follow-up) were obtained from 1031 WIC and 551 control women chosen randomly. Control families had higher incomes, spent more on groceries and in restaurants, and received fewer food stamp benefits. Women probably underreported the value of WIC benefits by recall (WIC vouchers are not dollar denominated). Although control families were more affluent, there were consistent effects of children's WIC benefits on weekly family grocery expenditure by diary (US $6.10, p0.05) and by recall (US $2.14, p0.01, and US $1.48, p0.05). WIC benefits to infants were associated with very large (nonsignificant) increments in grocery spending by diary (US $7.57). WIC benefits to the pregnant woman were strongly associated with larger amounts of WIC food entering the household (as were infant and child benefits) but effects on grocery spending were unclear.
Averting half a million births by 1992.
One of the aims of Morocco's Economic and Social Development Plan 1988-92 is to prevent 500,000 births by the end of the 5 year period. The number of married women aged 15 to 49 will increase from 3.5 million to 4.1 million in this period. The Ministry of Health aims to increase the prevalence rate of contraception from 37% to 45%, with 65% using oral contraception, 14% using IUDs and 8% with tubal ligations. The plan also recommends an increase in private sector provision of contraception from 30 to 35%, and removing restrictions on the sale and advertising of contraception. They report that in the last 20 years family planning communication in Morocco has failed, and attribute the low government priority given it to the high foreign aid component of this budget sector. In addition, it was believed that economic development and education would provide motivation, without the need for explicit efforts that could result in misunderstandings. The failures of family planning education have been officially recognized, and an increase in resources and emphasis devoted to it have been noted.
Women: avoiding the Bermuda Triangle.
While North African women have made great strides in education and paid employment, participants at a recent Round Table meeting organized by IPPF in Tunis described a "Bermuda Triangle" of street, politics and culture which women still enter at their peril. Shortly after Tunisia's independence in 1956, a far reaching "Personal Status Law" gave tremendous boost to the emancipation of women, outlawing polygamy, unilateral divorce by the husband, forced marriage and many other practices that had oppressed Tunisian women for centuries. Thanks to the prestige of President Habib Bourguiba, there was little opposition. While Morocco and Algeria lag behind, the Tunisian example has inspired women and women's groups. Political differences between the 3 governments have hampered cultural exchange. Women at the Round Table believed that Tunisia's progressive laws were not always the reality they should be, with magistrates often interpreting the law very conservatively. Women noted that change had occurred much more rapidly than they had expected 20 or 30 years age, due to population pressure, increases in the number of young people, education, the media and external influence. Modern contraception has been accepted remarkably quickly. While there are now professional women in North African countries, they are not always accepted as equals to men. A particular difficulty is that very few husbands share domestic responsibilities. Nevertheless, 391,000 women work in Tunisia, comprising 20% of the work force, with similar rates in Morocco, although women comprise only 9% of the work force in Algeria. Education is also viewed as essential to women's progress, and the enrollment rate for Tunisian girls has risen from 45% in 1975 to 68% in 1984, but is still lower than for boys. Emphasis on women's reproductive role by society is viewed as another major problem.
A 10 year old Moroccan program bringing family planning and primary health care to rural areas by government health workers on foot and motorcycle has expanded to reach 3/4 of Morocco's population. It accounts for 650,000 acceptors, 2/3 of the total reached by the public sector. This program covers 30 provinces, and aims to reach all women of childbearing age and all children under 5. The itinerant health workers provide 5 services: family planning, including supplying oral contraceptives and condoms, and referrals for IUDs and tubal ligation; referral of children for vaccination; supplying oral rehydration salts for diarrhea; detection of malnutrition and supplying weaning food; and distribution of iron and folic acid tablets to all pregnant and nursing women. The goal is to provide service to the most remote communities. The trained health workers reach people in their homes, and are an important source of health information. 4000 workers have been trained so far, including 1200 full time rural workers. Training covers communication and motivation, basic family planning, primary health care and data collection. In Marrakesh, the contraceptive prevalence rate among the 110,000 eligible women has increased to 67%, with an 80% continuity rate. The government intends to expand the VDMS program to provide nationwide coverage.
Compensation payments should stay.
For over 10 years, the government of Bangladesh has paid 175 taka (about US $5), which represents 1 week's earning to an unskilled rural worker, to men and women undergoing contraceptive sterilization, as well as paying 45 taka to those who refer them. The stated goal is to cover costs in travel, food and wage loss by a sterilization client. A concern exists that poor people choosing sterilization for short term financial gain may later regret it, and that the referrer payment may encourage high pressure persuasion. A comprehensive study commissioned in 1987 reported that sterilization is done with informed consent and knowledge of alternative methods. 12% of clients do later regret their decision, and this has been linked to small family size at the time of sterilization or loss of a child after sterilization. Sterilization is more common among the poor than those better off, so the small profit after expenses may be an incentive. The costs incurred in sterilization are 56 taka for women and 22 taka for men, with about 100 taka of wage loss for men. The referrer payment has created a large number of agents who recruit sterilization candidates for profit. Their clientele tend to be particularly poor. The client payments allow clients to meet costs, and the alternative, reimbursement of costs incurred, would be too difficult to administer. The referrer's payment poses a constant threat to the principle of informed consent and fair access. Replacement of the referrer payment by travel allowances for salaried staff would be beneficial.
Nigeria sets target of four children per woman.
Nigeria ratified an official population policy giving the Health Ministry responsibility for implementing a 4 children to 1 woman goal. The policy seeks to reduce the growth rate from its present 3.3%/year to 2% by the end of the century. In addition to the main goal of encouraging Nigerian women to limit themselves to 4 children, they wish to drastically reduce the number of women who marry before age 18. The policy has provoked public opposition, with the most vociferous protests from women's groups who believe it will encourage polygamy. Inaccurate press reports have exacerbated the problem. Planners are not concerned, as they believe that the open discussion which is resulting will be beneficial. Primary health care must be improved, as high childhood mortality is believed to contribute to a desire to have many children. In 12 months, the number of local governments providing comprehensive primary health care has doubled from 51 to 102, but 202 areas are still not covered. Planners believe the government should devote resources to a massive educational campaign utilizing the mass media, with emphasis on reaching Nigerian men. The official policy seeks to make family planning easily accessible and affordable to the whole population.
Senegal adopts population policy.
At the April meeting of the Interministerial Council on Population, President Abdou Diouf of Senegal stated that population issues need to be taken more seriously within the general development strategy of the nation. A population policy has been adopted. The Ministry of Social Development and the Ministries of Education and Health are responsible for fertility and childspacing. The Ministry of the Interior will try to control migration movements, and create employment opportunities for young people. Information, education and communication programs on population issues will be prepared. The National Population Commission will evaluate current legislation, taxation and social security systems to arrive at a better registration of births and deaths and to ensure the population policy's success.
The Sri Lankan government has decided to give greater emphasis to reversible methods of contraception in its family planning program. The program has been successful, with wide acceptance of sterilization, and it is believed that promoting spacing will encourage younger couples to use contraception. The Ministry of Health's of Formulary Committee has approved the use of the subdermal implant Norplant. A study conducted by the Sri Lanka Family Planning Association in 525 women over 2 years found 59% to be satisfied with the long term effects of the implant. 3/4 of the women had no specific complaints, but 19% complained of menstrual disturbances. The impant has a high cost, between Rs 400 and Rs 500 (US $14 to US $16) per implant. Cost is expected to decrease with increasing demand.
Race to save medicinal plants.
The vast wealth of chemicals obtained from plants plays a vital role in both traditional and Western health care, but many of these plants are threatened with extinction. 25% of US prescription drugs are based on active constituents from plants according to the World Health Organization (WHO). In March, health professionals and conservationists met in Thailand to discuss strategies to prevent extinction. Ethnobotany is a field that studies how primitive people use plants, and has led to the development of new plant-based drugs. In developing countries, every plant is viewed as having potential medicinal value and researchers study many plant-based drugs. The male oral contraceptive, gossypol, was discovered when investigation of the low birth rate in a region of China revealed that consumption of fresh cotton seed oil caused a low sperm count and infertility. Rain forests such as those in South America have the greatest wealth of plant species. In addition to the plants, development threatens the wealth of knowledge of the shamans, or witch doctors. 1 plant, piri piri, literally "women's medicine", is reputed to be an effective female contraceptive and is currently being studied in the University of Illinois. A WHO sponsored research program studied 300 plants over 12 years and identified 20 potential anti-fertility agents. The Dioscorea family, yams, have played a key role, as oral contraceptives are based on diosgenin, a derivative of the yam. While the role of plants in medicine is firmly established, many species are nearly extinct before their potential value can be determined.
Colombian clinics offer legal advice.
Profamilia's legal aid service is a departure from its policy of providing services only related to family planning. Previous departures have been only to attract users or raise finances. Maria Isabel Plata, the lawyer who runs the legal service, explains that there is a desire to improve the quality and range of services. In its 1st 14 months, 1500 people sought legal advice. Lawyers now work part time in 4 Bogota clinics. Profamilia handles only straightforward cases such as child support, marital separations and custody. One of the main aims of the legal service is to promote sexual equality. 3/4 of those who attended in the 1st 10 months were women, and questionnaires showed that 90% had a rough idea of their rights and obligations. Over 60% admitted to violence at home. Profamilia's lawyers encourage them to register complaints with the police. The program has Ford Foundation financing, which includes funding for educational projects to further women's rights.
Crossing the threshold of fear.
This interview was conducted with a 31-year-old US man from California, who has AIDS. He was 1st diagnosed in 1982. 4 years later, after a failed suicide attempt and a subsequent period of depression and withdrawal, he began a new career as an AIDS educator. His work has taken him across the US, where he is a member of the US National Association of People with AIDS (NAPWA), to Africa, as a consultant to the Norwegian Red Cross. He has also advised a number of European AIDS groups. He believes that people with AIDS (PWAs) and those who are seropositive have been under-used in the AIDS epidemic and in the epidemic of ignorance and prejudice which often follows the disease's spread. PWAs have a special role to play in helping people overcome prejudicial attitudes toward people with AIDS. This is both because people with AIDS have largely transcended the fear that people have of the disease, and because meeting a PWA humanizes the situation. The interview also considers racial prejudice in NAPWA, denial of the disease, and the benefits in forging links between different groups affected by AIDS.
Italy now ranks 8th in the list of countries worst hit by AIDS. The relatively low figures for homosexual AIDS cases give no cause for complacency. It is not known yet if the message about 'safe sex' has got across to homosexuals, or if there has been underreporting and the numbers with AIDS will start soon to show the same rising curve as that for drug users. The Vatican, as was always expected, has said 'no' to the use of condoms to combat the spread of HIV, even though its use would not be to avoid conception but to prevent disease. Many doctors working in the field resent the lack of consultation and communication between Rome and the regions. But Italian health services are decentralized; the 21 regional health authorities are autonomous bodies. They have never looked to central government for specific directions, but they do desperately need extra funding. Their literature has been important as means of countering 'disinformation' from the press, often prone to sensationalism. Discrimination against children of parents infected with HIV has occured in schools and frequently seropositive employees have been fired. Local authorities are now making great efforts to impart the correct information. The Italian family planning association, UNICEMP, plays a supportive role in the education and information campaign. Many voluntary organizations provide counseling. The government national commission on AIDS set up a free telephone service where experts are available to answer questions from the public. But although 18,000 calls were made in the 1st 6 weeks of opening, hardly any inqueries at all came from those most at risk--the drug users.
Film-making: the search for a storyline.
Many people in Africa are now aware of a disease called AIDS, but their knowledge and perception of what to do about it varies with their situation, the education they have received, and their contact with people with the HIV infection. International Planned Parenthood Federation (IPPF) AIDS Prevention Unit is supporting the production of a mini feature film on AIDS for the Africa region. Film making is expensive, so the makers wanted to find common themes that would enable different groups to place facts about AIDS into the context of their own lives and choices. To achieve these goals 25 small group discussions were held with men, women, and young people in urban and rural areas of 2 African countries. A few questions prompted people to talk together about AIDS, to ask questions and find answers, and to clarify each others' statements. There were misunderstandings about the facts, but even when the facts were correct, people did not necessarily believe or act on them. An important 1st discovery was that people find it difficult to change their behavior in response to a disease that they have never seen. People wanted to be convinced by videos of people with AIDS and monthly displays of the number of people who had become infected or died in their district. Rural people felt that they were safe from AIDS as long as they avoided, or tested and excluded, people coming into the community from the city or abroad. They had not reflected on the constant movement of local people between village and town. All groups thought that people with HIV infection should be isolated because they were not convinced that HIV is only transmitted through sex and blood.
Perinatal mortality (PNM) rates are reported for 146 twin-1 and 192 twin-2 breech births among 622 consecutive twin pairs delivered at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. Stillbirths and infants with severe asphyxia (Apgar score 1-3) were recorded in significant proportions of both 1st and 2nd twin breech infants. PNM rates were 13.7% twin-1, 18.8% twin-2; corrected PNM for infants weighing 2.0 kg or more, were 9.3% and 12.4% for twin-1 and twin-2, respectively. Twin specific breech PNM decreased with increasing birthweight of 1st and 2nd twin to a low optimum in the weight group 2.5-2.9 kg, and thereafter rose for both 1st and 2nd twin with birthweight 3.0 kg and above. Factors such as low birthweight, breech/breech presentation, breech extraction, and retained 2nd twin breech contributed significantly to the high PNM rates. More favorable PNM rates were recorded among a limited number of breech infants delivered by primary cesarean section for breech/breech or 1st twin breech presentations. A liberal approach to cesarean section delivery for breech twin births, and particularly for paired breech/breech presentation is strongly advocated. Cesarian section increases maternal and fetal risks, and the risks are further aggravated by anesthesia. While for the mother, the risks are related to increased cardiovascular stress and aorto-caval compression, for the fetus, low birthweight and asphyxia are real problems. Despite these known risks, there have been reports of favorable maternal and perinatal results for cesarian section in twin pregnancy. For optimum results, caution must, however, be exercised to deliver such infants in well-equiped hospitals with skilled personnel in attendance.
Birth patterns: are the Chinese in Guangzhou City different?
Diurnal birth patterns in the City of Guangzhou, China and the City of Calgary, Canada were compared. Chinese data were abstracted from the labor room log book of 1 large general hospital located in the Hai Zhu district of Guangzhou. Calgary birth data were abstracted from birth notification forms submitted to Calgary Health Services. Information included day of birth, time of delivery, type of delivery, and parity. Calgary births are concentrated on Tuesdays to Fridays whereas in Guangzhou weekly patterns varied tremendously according to whether it was assisted or unassisted. Calgary births are below average at night and during evening shift. The time of birth in Guangzhou variied substantially with above average rates for nonassisted births noted at 0800--2400 h, and above average rates for assisted births noted at 0800--1700 h. Differences in hour of birth appeared to be related to obstetric intervention practices. Several implications arise from the observations. 1st, better knowledge of birthing patterns could be used to help hospitals establish an appropriate schedule for personnel in the obstetric ward. The concern with safety combined with the reported increase in neonatal mortality associated with birth buring the night has been cited as a reason to examine the pattern. 2nd, considering the poor understanding of the normal physiological factors initiating labor, can the possible consequences of shifting birth patterns from a nighttime phenomenon to a daytime phenomenon be ignored? An explanation for these weekly and diurnal patterns, can, in a strict sense, only be speculative. Nevertheless, they do seem to suggest, especially in the case of assisted deliveries, that the pattern of birth appears to be related to the 24-h work rhythem of hospital personnel, especially in the Calgary hospitals.
Contribution of congenital malformation to perinatal mortality in Lagos, Nigeria.
Over a 17-month period identifiable congenital malformations at delivery in singleton births in Lagos, Nigeria were prospectively recorded. Despite the prevailing religous and cultural belief, autopsies were carried out in 41% of the perinatal deaths that occurred during the study period. Out of a total of 63 (21/100 singleton births) congenital malformations discovered, 21 (33%) were identified at autopsy only. About 16% of total perinatal deaths were due to congenital malformation. Cardiovascular malformations accounted for about 40% of perinatal deaths from congenital malformations followed by central nervous system malformation (23.3%), gastrointestinal malformations (20%), musculo-skeletal malformations (6.7%); renal malformations (3.3%), and others (6.7%). No relationship between maternal age, parity, and congenital malformation was found. The results from this study suggest that with the use of autopsy, teratology may contribute significantly to the prevailing high perinatal mortality in Lagos more than previously thought. Detailed and systematic studies of causes of high perinatal deaths in the developing countries would help in focusing attention on important areas of perinatal health so that the dwindling governmental health votes could be judicously and effectively utilized.
The 42nd session of the UN General Assembly in 1987 confirmed that the World Health Organization (WHO) should lead the urgent global battle against AIDS. It further urged all appropriate organizations of the UN system, in conformity with the Global Strategy for AIDS, to support this effort. In this context, and at the request of the 1987 Executive Board, this paper: 1) considers the special direct and indirect medical and socioeconomic problems created by AIDS for infants, children, adolescents, and women in developing countries; 2) reviews actions undertaken by UNICEF in 1987 at headquarters and field levels to address AIDS; 3) explores the problems of pediatric AIDS in relation to the UNICEF areas of special program competence; 4) outlines a policy framework in which UNICEF will approach AIDS; and 5) recommends a set of specific program actions for UNICEF in 1988-1989. Recommendations include: 1) considering the problems of AIDS as it affects children and women in all UNICEF country programming exercises and considering education and advocacy about preventative AIDS programs a matter of UNICEF concern in countries that do not yet recognize an AIDS problem, as well as those with significant numbers of reported cases and ongoing efforts; 2) bringing to the attention of the national and international communities through advocacy efforts the special needs of children and mothers affected by AIDS; and 3) strengthening UN collaboration with national governments, the WHO Global Program on AIDS; other multilateral and bilateral organizations and NGOs in efforts to prevent the spread of HIV and AIDS in the context of national programs.
Syringe exchange schemes [letter].
Syringe exchange schemes for drug users are part of a hasty reaction to the spread of HIV among drug users. Experience with prescribed methadone indicates that materials released to drug users often end up on a black market. A study of drug users revealed that many who do not inject drugs would if the means were more available. Drug users often share equipment to express commitment and communicate with one another. Furthermore, in a withdrawal state a drug user is likely to suspend logic and use the nearest available equipment. Making needles more available may spread HIV if more oral drug users begin injecting drugs. People motivated enough to seek clean equipment may be motivated enough to change their addictive behavior.
The "many faces of AIDS" and the toleration of the lesser evil.
This article discusses in detail the Bishops' pastoral letter, "Many Faces of AIDS: A Gospel Response" (MFA). The MFA is commended for teaching compassion for the victims of AIDS and its emphasis on monogamous marital relationships or abstinence as the best and morally correct ways to avoid AIDS. The most controversy surrounding the MFA stems from the following statement: "such educational efforts could include accurate information about prophylactic devices or other practices proposed by some medical experts as potential means of preventing AIDS. We are not promoting the use of prophylactics, but merely providing information that is part of the factual picture." This statement is assailed for its lack of clarity, and the remainder of the article is spent discussing its controversial elements, often referring to the writings of prominent church leaders. The author believes that the MFA does not succeed in providing a clear teaching on the proper response to AIDS, particularly in regard to suitable educational programs. It is suggested that the bishops reconsider the MFA, that they clarify what they mean to be advocating in this document, and that they explain clearly which Catholic moral principles justify their position.
Abstinence, sexuality, and natural family planning.
This paper resulted from a request to speak at a teachers' workshop for natural family planning, introducing some social and psychological aspects of abstinence in natural family planning (NFP) in Zambia. The themes of sexuality and abstinence are rarely broached in Zambian society, and so NFP opens new areas of dialogue and communication. The paper begins by breaking down and discussing the 4 instincts of love, namely: sexual desire, choice of mate, protection of offspring, and fidelity. In Zambia, the sexual relationship in marriage involves both complete availability and complete vulnerability. For the wife, there is a belief that she cannot deny her husband his sexual rights, and this leads to a fear of a resulting pregnancy if at that time she is not ready to bear another child. The husband's vulnerability is expressed in a different way in Zambia. Frequency of intercourse is applauded and is believed to show the husband to be virile. Infrequency of intercourse can result in being mocked by his wife or relatives. The husband must prove himself to be a man by his performance. His fear of failure creates an area of vulnerability for him also. These beliefs underscore the difficulty of instilling the practice of abstinence into Zambian life. However, abstinence can work if it is taught with a positive rather than a negative attitude. It can be regarded as an act of generosity and can remove the fears of the husband and wife explained above. The quality of the sexual relationship must be stressed rather than the quantity. Abstinence gives the couple power to choose when to have a family. Finally, abstinence can be thought of as an aphrodisiac where the couple returns to the marriage bed with new vigor.
AIDS: politics and science [letter].
This letter advocates widespread testing for the HIV virus. The author cites data from San Francisco which indicates that behavior modification in the homosexual population has brought the spread of HIV infection to a virtual halt in that group. It is argued that these data demonstrate that knowing someone with AIDS is the only factor that correlates with behavior modification. Therefore, the author rejects the notion made by others that counseling is more effective than testing in controlling the spread of AIDS. Rather, he asserts that knowledge of infection comes about by testing, and knowledge of infection is what leads to modification of behavior.
AIDS: politics and science [letter].
This letter responds to and approves of a previous letter written in favor of widespread education efforts to combat the spread of AIDS. The author then describes an AIDS liaison program at her hospital in which volunteer medical residents visit the classrooms in the local school district and provide an informal and frank discussion about AIDS. This not only provides an opportunity to disseminate information to a sexually active if not high-risk population, but also allows the medical community to become directly involved in AIDS education and provides them with an opportunity to maintain familiarity with current AIDS developments and participate in community preventive medicine.
AIDS: politics and science [letter].
This letter disagrees with a previous letter stating that mandatory tracing of sexual partners is a method of controlling sexually transmitted diseases that has never worked well. No tracing is ever mandatory. Health workers rely on communication and persuasion to help the infected patient realize the importance of notifying possibly infected partners. Cited is the historical significance of the successful partner notification process that occurred with syphilis when penicillin became available. Preliminary reports from states with partner notification programs indicate that 10-20% of the partners have been HIV positive. The best use of partner notification in AIDS prevention is to reach persons who may not recognize their risk, especially female partners of intravenous drug users or bisexual men, to prevent the perinatal transmission of HIV. Because the effectiveness of any voluntary partner-notification strategy may vary with the prevalence of HIV in the target population, studies to evaluate the potential usefulness, cost effectiveness, and benefit-to-cost ratio of partner notification should be implemented in areas of both high and low HIV seroprevalence.
A revision of the Reiss premarital sexual permissiveness scale.
A new version of the Reiss (1964) Premarital Sexual Permissiveness scale is introduced in this research. Changes are made in the sexual behaviors and relationship stages included in the scale, and experimental randomization is used to examine how standards vary for different categories of targets. The sexual behaviors in the Reiss PSP scale--kissing, petting, and full sexual relationships--are replaced by heavy petting (defined as touching of genitals), sexual intercourse, and oral-genital sex. The other major change in the scale is in the specific levels of intimacy. Reiss's 4 stages--no affection, strong affection, in love, and engaged--are not mutually exclusive and are replaced in this research with 1st date, casually dating, seriously dating, pre-engaged (informal commitment to marriage) and engagement (formal commitment to marriage). These labels mark the progression of a relationship. The gender of the hypothetical person referred to in the scale items was found not to affect the responses to the scale items. However, the person's age had a significant effect on responses to the revised scale. Standards for a teenager were less permissive than standards for a young adult. Another finding of the study is that males had more sexually permissive standards than females. Suggestions are made for how the revised scale may be used in further research.
The relation of family and partner support to the adjustment of adolescent mothers.
The influence of teenage mothers' perceptions of family and partner social support on their postpartum adjustment was examined in this study. A structured interview with teenage mothers was conducted prenatally and a follow-up assessment was done when their children were 8 months of age. Both partner and family support were related to greater satisfaction with life, but each was associated in a different way with parenting and concerns about daily living. At both assessment periods, family support was related to maternal reports of fewer concerns with daily living and with financial matters, whereas support from the male partner showed no such associations; this difference is most likely due to the fact that 75% of the teen mothers in this sample continued to live in their parents' homes and were therefore primarily dependent on their family of origin, rather than on their mates, for satisfaction of practical needs. However, the teen mother's parenting behavior--as assessed by her responsiveness to the infant and the total home score--was associated with her perceptions of current partner support and not related to perceived current family supportiveness. The results indicate the importance of distinguishing between specific sources of social support and different aspects of adjustment to teen parenthood.
Japan's family planning pioneer.
This article summarizes the work of Shizue Kato, Japan's family planning pioneer, and includes excerpts from an interview with her. When Margaret Sanger visited Japan in the early 1920s, Baroness Shizue Ishimoto, as she was then known, organized secret speeches for the American family planning pioneer because she was forbidden to speak publicly about the subject. The baroness would stand outside the meeting places where Mrs. Sanger was speaking to guard against police informers. It was Margaret Sanger who inspired the baroness to promote family planning in Japan--a concept which in that era was akin to treason, and which took many years for the nation to finally accept. Now at the age of 91, the venerated Shizue Kato has been honored with the 1988 UN Population Award, a prize which she shares with the Colombian Association known as Profamilia. After World War II, those in Japan who had spurned her for so long now saw the wisdom of what she had preached for so many decades.
Childhood gastroenteritis in Barbados: occurrence of camplylobacter and rotavirus.
400 children with diarrhea whose ages ranged from 3 months to 6 years were investigated to determine the etiology of childhood gastroenteritis in Barbados. Rotavirus (11%) was the most frequently identified pathogen, followed by Shigella (7%), enteropathogenic E. coli (4%), Salmonella (3%) and C. jejuni (1.3%) with 2% of patients having multiple pathogens. No pathogens were identified in the remaining cases studied. The ages of the patients with C. jejuni enteritis ranged between 4 months and 2 years (mean 1.3 years). The male/female ratio was 2:1. The most frequent symptoms were fever (66%) and bloody diarrhea (66%). The duration of stool excretion ranged between 1 and 7 weeks. The organisms were uniformly sensitive to antibiotic tests against erythromycin, tetracycline, chloramphenicol, gentamicin and nitrofurantoin. In contrast, the ages of patients with rotavirus enteritis ranged between 3 months and 4 years (mean 1.3 years) with a male/female ratio of 1:1, and the most frequent symptoms were diarrhea (80%), vomiting (70%) and upper respiratory infections. In 60% of patients, hospitalization was necessary. All patients had an uneventful recovery. (authors)
U.S. women's contraceptive attitudes and practice: how have they changed in the 1980s?
Between 1982 and 1987, favorable opinion of the pill increased steadily among American women (from 65 to 76%), and favorable opinion of the condom rose sharply (from 38 to 60%). Approval of the IUD dropped during the period (from 26 to 19%). During the 5 years, the proportion of married women aged 18-44 who were exposed to the risk of unintended pregnancy remained the same (78%), but the proportion among unmarried women rose significantly (from 64 to 69%). This change was primarily the result of an increase--from 68 to 76%--in the proportion of never-married women who had ever had intercourse. The overall level of contraceptive use among 18-44 year-olds who were exposed to risk remained stable over the period, at about 93%, but use of the most effective methods (sterilization, pill and IUD) went up, from 68 to 71%. All of the net increase in effective-method use, however, was limited to married women, among whom reliance on both sterilization and the pill increased (from 46 to 51% and from 17 to 22% respectively). Pill use also rose among unmarried women (from 43% to 48%), but there was no change in the level of sterilization. The prevalence of IUD use declined among both married and unmarried women (to 3% in each case). Condom use remained steady among married women, at about 15%, but among the unmarried it increased markedly, from 9 to 16%. Despite the increases in use of the pill, sterilization and condom that occurred during the period, nonuse remains a point of concern. 8% of all women of reproductive age at risk of pregnancy were using no contraceptive method in 1987, and the level was even higher--13%-- among unmarried women. (author's)
Intermediate determinants of racial differences in 1980 U.S. nonmarital fertility rates.
There are 4 major determinants of racial differences in nonmarital fertility rates in the US: differential sexual activity (exposure to risk); differential in spontaneous and induced abortion; differential contraceptive use (including method efficacy); and differential legitimation, through marriage, of births conceived out of wedlock. Racial differences in all 4 indicators encourage higher black than white nonmarital fertility rates in every age group examined; however, the relative contribution of each determinant to differences in nonmarital fertility varies according to age. Among whites, the estimated proportion of sexually active women increases from 30% of the 15-19 age group to 52% of the 20-24 age group and then remains stable through ages 25-29. Among blacks, sexual activity increases modestly with each successive age group, from 53% of women aged 15-19 to 60% of those aged 20-24 to 66% of 25-29 year-olds. Nonuse of contraceptives declines with age among both white and black never-married women. Legal induced abortion ratios among unmarried women increase with age for both whites and blacks. Whereas the proportion of women who legitimate births conceived out of wedlock declines sharply with increasing age among whites, the proportion stays very low for blacks in all 3 age-groups. The gap between whites and blacks in contraceptive use is of greatest concern to policy makers, because family planning effectiveness can, at least theoretically, be changed by program effort. However, even if black women and white women had equivalent levels of contraceptive use, sexual activity and recourse to abortion, there would still be substantial racial differences in nonmarital fertility rates because of the greater propensity among whites to legitimate premaritally conceived births.
The role of sexual self-concept in the use of contraceptives.
Sexual self-concept--defined as an individual's evaluation of his or her own sexual feelings and actions--is proposed as an important predictor of contraceptive behavior among teenagers, and a scale measuring the concept is described. In exploratory analyses among US university students, sexual self-concept is found to be associated with frequency of contraceptive use and use at most recent intercourse. It is also associated with their choice of contraceptive--students who had used prescription methods at last coitus had significantly higher scores on the sexual self-concept scale than did those who had used nonprescription methods or no method. These findings, together with the finding from analysis among high school students that sexual self-concept appears to improve with age, suggest that younger teenagers may be poorer users of contraceptives because of a lower sexual self-concept. A Pearson product-moment correlation confirmed that older participants had a more positive sexual self-concept than younger subjects. A 1-way analysis of variance showed that sexual self-concept scores were strongly related to the method of choice. The students who had used prescription contraceptive methods at last coitus exhibited the highest SSC scale scores, followed by those who had used nonprescription methods, then the withdrawal group and then the group who had used no method.
Linkages between sexual activity and alcohol and drug use among adolescents.
Among a nationally representative cohort of young men and women reaching maturity in the late 1970s and early 1980s, over 3/4 of males and 1/2 of females had sexual intercourse by age 19, and a substantial minority used marijuana prior to their 16th birthday. However, in most cases, much smaller proportions began weekly alcohol consumption, tried drugs besides marijuana or experienced sexual intercourse before age 16. Males are generally more likely to have begun participating in these activities, at all ages, than are females. Only modest %'s of youths participated in more than 1 activity at early ages or engaged in them in close proximity to one another. Indeed, only by age 19 did even 1/3 of the young women engage in sexual intercourse and use both marijuana and alcohol. In fact, the norm for girls under 17 and for boys under 16 is either abstention or participation in just 1 activity. Although younger blacks are more likely to have initiated sexual activity than are their white or Hispanic counterparts, young minority women are less likely than white women to have begun using alcohol or mauijuana. Young people who use 1 or more substances by a given age are more likely than those who do not to become sexually active within a year. However, marijuana use at a young age appears to be more strongly linked to subsequent sexual initiation than is regular monthly alcohol use. The converse is also true: boys and girls who become sexually active are much more likely than those who abstain to begin using alcohol or marijuana within a year, although the linkage is stronger for girls than for boys. In addition, the link between sexual activity and marijuana use appears stronger than the link between sexual activity and alcohol use. Nonetheless, young people under age 16 who begin using marijuana or alcohol before 1st intercourse are more likely not to have intercourse over the following year than they are to do so.
FDA approval ends cervical cap's marathon.
The cervical cap--a small, rubber, thimble-shaped barrier contraceptive--fits tightly across the cervix and prevents sperm from entering the uterus. On May 23, 1988, the US Food and Drug Administration (FDA) announced its approval of the Prentif cavity-rim cervical cap for general use in the US, ending a nearly decade-long struggle for federal approval. The decision was largely a result of a study sponsored by the NIH showing that the cap is approximately as effective as the diaphragm, with about 17 failures per year among every 100 typical users. The FDA's approval comes with 1 string attached, however: Because of concern over its effect on cervical tissue, the cap is recommended only for women with a normal Pap smear, and the device's labeling will suggest that providers have users return for a Pap smear after 3 months of use. Although the FDA has now given the cervical cap its blessing, a few remaining problems will still limit the device's availability in the US. Because the cap comes in only 4 sizes, some of the women who might like to use the cap will be unable to do so. Another difficulty is the manufacturer has not yet reached an agreement with a distributor in the US. Finally, there may be training-related delays in the cap's availability. A great deal more training and fitting are needed for the proper use of the cervical cap than are required for the diaphragm, both for the potential user and for the clinician who trains her.
Baseline study on MCH-FP field workers job performance.
This study aimed at assessing the level of performance of the maternal health, child health, and family planning (MCH-FP) field personnel, family planning assistants (FPAs), family welfare assistants (FWAs) and health assistants (HAs) in compliance with their job responsibility, to provide a baseline of information for future evaluation of workers. The study also envisaged to identify the constraints which hamper effective service delivery with special emphasis on worker's motivation and their knowledge and skill in MCH-FP service delivery. The most useful training topics were preparation of monthly reports, achieving monthly target, couples registration card, contact with FWA, distribution of contraceptives, motivation, and MCH. An extension of training time and more frequent refresher training was requested in order to improve training. In order to improve the performance of FWAs, the most common suggestions were that workers be supplied with vitamins and medicines, and that FWAs should make more frequent visits. The findings presented here have been confirmed by a separate observational study. In addition, the observational study revealed in detail some shortcomings and bottlenecks of field workers job performance, which are to be critically considered for future improvement.
A prospective study of maternal and fetal outcome in acute Lassa fever infection during pregnancy.
Several viral infections have been reported to result in more severe disease in pregnant than non-pregnant women, but the relative risks have not been well characterized. This has now been done for Lassa fever in a prospective study of 68 pregnant and 79 non-pregnant women who were admitted to hospital in Sierra Leone with confirmed Lassa fever. Lassa fever was the main cause of maternal mortality in the hospital, accounting for 25% of maternal deaths. 12 of 40 patients in the 3rd trimester died, compared with 2 of 28 in the 1st 2 trimesters and 10 of 79 non-pregnant women. The odds ratio for death in the 3rd trimester compared with the 1st 2 trimesters was 5.57 (95% confidence intervals 1.02 to 30.26). The condition of the mother improved rapidly after evacuation of the uterus, whether by spontaneous abortion, evacuation of retained products of conception, or normal delivery; 10 of 26 women without uterine evacuation died, but only 4 of 39 women with evacuation died (p=0.0016). The odds ratio for death with pregnancy intact was 5.47 (95% confidence interval 1.35 to 22.16). Fetal and neonatal loss was 87%. The risk of death from Lassa fever in the 3rd trimester is significantly higher than that in the 1st 2 trimesters and higher than that for non-pregnant women, but evacuation of the uterus can significantly improve the mother's chance of survival. (author's)
Hands across the equator: the Hereford/Muheza link.
This article describes how a doctor in England and a doctor in Tanzania began a program in which the health workers in their respective hospitals were exchanged. There were 2 aims of the program: each group should learn something about the other's way of life, and some practical help should be given by the richer community to the poorer one. The authors describe the 2 communities involved in the exchange and also give practical information on travel and financial arrangements. The bulk of the article is devoted to the remarks of the health workers who participated in the program. Finally, the changes initiated by the English health workers into the Tanzanian facility are described. These included minor changes in the operating room procedures and changes in the organization of the emergency department. Some of the shortfalls are also included, notably the lack of change in neonatal resuscitation and lack of change in maternal or neonatal mortality.
Thailand. Findings from systems analysis identify operations research priorities.
In Thailand, the Ministry of Public Health and PRICOR have begun a pilot project to design and test a decentralized primary health care (PHC) model in Northeastern Srisaket Province. As an initial step in this multi-phase project, researchers from PRICOR and the Ministry's Management Improvement Unit (MIU) conducted a systems analysis of key child survival and maternal health interventions. This approach included a comprehensive assessment of the PHC program at both the national and provincial levels. Information was collected for priority interventions such as immunization, oral rehydration therapy, water and sanitation, maternal care, child spacing and growth monitoring/nutrition. Training, supervision, health information systems and other support areas were also examined to provide a clear picture of PHC service delivery in Srisaket province. This comprehensive assessment relied on both qualitative and quantitative research methods and used a variety of data sources. Taken together, the information provided a clear profile of the strengths and challenges faced by the Srisaket health staff. Overall, findings for the different interventions showed great variation in program performance. Findings from the systems analysis have been instrumental in identifying alternative program strategies and operations research priorities.
Ecuador. A health information system for child survival.
This report describes an operations research project in Ecuador which developed and tested a strategy for meeting information needs for child survival. It was originally expected that evaluation of the Ecuador nationwide child survival program activities could be achieved through the existing Ministry of Health information system. However, each of the programs added its own reporting system. As a result, staff at health centers and posts are currently responsible for some 16 different daily and weekly reporting forms. The system is fragmented, error-prone, and inadequate to comprehensively evaluate the child survival program. PRICOR worked with the separate program directors and USAID Child Survival Advisors to define the basic evaluation indicators and replace the 16 separate, manually tabulated forms with a single form designed for direct computer entry and analysis. In the new system, all service providers, including nurses and auxiliaries, would use the same format to record his or her activities. Each patient would be identified by a unique clinical history number that would avoid duplication of information when the same patient was seen by multiple providers. The forms would be computer entered, and monthly consolidations, currently calculated by hand, would be performed by the computer, as would all other analyses. This approach enabled the full range of preventive and curative child survival services to be registered and multiple interventions for the same patient consolidated into a single record. Results indicated that the integrated form was mastered by service providers at all levels, from nurse auxiliaries to physicians. Based on these findings, the Ministry of Health has incorporated the design of an integrated reporting form into its master plan. This plan also calls for automated information processing and tighter coordination of information needs throughout the Ministry.
Fundamental building blocks of early life.
This article is a reprint of the annual essay of the president of the Carnegie Foundation of New York. Previous essays stressed early life as the foundation for the rest of life, and the basis for the kind of person an individual can become. While the other essays stressed adolescence and early adolescence, this one centers on another crucial phase, the 1st few years of life. The common feature of all these essays is a quest for an understanding of great leverage points for the human future. Poverty is cited as 1 factor which has a direct bearing on the experiences of children who undergo a high degree of suffering in the 1st few years of life. Secure attachment and bonding between parent and child is another experience which can determine the type of individual who develops later in life. Yet it is this attachment and bonding which is endangered in our age of single parents and adolescent parents. Prenatal health care and infant health care are undeniably important in the development of a person, yet much improvement could be achieved in this area. Cognitive stimulation in the preschool years is lacking, and research shows that early intervention, if well-designed, can have considerable utility not only in cognition but also in human relationships.
Go to the people, releasing the rural poor through the people's school system.
This book takes the view that the greatest challenge of the present era is not the conquest of outer space, but the emancipation of millions of impoverished and disenfranchised people in the rural areas here on earth. For more than 60 years, the sacred mission of the rural reconstruction movement has been to help these underprivileged peasants overcome the interlocking problems of poverty, ignorance, disease and civic inertia. The People's School approach described in this book has evolved through a program of empirical research which the rural reconstruction movement began in the 1920s in the county of Ding Xian, China. An important objective of this program has been to bridge the gulf between the 20th century scientists and the impoverished peasants of Asia, Africa, and Latin America. Modern science, which has made possible the conquest of land, sea, air, and outer space, also has the power to conquer the disease and poverty that victimize millions of people in developing countries. What the People's School has been trying to do is to simplify appropriate scientific disciplines--agriculture, medicine, political science--so that the technical know-how of the expert becomes the practical do-how of the peasant. As this book makes clear, this technology transfer is not an end in itself. What is more important is the creation of a new mentality among the people who are learning to help themselves.
This meeting of the ASEAN population program considered the following objectives: 1) To review Phase I ASEAN Population Program; 2) To consider the report of the Penang Pre-Implementation Meeting of Phase II ASEAN population Program including other progress reports, if any; 3) To consider the interrelationships between and amongst Phases I and II Projects of the ASEAN Population Program; and, 4) To consider administrative, financial, and policy issues related to the implementation of the ASEAN Population Program. Summaries are given of the current status reports and recommendations presented by the respective Regional Project Coordinators, while the full reports are attached as appendices of the proceedings. The ASEAN countries include: Indonesia, Malaysia, Philippines, Singapore, and Thailand. Issues in the conference included: Integration of population and rural development policies; Population and development; Women in development; Family planning; and Migration in relation to rural development.
World list of family planning addresses.
This document is a listing, alphabetically arranged by country, of family planning and planned parenthood associations, foundations, and societies throughout the world. It includes street addresses, mailing addresses, telephone numbers, cable numbers, and telex numbers.
[Childbearing among Hispanic teenagers in the United States]
The impact of adolescent fertility upon young mothers and their children has been documented extensively, yet little research has focused upon US Hispanics. The main reason is that only a handful of fertility-related studies have included or identified Hispanic respondents. Even among those that have, only rarely are there enough Hispanics other than Mexicans for separate analyses by country of origin. This omission is lamentable, since, in the US, social problems often need to be documented before they receive public attention. The lack of data on Hispanic adolescent pregnancy and its impact renders the problem invisible to many providers and policy-makers. Adolescent pregnancy in the Hispanic community also warrents attention because its consequences may be particularly dramatic. In addition to economic disadvantage, Hispanic adolescents in the US receive conflicting messages from 2 cultures regarding standards of sexuality, timing of childbearing and appropriate roles for women. While teenagers of all ethnic groups experience some contradictions between family and peer-group attitudes toward these issues, for Hispanic girls the contrasts are often especially sharp. This is most likely to be true when they or their parents have been raised outside of the US. If norms and customs of the society of origin differ greatly from those of the US, the result is often severe personal stress and conflicts with parents. This can make parent-child communication about sex--never an easy process-especially problematic in Hispanic families.
Pacific partners, a guide to United Nations agencies in the Pacific.
This booklet, describing support available from the UN, is a valuable resource for decision-makers and others interested in development issues. The South Pacific, a vast oceanic region of 100s of scatted islands, is rapidly changing. Since the early 1960s, 11 South Pacific countries have attained self-government or independence, and 5 are now numbered among the 159 member states of the UN. New issues and events keep the region is sharp international focus. While technological progress has reduced distances between the islands, the South Pacific countries continue to face many development challenges in health, housing, education, and adequate nutrition and water supplies. Growing urbanization, increased dependence on imported foods, and cash crops for exports are affecting the environmental and cultural patterns of the South Pacific. These issues are of primary concern to both the South Pacific and the UN. Over 30 of the UN family of agencies are cooperating with the governments of the Cook Islands, Fiji, Kiribati, Republic of the Marshall Islands, Federated States of Micronesia, Nauru, Niue, Republic of Palau (Belau), Papua New Guinea, the Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu, and Western Samoa. The UN provides expertise and training opportunities, as well as capital assistance, to help improve the lives of the South Pacific islanders as they move towards self-sufficiency.
Compendium of approved projects, as of 30 September 1985.
The United Nations Development Program (UNDP) Compendium of Approved Projects contains a listing of ongoing UNDP-assisted projects financed under the Indicative Planning Figures (IPF), Special Program Resources, Special Measures Fund for Least Developed Countries, and Special Industrial Services. Part I of the Compendium presents summary tables for the program as a whole, classified by source of funds, type of project, sector, executing agency, region, and by country within each region. In Part II the following information is shown for each approved project, listed by country: Executing agency; date of approval; estimated completion date; and estimated project cost in US dollars, equivalent, including UNDP contribution, 3rd-party and government cost-sharing, and government contribution in cash and kind. The cost-sharing component of projects has been separated from "government inputs in cash and in kind" in Part II. Part III provides information on approved intercountry projects (regional, interregional, and global). Following Part III is detailed information on the participants in intercountry projects. Part IV presents a detailed listing of all projects with 3rd-party cost sharing and the donor. Program categories include: political affairs; general development issues, policy, and planning; natural resources; argriculture, forestry, and fisheries; industry; transport and communications; international trade and development; population; human settlements; healthl; education; employment; humanitarian aid and relief; social conditions and equity; culture; and science and technology.
World population prospects: 1988.
The 1988 UN population revision estimates that the total population of the world in mid 1988 is 5.1 billion persons and that the annual rate of increase is 1.7% for 1987-1988. It proposes a plateau in the rate of world population at around 1.7%, starting in the late 1970s and ending around the early 1990s, with annual fluctuations. In 1985, just under 1/4 of the world population resided in the more developed regions. By 2000, the proportion is expected to decrease to 1/5 and by 2025 to 1/6. The proportion was about 1/3 in 1950. The regions that are growing most rapidly at present (1985-1990), with a rate of 2.5%, include Western Africa (3.3%), Eastern Africa (3.1%), Middle Africa (2.9%), Western Asia (2.8%), Northern Africa (2.7%), and Melanesia (2.6%). The regions that are growing most slowly, with a rate 1%, are Eastern, Northern, Southern, and Western Europe, the Soviet Union and Northern America. Many countries in Eastern, Middle, and Western Africa continue to have among the highest fertility rates in the world, with a total rate of 6 births/woman in 1985-1990. Africa also has the highest mortality rates, with an average life expectancy at birth of 51.9 years for 1985-1990. Of the 7 countries in the world having a life expectancy below 45 years for that period, 5 are in Africa. For the world as a whole in 1985-1990, for every 1000 infants born, 71 are expected to die before reaching their 1st birthday.
Projected fertility and contraceptive use.
Between 1987 and 2025 nearly all the projected growth in the number of contraceptive users will occur in the developing world, since in developed countries the number of women of reproductive ages will change very little and contraceptive prevalence is unlikely to increase much beyond the high levels already attained. The number of contraceptive users in developing countries is projected to increase by roughly 170%, from an estimated 326 million in 1987 to 883 million in 2025. About 1/2 of that increase is due to growth in the number of women. Simply to keep pace with the expected increase in the number of married women, with no increase in contraceptive prevalence, the number of contraceptive users would have to grow by approximately 80%. The projected growth in the number of contraceptive users is very uneven across developing regions. In Africa the number of contraceptive users in 2025 is projected to be about 12 times the number in 1987. In South Asia the number of users will be approximately 3.5 times, in Latin America 2.3 times, and in East Asia only 1.2 times. These radically different rates of increase in numbers of contraceptive users mean that the geographical distribution of users will be very different in 2025 than at present, if the projected changes come to pass. In 1987 women in developing countries already made up about 70% of the total number of users worldwide, but the % is projected to increase to about 85% in 2025 (assuming that contraceptive prevalence is developed countries remains at its current level of 70%). Developing countries in East Asia, which currently contain 1/3 of the world's users, would account for under 20% in 2025. The proportion of the world's contraceptive users in South Asia would grow to over 40%, from roughly 1/4 at present.
Protecting the World's Children, "Bellagio II" at Cartegena, Colombia, October 1985.
This volume contains the papers and presentations listed on the formal agenda of the Cartagena Conference organized and sponsored by the Task Force for Child Survival. (Other papers are available on request by the Task Force.) Approximately 90 world leaders and public health experts participated in the conference. In attendance were ministers of health and senior representatives from 10 developing countries; heads and technical experts from the World Health Organization, UNICEF, UNDP, the World Bank, and the Rockefeller Foundation; senior representatives of several bilateral government agencies and nongovernmental organizations; and representatives of the Task Force itself. The conference focused on current progress in accelerating and expanding childhood immunization programs, plans for meeting the WHO 1990 Objectives for Universal Childhood Immunization, and strategies for using immunization programs to build better primary health care (PHC) systems. In the months since the Bellagio Conference, support for immunization programs has markedly increased, as has the commitment to meet the 1990 WHO goal. Immunization coverage levels have shown a heartening increase. However, these coverage levels still permit over 3 million children to die annually from measles, neonatal tetanus, and whooping cough, and over 1/4 million children to be crippled by poliomyelitis. Much remains to be done.
Global overview: the expanded programme on immunization.
From the global perspective, management capacity within national programs remains the most severe constraint for the Expanded Programme on Immunization (EPI) of the World Health Organization. Lack of management capacity is reflected in weakness of the health infrastructure, weakness which must be overcome by more effective use of existing resources, coupled in many countries with the expansion of those resources. While the increase in external resources available to the program is gratifying, the capacity to absorb them remains limited in many countries. Not enough capable individuals are being appointed, and even capable staff are often being hindered by levels of remuneration requiring them to take additional jobs outside of their government work. National staff continue to need training in practical management and continue to need motivation and on-the-job training by supportive supervision. Expectedly, the problems are most severe in those countries with the least resources. Recommendations include the following: 1) Promote the achievement of the 1990 immunization goal at national and international levels through collaboration among ministries, organizations, and individuals in both the public and private sectors; 2) Adopt a mix of complementary strategies for program acceleration; 3) Ensure that rapid increases in coverage can be sustained through mechanisms that strengthen the delivery of other primary health care interventions; 4) Provide immunization at every contact point; 5) Reduce drop-out rates between 1st and last immunizations; 6) Improve immunization services to the disadvantaged in urban areas; and 7) Encrease priority for the control of measles, poliomyelitis, and neonatal tetanus.
Review of task force activities.
It is clear that the World Health Organization's Expanded Programme on Immunization (EPI) is dependent on good coordination between the international agencies and the individual countries. More countries are now developing national immunization programs, and international agencies are increasing their investment in these activities. Groups such as Rotary International have entered the immunization arena, and basic scientists have been challenged with a new array of tools to provide a face-lift to current vaccines and to develop new vaccines unexpected a decade ago. Whereas resources constituted the primary obstacle to global immunization 18 months ago, that is no longer the case. This major change reflects the fact that the world is no longer willing to accept that children should suffer from polio or die from measles or tetanus. The major barriers to immunization now are the development of country programs to take advantage of the available resources, and the mobilization of managerial skills to effectively deliver immunizations. The Task Force for Child Survival has continued to develop resource files on individuals with experience in developing countries and/or immunization who might be possible candidates for short-term and long-term work on the EPI. The research interest of the Task Force has gradually changed from the idea of developing a research agenda to one of support for ongoing efforts to prioritize and promote basic research.
Under the volcano: the inevitable new age of vaccines.
Advances in vaccines may render antibiotics virtually obsolete by the year 2000. Oral rehydration would be rarely used, and even family planning will be aided by vaccines. Agencies are now moving into the picture. Most prescient was the National Institutes of Allergy and Infectious Diseases (NIAID) in Bethesda, Maryland, which realized the great potential of biotechnology for vaccine development as early as 1980 by proposing a new program entitled "Accelerated Development of New Vaccines." In the World Health Organization's (WHO) Tropical Diseases Research Program, malaria and leprosy are a major focus for vaccine research. Recently, WHO has inaugurated a new program in vaccine development which is initially directed toward tuberculosis, encapsulated bacteria, hepatitis A, poliomyelitis, respiratory viruses and dengue. In spite of the great potential for vaccines, however, there has been little, if any, increase in support for vaccine research by most funding organizations. For instance, the NIAID program was approved, but never funded. This slack has been made up by the interest of large numbers of scientists who have "bootlegged" vaccine research under other grants with the astonishing results presented at the 3 annual Cold Spring Harbor meetings. Although there are still relatively few new and better vaccines on the market, it is now inevitable that there will be a virtual eruption of vaccines within the next 15 years.
Program managers desire to approach zero incidence of the vaccine-preventable diseases at the lowest possible cost. If program managers could design the ideal vaccine, they would develop a multiple-antigen vaccine (that is, containing all antigens in a single injection that would: 1) provide life-long immunity with a single dose; 2) have no short-term or long-term adverse reactions; 3) be inexpensive; 4) be easily administered without costly equipment or techniques by relatively untrained workers; 5) be stable at tropical temperatures for months, or even years; and 6) be efficacious an time after birth. In addition, one would desire an easy way to identify those persons who have been immunized, such as has been available with smallpox and BCG. Whereas basic research must continue at maximum speed for providing new and better vaccines for the future, great opportunities exist for improving the effectiveness and efficiency of current immunization programs. Engineering research is needed to improve diagnostic techniques, to provide more potent vaccines, and to develop a more systematic approach to adjuvants. The greatest impact in the short term, and especially for the 1990 objectives, is to be found in operational and field research to improve coverage and return rates, reduce doses needed, decrease the age of administration, and improve the safety of vaccine administration.
Family planning and diarrheal disease control in primary health care.
Family planning and diarrheal disease control (CDD) programs are examples of primary health care (PHC) interventions that need to be promoted alongside expanded immunization programs (EPI) in countries having the managerial capacity. They are also among the most cost-effective health interventions available. Any of the 3 programs--EPI, CDD, or family planning--can be a lead program. But the others should not be left too far behind. In many lesser developed countries such a variety of conditions are threats to a child's life, and the potential of each for immediate and serious mischief may not be easy to assess. Therefore, combinations of interventions that may prove synergistic in their impact should be the goal. Mere survival of a child is not sufficient as an objective. The survivor should be well nourished and have hope and security in the life gained. Within the health service, specific aims of a family planning program should be the following: 1) to ensure a gap of from 2-4 years between pregnancies; 2) to ensure the postponement of 1st pregnancy until the mother is in the early 20s; 3) to ensure the cessation of reproduction after the age of 35 years; and 4) to ensure the achievement of a planned total family size commensurate with family and community resources. Some 100 countries are now implementing national CDD programs as a part of PHC, alongside or as an "entry point" for other essential care activities. A case management strategy, and other cost-effective strategies, are being implemented.
Future directions for child survival efforts.
Today, the vision pursued by the Task Force for Child Survival appears to be a narrow-minded approach. Should it remain focused on immunizations? The answer to that, at least for the time being, is probably yes. More progress will be made by dedicated people focusing on specific problems in parallel. 3 overriding observations have been made about nutrition programs that have failed: 1) things are always more complex than they seem; 2) conceptual simplicity is essential, because if you start with conceptual complexity, then implementation can't even be considered; and 3) the operational complexity is compounded by the number of steps involved, the number of actors whose preferences determine the outcome, and the number of discrete decisions involved. Things must be kept simple, and 1 way to do this is to pursue programs separately until their full maturation before integration in the best sense is considered. There is no problem with parallel movements in the Expanded Programme for Immunization (EPI), diarrheal disease, and family planning with appropriate coordination, and integration should not be confused with coordination. The World Health Organization has coordinated these programs for years, and coordination should continue.
Illegal aliens and census counts.
This paper examines the issue of including illegal aliens in the 1990 US census counts. It considers the demographic, economic, and social contexts within which this question arises, as well as the legal history of the issue. The number of undocumented aliens living in the US in 1980, while substantial, fell considerably below the numbers often thought to have been residing in the US at the time. A number of studies show that the impact of undocumented immigration on the employment and wages of other groups in the US is uncertain in its direction and insubstantial in magnitude. To the extent that questions about including the number of illegal aliens in census counts emerge from concerns about the economic impact of undocumented aliens on the American economy, the research evidence indicates that the problem is not as great as many have thought. Anti-immigrant sentiments appear to have grown and illegal immigrants are increasingly viewed as contributing to the development of economic problems. There is also the perception that illegal aliens benefit from social services to which they are not entitled and for which they do not pay. Academic analysts have found that undocumented aliens do not use these services extensively and that their tax contributions equal and often exceed the value of the services they receive. It is also unclear what effect the Immigration Reform and Control Act of 1986 will have on the size of the undocumented alien population in 1990. Historically, concern over whether illegal aliens should be included in census counts has arisen when it was thought that the nation was experiencing social and economic problems. In legal terms, the issue of including illegal aliens in census counts involves how to define the "persons" that the census is required to enumerate. Several times Congress has reviewed the policy of including undocumented aliens in the census and it has always been considered unconstitutional to exclude undocumented aliens. If for no other reason than that a constitutional amendment is always a legal possibility, the demographic features and economic consequences of illegal immigration are relevant to, if not decisive for, resolving the question. In the case of the 1990 census, both legal and practical reasons suggest that illegal aliens should be enumerated according to the same rules as the rest of the population.
The determinants of breastfeeding for Mexican migrant women.
This article develops an economic model for assessing Mexican agricultural migrants' decision to breastfeed in a sample of 137 women in 3 agricultural communities in California. The resulting hypotheses from the model are linked to health care and welfare program access, cultural factors, and employment. Using a probit analysis of the variables, a major finding is that non-traditional practices such as out-of-home child care, birth control, and alcohol use have a negative impact on the probability of breastfeeding. These findings were consistent with the hypothesis that women with more traditional values would be more likely to breastfeed. The authors also found that working women in the sample population were less likely to breastfeed. (author's modified)
Expanded program on immunization: western hemisphere perspective.
The Expanded Programme on Immunization (EPI) was initiated in accordance with a 1974 World Health Assembly resolution. The EPI was endorsed for the Americas by the Directing Council of the Pan American Health Organization (PAHO) in 1977. Since its inception in 1977, the EPI program in the Americas has made considerable progress. More than 15,000 health workers have been trained in EPI workshops. A cold chain regional focal point in Cali, Columbia, has trained over 150 technicians in cold chain equipment, maintenance, and repair. Schools of public health in the region have been actively involved in EPI training. Most countries have made notable strides in improving and expanding the equipment and proceedures used in the cold chain to assure the potency of vaccines. PAHO created the EPI Revolving Fund, which has assisted countries in the region with vaccine purchases worth more than US$19 million. This fund has contributed to improved vaccine quality and the ready availability of vaccines at the country level. Since November, 1980, PAHO has collaborated with other organizations that support immunization activities, including UNICEF, USAID, Rotary International, and the Bellagio Task Force for Child Survival. An additional effort in priority countries specifically directed at polio can lead to the interruption of indigenous poliovirus transmission in the Western Hemisphere in a short period of time.
The National Vaccination Crusade in Colombia had 2 fundamental goals. The 1st was to expand preexisting vaccination coverage in the under-4 population by 50%, and the 2nd was to strengthen the channeling strategy in areas where it was already being used, and to implement it by 50% in areas where it had yet to be applied (the cities of Bogota, Medellin, Cali, and the departments of Cundinamarca, Valle del Cauca, and Meta). The Vaccination Crusade satisfied both of these goals. In the 1st case, coverages for polio, DPT, and measles increased by 54%, 54.3%, and 88%, respectively, as compared to preexisting levels. Complete vaccination series were achieved for 67.3%, 66.8%, and 81.6% of the population less than 1 year old for polio, DPT, and measles. Coverages in the under-4 population group were 72.3%, 72.7%, and 75% for polio, DPT, and measles, respectively. This Crusade also achieved its 2nd objective; channeling was implemented in the departments of Meta, Valle del Cauca, and Cundinamarca, as well as in the cities of Cali and Medellin, and, with less success, Bogota. It is important to note that despite success in achieving these objectives, there is still a group of the population that has not been vaccinated. 3 of every 5 children who had not received a single dose prior to the Crusade were still in the same situation after the campaign. 1-year-olds continued to register coverages below 70%, even after the campaign, due to extremely low levels of coverage prior to this effort. Other accomplishments by the campaign included social mobilization, reawakening of the health sector, and massive health education.
National child survival and development plan.
The National Child Survival and Development Plan in Colombia constitutes an effort to organize action being carried out by the different health programs to substantially reduce morbidity and mortality in the population under 5 years of age due to diarrheal disease, acute respiratory infection, perinatal problems, immuno-preventive disease, malnutrition, and psycho-affective deprivation. This plan also contemplates action directed towards care for pregnant women and those of childbearing age (15-44 years) given their vital role to the health and welfare of the child. Once implemented on a nationwide scale, the plan is intended to reduce the current mortality rate from 57 to 40/1000 live births during a 5-year period (1985-1989), and forster psycho-affective development of the child population. The plan is founded on 3 basic principles: 1) emphasis on maintaining health; 2) development of self-care at the individual, family, and community levels; and 3) use of appropriate technology. Strategy areas include expanded social mobilization, use of mass media, and innovative methods for community education. Extended channeling is being developed at the operational levels of the National Health System, and includes planning activities, execution, control of the vaccination process, and promotion and community education so as to allow for establishing a permanent link between the health organization and members of the population through the support and cooperation of community leaders.
Comparing family planning methods.
This table compares family planning methods. Hormonal methods include: Norplant implants; oral contraceptives, including combined oral and progestin only (minipill); and injectables, including DMPA, Depo-Provera, NETEN, Novisterat; medicated intrauterine devices, including Copper T380A and Progestasert; barrier methods, including diaphragm or cervical cap (with spermicide cream or jelly); vaginal contraceptives, including spermicides and sponge; and condoms (without spermicides); sterilization, including vasectomy (male) and tubectomy (female); and periodic abstinence. Points of comparison cover: 1st year pregnancy rate; frequency of administration; what it is/how it works; reversibility/returning to fecundity; side effects; advantages; and special characteristics.
"In this report, official [U.S.] life tables by cause of death are published for 1979-81. Multiple-decrement life table functions and cause-elimination life tables are presented. Separate life table values are presented for each of the seven categories: total population, white males, white females, males other than white, females other than white, black males, and black females." The data are from the 1980 census and other official sources. (EXCERPT)
Indirect estimates of the birth and death rates and age-sex composition of Palestinian refugees.
Fertility, mortality, and age and sex distribution among Palestinians living in Jordan, the West Bank, Gaza, Lebanon, and Syria in the 1970s are examined. Indirect estimation techniques developed by Preston are used to estimate crude birth and death rates, population size, and age and sex composition for each of the five geographical areas. The estimates are compared with figures from the registers maintained by the U.N. Relief and Works Agency (UNRWA). This is a revised version of a paper originally presented at the 1984 Annual Meeting of the Population Association of America (see Population Index, Vol. 50, No. 3, Fall 1984, p. 415).
In the 1950s ESCAP assumed that capital intensive investments in industrial activities mostly located in large cities would efficiently bring about rapid economic growth at the national level and that the benefits would "trickle down" to the whole country. By the early 1960s the countries were growing as expected. In the 1970s regional development planning was more concerned with integrated and balanced spatial framework as a means of alleviating regional imbalance. At present, the promotion of small and intermediate towns in ESCAP countries is concerned with indigenous resource development in an agro-based context. Small and intermediate settlements are expected to perform multifarious functions in a national settlements strategy. They 1) can provide the rural hinterland with essential social services and facilities, 2) can create off-farm employment opportunities, 3) can activate agricultural activities within a local market, 4) may function as locale of small-scale industries, and 5) can channel the adminstrative guidance and support. Many ESCAP countries advocate the development of small and middle-sized cities in non-metropolitan areas. These policies are concerned with spatially-balanced regional development, promotion of rural development, taming of primate cities, and frontier-region development. Small settlements and local growth points are of strategic importance. Between 1960 and 1975, 1) the number of cities of more than 4,000,000 and their population increased enormously in the ESCAP region, and 2) intermediate cities grew fast and the city size class of 500,000-1,000,000 swelled conspicuously, while rural population increased at 2.2% per year. Rural settlement planning should be viewed in the overall context of integrated rural development to strengthen productive capacity in rural areas. Establishment of rural centers, where certain facilities and services are concentrated for the benefit of rural people, is a focal point of rural settlement planning. National policy alternatives for spatial distribution of population and industry should depend on several criteria, including 1) the relative growth of urban and rural sectors, 2) internal migration trends, 3) the degree of regional disparities, and 4) the extent of the transportation network over the country. International organizations should 1) support governments' efforts in pursuing balanced growth of human settlements, 2) provide technical advice to countries formulating policies, 3) train and/or assist member countries in training programs, 4) study relevant subject matters, and 5) disseminate information and study results.
Disaggregate migration behavior and the volume of interregional migration.
Nested multinomial logit models are used to investigate migration behavior during the 1971-1974 period for a large sample of the population of Ecuador. (760,764 individuals) The nested form of the model makes it possible to test hypotheses about the importance of destination characteristics in conditioning the odds for out-migration. Our empirical results indicate that the odds for migration from each origin are conditioned by the expected utilities of the available set of destinations, as well as characteristics of the origins and the personal characteristics of the potential migrants. The association between destination characteristics and the frequency of out-migration allows the total volumes of migration to be adjusted to interregional differences in place-specific utilities. (author's)
Employment effects of multinational enterprises: the case of the Republic of Ireland.
The industrialization policy of state-sponsored agencies has promoted the share of foreign multinational enterprises (MNEs) in industrial investment, employment, output, and trade in the Republic of Ireland in the past 20 years. This working paper describes the growth and employment distribution of foreign MNEs in light of available statistics. Employment by foreign MNEs in Ireland consists of a contracting and an expanding sector. The majority of the contracting sector are of British origin; their employment as a whole declined from 25,000 in 1973 to 21,000 in 1980. The expanding sector encompasses foreign enterprises in what has been termed New Industry. Their employment increased from about 14,000 in 1966 to almost 60,000 in 1980. Proponents of a science policy-based approach to industrialization strategy have argued that the state should take measures to correct the imbalance between the economy's supply of educated and skilled human resources and the MNEs' demand for them. Accounts of the electronics and food industries show that the imbalance is left uncorrected by conventional Industrial Development Authority (IDA) policies and that problems can also occur when the state seeks to pursue an alternative course. The appropriateness of the IDA strategy is discussed in 2 unpublished reports commissioned by the National Economic and social Council. The first report, which relates to the period up to 1974, emphasizes that policy-induced industrial development has increased net exports and, by lifting the balance of payments constraint, has allowed aggregate demand to be expanded to the benefit of employment in other sectors. The second report, the Telesis Report, concludes that Ireland may be paying more than is necessary to attract foreign enterprises and that development policies may not be making full use of the foreign enterprises in Ireland. The question at the forefront now is whether the prevailing package of incentives can be modified so as to harness trade benefits that have previously been neglected and thus achieve a more equitable distribution of the reciprocal advantages flowing from foreign direct investment in Ireland.
200 nurses in 4 maternal and child health centers, 28 family planning clinics and 3 specialized maternity hospitals in Alexandria, Egypt, were examined to assess their knowledge about tubal sterilization and vasectomy and to investigate the association between such knowledge and parameters such as age, education, in-service training and place of work. Only 40.5% and 37.0% of the nurses were knowledgeable about pre- and post-operative care for women who undergo tubal sterilization. 37.5% were aware of the complications possible after such surgery. Only 39.0% knew the correct mechanism by which vasectomy prevents pregnancy, and only 30.5% were able to state the possible complications. Pre- and post-operative care for vasectomy patients was understood by just 14.51% and 12.5% respectively. Nurses who had attended in-service training programs were more knowledgeable about all the parameters, while the effects of formal education did not appear to be significant overall. Nursing school curricula should be updated to include more training in family planning and, specifically, in sterilization. Periodic in-service training should be provided. The ominousness of the terminology in Arabic should be addressed, perhaps by a change of terms.
Team approach to vsc - Benue experience.
This paper describes the team approach to voluntary surgical contraception (VSC) as it is practiced at the Katsina Ala General Hospital in the Buene State of Nigeria. The hospital has 4 medical officers, 2 of whom had received training in Family Planning methods. Only 1 of these medical officers had trained in both nonsurgical and surgical minilap methods. As a result of working together and sharing experience as a team, all 4 have now fully acquired the VSC minilap operative technique. The family planning clinic also has a staff of 3 nurses, 2 of whom have received family planning training. The Nurse Counselor in charge of the clinic explains the nature of the operation to prospective clients and conducts the pre-operative evaluation which includes a general and pelvic examination. The Nurse Counselor can do this screening, because the team approach has given her the opportunity to work closely with the medical officers. Only clients with contraindications are required to see the medical officer before operation. During the operation, a nurse assists the medical officer. Clearly defined roles have been established in this team approach, with the Medical officer serving as head of the team. The medical officer talks to his team mates with respect--and as equals--but his instructions must be followed. According to this report, the family planning clinic has become the unit best conducted in the hospital. Job satisfaction is very high as a result of the team approach. There is also increased acceptability of family planning services by the public.
Married and unmarried couples, United States, 1982.
This report presents final data from the US National Survey of Family Growth, Cycle III, on a variety of topics related to exposure to sexual intercourse both within and outside of marriage. These include 1) the timing of 1st date, 1st sexual intercourse, and 1st marriage; 2) the proportions of women who have ever had sexual intercourse in a recent period; 3) current status and number of marriages; 4) unmarried cohabitation; and 5) marital dissolution and remarriage. This report presents statistics relating to 1 important set of intermediate variables--the formation and dissolution of marriages and other sexual unions--for women aged 15-44 years in 1982. Results show that in 1982, 86% of women 15-44 years of age and almost all women aged 25 years and older had ever had sexual intercourse. Nearly 7 out of every 10 ever married women had begun their sexual experience before they married for the 1st time. Most American women of childbearing age have continued to marry at some time, and marriage continues to be an important determinant of fertility. Patterns of marriage and 1st sexual intercourse differ substantially by race. Patterns of 1st intercourse and marriage also were associated with family background--whether or not the woman was still living with both her parents when she was 14 years of age. Other factors affecting marriage an the timing of 1st intercourse include religious affiliation, region of residence, and poverty status.
Knowledge, attitude, practice study.
Annotated bibliography of Canadian demography 1984-85 update.
This is the second annual update to the ANNOTATED BIBLIOGRAPHY of CANADIAN DEMOGRAPHY, 1966-1982. It includes materials on population in Canada published in 1984 - 1985 that were located by January 1986; some earlier items not listed in previous editions are also included. The items are listed alphabetically by 1st author and are cross-listed under 2-3 subject headings in the subject index. Subject headings used in this edition are defined and are grouped into the following categories: characteristics, demographic data, family and household, fertility, general population studies, historical demography, marriage and divorce, migration, mortality, policy, regions, spatial distribution, techniques, and theory.
Contraceptive use effectiveness evaluation techniques for field workers.
Causes and consequences of sex-age differences in human populations.
Participation of the health sector in population policy.
A proposal to establish a family planning resources center.
Demographic microsimulation model for population change.
Evaluation of family planning (first draft for discussion).
Cultural patterns, social structure, and reproductive differentials in northwestern Thailand.
An inventory of fertility and related surveys conducted or planned since 1968 [draft].
[Basis for the family planning program]
Consultant report on the distribution and use of oral contraceptives in Pakistan.
Fertility characteristics, region X.
Population and environment: a select bibliography.
The role of legal abortion in fertility decline: the California experience.
Evaluation: by whom and for what.
Proception and contraceptives as components of dependent fertility variables in the United States.
A microsimulation of Yoruba fertility.
[The midwife in a rural setting in Togo]
The effectiveness of social action programs in health and welfare.
Problems and adequacy of vital statistics in Korea.
Maternal-child health care, midwifery and childbearing customs: Tanzania, East Africa.
This study on maternal-child health care, midwifery, and child-bearing customs in Tanzania covered the period July 11- August 5, 1983 and focused on health and educational facilities in the urban and rural areas of Dar Es Salaam, Dodoma, and Arusha with management by zonal and district public health nurses in each city. It presents a concise overview of the country while concentrating on issues involving women and children's health care.
The 1st training seminar/workshop on POPIN-Africa methodologies for input/output, documentation and population information networking which was organized by the POPIN-Africa Coordinating Unit took place at the Economic Commission for Africa (ECA) in Addis Ababa in October 1986. Analysis of evaluation questionnaires completed by the participants revealed that: the seminar was useful since it brought network members together as a team to discuss problems relevant to their duties at the country and subregional/sectoral levels; the discussion sessions following lectures which highlighted practical issues were very useful; and the sessions on management, monitoring and evaluation, acquisition, abstracting, report writing and editing, training design and management and the simulated models of action plans were particularly useful. It was recommended that similar training seminars be held to cater specifically to the topics of network planning and management, abstracting, report writing and editing.
[Population growth rate of one percent in the year 2000: an unattainable target]
The author demonstrates the unattainability of Mexico's population policy target of reducing the natural increase rate to one percent by the end of this century. In order to reach this goal, the net reproduction rate would have to decrease to significantly below replacement level, or 0.667; this would produce dramatic changes in the age structure as well. The policy's objectives are also analyzed in terms of the extent of family planning necessary to reach the target growth rate. (ANNOTATION)
[Trends in birth rates and fertility among foreign women in the Federal Republic of Germany]
Recent trends in the fertility of the foreign population of the Federal Republic of Germany are analyzed. Consideration is given to fertility differentials by nationality. The results suggest that, with the exception of the Turkish population, the fertility of foreign women is only slightly higher than that of German women. (ANNOTATION)
[Problems in the measurement of internal migration]
"The paper analyzes some problems related to the census measurement of internal migration according to the three following aspects: The lack of agreement between the proposed objectives and the type of question made; questionnaire design errors and enumeration errors; and inadequate data elaboration." The geographic focus is on Latin America. Problems concerning data on place of birth or place of previous residence and how these can affect the calculation of migration trends are considered. (SUMMARY IN ENG) (EXCERPT)
Methods of data collection in the 1980 census round in Latin America are described and evaluated. The authors first note that 16 out of 20 countries concerned have already carried out censuses in this decade. They describe how these censuses contain more data on fertility, mortality, and international migration than in the past. Problems involved in preparing reasonable estimates for such demographic variables are considered, including the preparation of questionnaires, census omissions, lack of response, and the use of sampling. (SUMMARY IN ENG) (ANNOTATION)
[Immigrants and the national question: a comparative study of Quebecois and Walloon societies]
"The essay presents a comparative analysis of two Francophone regions, [Wallonia, Belgium] and Quebec [Canada], which have experienced similar institutional and cultural problems, following the great migrant inflows. If, on the one hand, these immigrants constitute an enriching opportunity for the local population, on the other hand, they can aggravate pre-existing difficulties or raise the question of their integration. While the Canadian federal system allows Quebec an autonomous legislation in the field of immigration and of linguistic choices, [Wallonia] is bound to the decisions of the central Belgian government. The expectations of local and immigrant population push toward more open policies regarding citizenship, immigration and linguistic choices." (SUMMARY IN ENG) (EXCERPT)
[The character of reversibility in the study of migration]
"Consideration of the concepts of spatial mobility has made the criterion 'change of residence' obsolete, in the study of various forms of contemporary migration. The introduction of the concept of eventual 'reversibility of migration' has made it possible to make greater use of the concept of 'life space'....The authors attempt to relate this 'life space' to the notion of 'home base'. They can thus define various types of flow that were not covered when the concept of 'change of residence' was used. In particular, the introduction of the 'eventual reversibility of migration' renders the dichotomy between temporary and definitive moves obsolete, although the precise nature of this 'reversibility' remains to be defined." The geographic focus is on developing countries. (SUMMARY IN ENG AND SPA) (EXCERPT)
[Time, cultures, and coexistence]
"In this essay, the authors try to illustrate the relevance of the sociology of time for the study of migration and inter-cultural relations. It is argued that by taking the time-dimension more explicitly into account, our insights in the dynamics of these relations can be [improved]....In connection with international migration processes, this relationship appears to be influenced by at least six different factors: 1) the sudden transition from a rural to an urban, industrial environment; 2) the perspective of the return to the homeland; 3) the confrontation with the culture of the host country and with other migrants' cultures; 4) the religious, ideological and political developments in the homeland; 5) the reactions of the host country and the problems these create; 6) the minority position of the migrants." (SUMMARY IN ENG) (EXCERPT)
[Immigration in the countries of the Gulf: some specific aspects]
"This essay analyses some aspects of the in-migration flows to the Gulf countries, coming from other Arab countries as well as developing nations. Since the 80's, the Gulf countries have endorsed a restrictive policy concerning manpower import, even though they still need foreign workers. The Gulf countries pursue this policy as they fear that the presence of millions of foreign labourers will create social tension. The situation of the foreign labour force is uncertain and is bound to the role of the middleman, the local kafil, and that of the recruiting agencies. Rotation of foreign workers is very high. It has reached the 10 million mark in ten years." (SUMMARY IN ENG) (EXCERPT)
[Two decades of demographic change in industrialized countries(1965-1985)]
Demographic changes in developed countries over the past 20 years are analyzed. The emphasis is on factors common to the changes that have occurred in basic demographic indicators such as fertility and nuptiality. These intermediate factors are identified as a decline in the institutional aspects of marriage and the family, the practice of family planning, and the greater economic independence of women. These factors are seen as part of a more complex cultural change involving the relationship between spouses, which is increasingly based on greater equality, discussion, and convergent attitudes. (SUMMARY IN ENG AND SPA)