Formulation, implementation and impact of population policy in Ghana.
In the nearly 2 decades since Ghana's Population Policy (1969) was promulgated, progress has been slow in terms of translating policy objectives into quantifiable achievements. The policy itself is unique for its comprehensiveness; the problems that rapid population growth poses for socioeconomic development are identified and short-term targets are clearly defined. The national family planning program has been noteworthy for its noncoercive approach, integration with other health-sector activities, multiagency participation, and public-private sector partnership. Nonetheless, 1 fertility survey indicated that only 13% of married women of reproductive age in Ghana had ever visited a family planning facility and the proportion currently attending an outlet was 6%. In part, this situation reflects leadership problems and a lack of political commitment on the part of various governments to give family planning program implementation the necessary attention in the face of other crises such as food shortages. Needed is a more vigorous, sustained commitment on the part of the government to population planning and the funding of population programs. Incentives should be considered to increase the participation of women, especially those with low levels of education, in family planning programs. In addition, the issues of women's status (female employment and education, in particular) should receive more attention in order to reduce pronatalist sentiment, and laws that serve as obstacles to family planning acceptance (e.g., age requirements) should be removed. Finally, to improve administrative efficiency, the relationship between the coordinating national family planning secretariat and participating agencies should be changed from voluntary to a statutory compelling obligation.
Evolution and growth of family planning in Zimbabwe.
The remarkable success of the Zimbabwe National Family Planning Council is due, in large part, to community involvement, especially the guarantee to women of participation in decision making at all levels. Other factors responsible for this success include strong political commitment to family planning, sizeable resource inputs, systematic application of a strategic analysis, well-planned and designed programs, the selection of appropriate strategies (i.e., the integration of family planning and maternal-child health services), and a clear articulation of short- and longterm goals. A multisectoral, interministerial board composed of representatives from the social sectors that interface with population concerns plays an advisory role, but employers, employees federations, religious organizations, and women's groups are also represented. Managers of Zimbabwe's family planning programs continually assess changing trends in acceptable methods, the cost-effectiveness of various modes of delivery, and the extent to which the goals of birth spacing, health improvement, and socioeconomic development are being met. The contraceptive prevalence rate for modern methods reached 33% in 1985, and 75% of users receive their contraceptive supplies at their homes or are within 30 minutes of travel time from a service provider. A special target group for the coming period is the youth of Zimbabwe. Overall, the Zimbabwean experience demonstrates that a flexible, responsive leadership style can avoid the bureaucratic patterns that thwart many population programs.
Evolution and status of family planning in Nigeria.
Nigeria's population policy, formulated in 1988, is not yet fully operational and thus has had a negligible impact on fertility as yet. Moreover, family planning programs face formidible challenges due to early marriage, high fertility, pronatalist values, low contraceptive prevalence, widespread illiteracy, and the low status of Nigerian women. A key strategy for reducing fertility--female employment in the wage sector of the economy--has been endangered by Nigeria's current economic crisis and massive layoffs. While the family planning promotion campaign has been enthusiastically embraced by government officials, it is dubious whether this commitment can be matched by an adequate provision of contraceptive materials and services. Another concern is the type of message that is being delivered by family planning programs in this traditional, pronatalist society. The emphasis has been on using family planning to produce the number of children that can be adequately cared for; however, the predominant cultural belief in Nigeria is that God gives and provides for all children. IEC activities must be targeted at aspects of Nigerian culture that promote uncontrolled childbearing and made understandable to illiterate men and women. A concern with improving the overall standard of living of the masses should be another key component of family planning motivation. Although there are many obstacles to family planning practice in Nigeria, the government's official endorsement of family size limitation is a major advance and will provide new legitimacy to the struggling Family Planning Federation of Nigeria.
Women's roles and gender issues in family planning in Africa.
The low contraceptive prevalence levels in most African countries reflect, in part, a failure to design and provide family planning services in a way that is responsive to women's needs. A female user perspective requires consideration of 3 factors; 1) acceptance of the acceptor's birth control goals (e.g., birth spacing) as valid; 2) the need to make a wide range of family planning methods available; and 3) responsiveness to anxieties regarding possible side effects and cultural taboos. An experiment in Zaire has documented the effectiveness of female-centered, gender-sensitive, household-based contraceptive distribution schemes. Vaginal tablets and foam were the methods most frequently selected, and levels of contraceptive acceptance were achieved more rapidly than would have been the case had the distribution been through service outlets. Needed in addition to sensitivity to female users is attention to the role of women as participants, managers, and decision makers in family planning projects and programs. Numerous experiments have demonstrated how effective African women can be in promoting contraceptive usage in their own communities, especially when community leaders and traditional healers are involved. Work-based systems of delivery of services and information are also effective. Basic to any efforts to reach African women with family planning methods is more research into folk theories regarding conception, pregnancy, and contraception. Real or imagined side effects of modern contraceptives can have profound effects on their adoption and lead women to believe that abortion of unwanted pregnancies is a safer practice than prevention through contraception.
Despite the poor quality of demographic data in Nigeria, both indirect and direct estimates have indicated consistently high levels of fertility since the 1950s. All population surveys in this period have recorded ideal family sizes of 6 children and above, and even among the educated sector of the population, there has been no change in fertility levels. The persistence of large family size has been attributed to the socioeconomic benefits parents expect to derive from having many surviving children and the desire to have at least 1 surviving son for lineage continuity. Nigeria has formulated policies aimed at reducing fertility and rural-urban migration, but government action has, in the past, been limited to mere recognition of the link between demographic factors and economic development. In contrast, Nigeria's most recent population plan (approved 1988) is explicit in setting goals and spells out the institutional mechanisms required to implement the policy. The general objectives of the national population policy are: 1) to improve the population's standard of living and quality of life; 2) to promote health and welfare, especially among high-risk mothers and children; 3) to reduce birth rates through voluntary contraceptive acceptance; and 4) to achieve a more even rural-urban population distribution. Components of the population program include the provision of family planning services to all those who want them and the strengthening of maternal-child health services. To reverse rural-urban migration, efforts are being made to strengthen rural economies. The plan further calls for the regular collection of demographic data. An office of Planning and Coordination for the Population Program is being established within the Ministry of Health. It remains to be seen whether the voluntary nature of the program will be sufficient to achieve the demographic goals, yet the commitment of the Nigerian Government to this task has been impressive.
Formulation, implementation and impact of population policy in Kenya.
Kenya's population policy, which dates back to 1966, has been characterized by an overreliance on the advocacy of family planning as a means of reducing high rates of population growth. In the 1980s, however, this policy was reoriented toward creation of an environment conducive toward smaller family size and the integration of family planning and maternal-child health services. Still, policies pertaining to migration, human settlements, the spatial distribution of the population, urbanization, and the status of women remain inadequately defined or implemented. Also lacking has been solid government support for population programs. The government has relied on foreign institutions rather than local ones for direction, and these experts have made recommendations based on Western paradigms that are inappropriate to Kenya. The recent shift from child spacing to birth limitation took place without any analysis of the value and cost of children; moreover, it threatens to violate fundamental human rights. Bureaucratic inefficiencies resulting from having country project officials assigned by the United Nations Fund for Population Activities are commonplace and could be reduced by formation of a strong interministerial monitoring and evaluation committee. Again, the failure of the Government of Kenya to address the proximate determinants of fertility, mortality, and urbanization limits the effectiveness of population programs. Urgently needed is a thorough review of the quality and type of personnel employed by Kenya's family planning organizations, target clientele, program activities, institutional structures, and funding. In short, Kenya's population policy must become more comprehensive, more responsive to societal changes, and receive more attention from the government than mere policy pronouncements.
Formulation, implementation and impact of population policy in Mauritius.
Postwar increases in the crude birth rate combined with decreased mortality due to malaria eradication and improved socioeconomic conditions led to the formation, in 1950, of a Population Commission to address population growth in Mauritius. Family planning services became available in 1960, but were delivered through the private sector due to religious opposition. It was not until the late 1960s that the Government of Mauritius entered the family planning arena and services provided by the Mauritius Family Planning Association were integrated with maternal-child health services at Ministry of Health outreach points. The Association's approach has included the provision of a wide range of contraceptive choices, incentive schemes for field workers, continuous independent monitoring and evaluation of program activities, and coordination with other organizations. Mauritius is unique among African countries for having achieved spectacular reductions in the population growth rate during the 1970s, despite its polylingual, multicultural character. This success was in part attributable to sudden overcrowding on this small island, which motivated the population to practice fertility control, but also to support from the intelligentsia and other public opinion modlers. Fertility is now at a below replacement level; in 1990, the gross reproduction rate should be 0.9 and the crude birth rate is expected to be 16.5/1000. At the same time, problems remain in areas such as adolescent pregnancy, high drop out rates among contraceptive acceptors, and a reliance on temporary methods, expecially the costly pill. Moreover, in another decade, Mauritius will begin to experience the demographic aging associated with dramatic population declines and will have to formulate measures to provide social support for the aged.
The problems of fertility regulation in Africa.
Efforts to regulate fertility in Africa have had a negligible impact. Moreover, many African countries were worse off in terms of indicators of development in 1988 than they were in 1970. Annual population growth rates of 3-4% are undermining government attempts to provide the education, employment, and health services required for economic development. In addition, the low level of female education (associated with desires for a large family) comprise a major obstacle to acceptance of fertility regulation among the population. Legal issues, such as the lack of a minimum limit on age at 1st marriage, the continuation of polygamy, laws that deny women access to credit or ownership of property, and regulations restricting contraception to married women are further impediments. The technologies available for family planning, largely imported from Western societies, have proved inadequate to the African situation. There is a need for contraceptive methods that produce fewer side effects than the IUD and pill and are less dependent on regular clinic visits. There is also a need to make African men more committed to participating in fertility control through condom use. Integration of family planning into maternal-child health programs has been proposed by many government officials as a solution to Africa's population problem, yet such services reach only 20-30% of the population. Community-based distribution programs and social marketing offer more potential for increasing contraceptive availability. Poor policy articulation, program planning, and implementation are at the heart of the failure of most African family planning efforts and, until these management problems are overcome, little progress can be expected.
Economic constraints in family planning and contraceptive use in Africa.
Sociocultural norms emphasizing the importance of large family size comprise a formidable barrier to family planning acceptance in African countries. A dependency effect, in which fewer adult producers are supporting a large core of children in the economically nonproductive age group (under 15 years), has meant falling savings rates and further deterioration in the economic situation. Given the concern of African governments with economic development rather than the future threat of population explosion, it is recommended that family planning programs place greater emphasis on this issue. Any advances in the area of economic development will, moreover, remove many of the economic constraints currently limiting family planning programs in Africa. These constraints are both demand-side and supply-side in nature. The demand-side contraints operate at the household level and involve accessibility to family planning services and their costs. Access to contraceptive supplies is especially limited in rural Africa, suggesting a need for community-based distribution, the integration of family planning services into government health programs, greater involvement of the private sector to supplement government efforts, and more widespread use of trained paramedical staff. On the supply side, the low gross national product in African countries implies that family planning provision will not receive priority status. This resource issue also undermines efforts to reallocate staff to rural areas or to implement integrated programs. Moral, social, and cultural disincentives to contraceptive practice are barriers to marketing, and clinic and hospital-based family planning services may not be the most effective means of delivery. Since educated women are more likely to be responsive to family planning programs, greater investments should be made in education and public awareness programs.
The Gambian national population policy and programmes.
More comprehensive family planning and population policies, and the integration of population control projects into other development activities, are essential if development objectives in The Gambia are to be met. It was not until 1979 that the government established an explicit population policy that endorsed the delivery of family planning services within the maternal-child health system. A 3-year project was initiated in rural areas to strengthen basic maternal-child health services through the construction of 8 dispensaries and 1 health center, the provision of needed supplies and equipment to health facilities and mobile teams, the provision of health education materials for field workers, and the provision of contraceptives. Village health workers resupply condoms, while traditional birth attendants provide oral contraceptives and make referrals for other modern methods. A community-based contraceptive distribution system is in the process of being expanded to cover all of The Gambia. The government's strategy for reducing family size has 2 components: 1) to help parents understand the value of having only the number of children for which they can provide adequate care, nutrition, housing, and education; and 2) to provide the necessary facilities to enable couples to exercise choice in determining the size and spacing of their families. At the same time, these goals are begin undermined by numerous factors: the restriction of contraception to those aged 21 years and above, a lack of trained personnel, low staff morale in public sector family planning programs, a lack of reliable data for planning, the dependence of the government and private sector on external funding sources, and Islamic religious values. Reform of laws pertaining to the low status of women in The Gambia would be a major step toward enabling implementation of population control goals.
Family planning evaluation--data, methods and research issues with special reference to Africa.
Evaluation of the impact of family planning program efforts in Africa can be carried out through statistical measures of changes in the numbers of contraceptive acceptors or in knowledge of and attitudes toward family planning as well as an examination of fertility statistics such as the crude birth rate and the age-specific fertility rate. From a data requirement perspective, the contraceptive prevalence method (an estimate of the number of births averted and the reduction in the crude birth rate that is attributable to contraceptive use) is most valuable for sub-Saharan countries; however, the differences between observed and potential fertility is too small to be of significance in all countries except Botswana, Zimbabwe, and Mauritius. In fact, Mauritius is the only sub-Saharan country with data of sufficient quantity and quality to allow an evaluation of the impact of family planning programs. It is essential, however, that research be undertaken to determine the causes of the wide gap between knowledge of contraceptive methods and actual use, especially of modern methods. Such research could begin in the 16 countries of sub-Saharan Africa that accept family planning as an integral component of maternal-child health care. Specific targets should be set in terms of fertility and infant mortality, and evaluation techniques designed to measure progress. The United Nations should be encouraged to develop software that could be used in such evaluations. Other data sources include periodic national surveys, censuses, and service statistics.
When aggressively implemented and accessible to the entire target population, integrated maternal-child health/family planning programs can have a substantial impact on fertility, infant and child mortality, and maternal health. This approach has gained increasing acceptance in African countries as a means of maximizing scarce resources. The total fertility rate in Africa now stands at 6.2 and is not expected to drop below 6 until 1995-2000. Among the factors responsible for persisting high fertility in Africa are early marriage, acceptance of large family size as the social norm, little or no use of contraception, erosion of the traditional practices of prolonged breastfeeding and sexual abstinence during lactation, high infant and child mortality rates, and women's low social and economic status. There is some evidence, however, that African women would like to reduce their fertility but lack the means to do so. Maternal-child health/family planning programs can play a valuable role in providing information on methods of achieving this goal and contraceptive supplies. By encouraging women to restrict childbearing to the 18-35-year age period and spacing births 2 years apart, such programs can improve both maternal and child health. Interventions such as mass immunization, nutrition education, encouragement of birth spacing, and regular medical check-ups for children can lead to significant reductions in infant and child mortality. Such programs are maximally effective when accompanied by sociocultural changes that lead to a preference for smaller family size.
Social consequences of population decline.
The possible social effects of demographic aging and eventual population decrease in West Germany are discussed, with a focus on the long-term effects after the year 2020. Consideration is given to the very aged, including health-care needs, migration, and living arrangements; the middle-aged population's labor force participation and the dependency burden; the young generation; and foreigners. Questions concerning future changes in societal values are also explored. (ANNOTATION)
[Female activity and fertility]
Longitudinal data are used to analyze the fertility and labor force activity of French women. The data, from a survey undertaken by INED, concern 2,390 women aged 45-69 in 1981 who were married during and after World War II. The focus of the article is on the active and inactive phases of women's professional lives and their correspondence to fertility levels. (ANNOTATION)
Population decline and economic development.
The relationship between demographic and economic development in industrialized countries is examined, with a focus on the effects of population decline and demographic aging on the labor force and the economy. The need for a highly educated and well-trained labor force to assure sufficient rates of technical progress and productivity is stressed. (ANNOTATION)
Survey of Fertility and Contraception INED-INSERM 1988: a presentation.
The author reviews the results of several fertility surveys conducted in France since 1967, when contraception became legal. Calling the dramatic rise in contraceptive use a "revolution", he considers abortion levels, changes in the rate of unwanted births, and socioeconomic characteristics of contraceptive users. Fertility projects and questions from a proposed 1988 survey are also discussed. (ANNOTATION)
Migration, urban poverty, and the housing market: the Nairobi case.
"The aim of this paper is to show the complexity of the relationship between rural-urban migration and the creation of urban problems....It questions the common assumption that urban problems are partly the result of too many individuals migrating to the city, and instead considers the importance of the labour market, and of changes in methods of obtaining housing, i.e. entitlement relations, in a situation of declining urban incomes." The author uses Nairobi, Kenya, as an example. Findings indicate that it is the urban wage structure and not the rate of migration that is the main determinant of urban problems. (EXCERPT)
The political economy of migration: Pakistan, Britain, and the Middle East.
The focus of this article is on the political and economic changes and socioeconomic inequalities initiated by international migration. The experience of peasant farmers from northern Pakistan who have migrated to Great Britain and the Middle East over the past three decades is used as an example. Their acculturation, including marriage patterns, labor force participation, and social behavior, is examined. Emphasis is given to migrants' lack of political power in their new homeland. (ANNOTATION)
Some aspects of probable future demographic trends in developed countries are examined, with particular reference to the costs of providing health services and pensions to an aging population. The author suggests that the health costs of aging are of secondary importance, whereas the costs of retirement will be a major problem. In considering how and by whom these additional costs should be paid, the author suggests that the answer will be found in the evolution of the labor market to adjust to demographic factors. (ANNOTATION)
Who moves? Women and migration in West Africa in the 1980s.
"I shall focus mainly on the facts, nature, and consequences of the movement of women: the kinds of evidence and data available, and some of the ideological presumptions long associated with women's migration, but first I discuss briefly both problems in studies of migration and the evidence for and consequences of skilled worker movement....I have suggested...that women tend to fill a much narrower range of jobs than do men, and that financial problems in urban areas, the facts of maternity and non-marriage, have brought about significant changes in both population and 'traditional' residential group structures in the rural areas." Data are from studies conducted during the period 1977-1985 in Avatime, Ghana. (EXCERPT)
[The inversion of the age pyramid in Europe: perspectives and problems]
This study is concerned with the consequences of current demographic trends in Europe, particularly demographic aging. The factors that might affect the pace of this process are examined, and comparisons are made with other regions of the world. A final section considers how European countries propose to cope with the consequences of demographic aging. The author concludes that although the short-term effects may be positive, Europe will face a serious, long-term problem after the year 2000. These problems can be mitigated, if not resolved, by redirecting a higher percentage of public expenditures for the benefit of future labor force participation.
Prelude to an exodus: chain migration, trade, and the Yoruba in Ghana.
"This paper considers the relationship between chain migration, success in trade, and political marginality among Yoruba migrants from western Nigeria in northern Ghana prior to 1969....[when] the Ministry of the Interior announced...that all aliens in the country without residence permits should either obtain them in the next two weeks or leave the country....This paper reflects on theories of migration, economic activity, and the state in the light of this incident. It argues that the characteristic pattern of chain migration which took the Yoruba to Ghana not only helps account for their success in trade there, but also helps explain why they, of all the immigrant groups in Ghana, left the country the most completely and the most rapidly in the last days of 1969." (EXCERPT)
Migration, labour markets, and the international economy: Jalisco, Mexico, and the United States.
"Our focus is the contemporary patterns of migration in the west of Mexico, using data from Guadalajara, the regional centre and Mexico's second largest city....We outline the types of labour markets that are available to migrants from the west of Mexico, indicating some of the major ways in which they have been shaped by the interdependence of the Mexican and United States economies....We examine some of the factors that influence the decision to migrate, exploring how personal situations and perspectives influence reactions to the constraints on choice resulting from labour market structures. We concentrate on the move to the United States as compared with that to Guadalajara....We examine the ways in which the fit between the individual characteristics of migrants and the requirements of labour markets are mediated by life cycle and household composition." (EXCERPT)
Genetic constitution and the demography of human origin: the mtDNA arguments.
The authors discuss human genetic constitution and the demography of the origins of humanity. "We propose to review here mtDNA restriction fragment length polymorphisms...data which have been gathered after analysis of ten samples...drawn from three main continental groups (Caucasoids, Orientals and Africans). We shall focus on the hypothetical genetic constitution of a primitive population from which all present modern humans would have diverged. Hypotheses concerning this population's probable age and size will also be discussed." (EXCERPT)
Migration, resistance, and the law in colonial Papua New Guinea.
The author reviews Papua New Guinea's labor system transition from indentured labor to free labor. The main focus is on the popular resistance to labor migration and its long-term effects on labor and the law. (ANNOTATION)
Migrants and natives: urban bases of social conflict.
The author identifies conflicts between natives and migrants in the town of Gebze, Turkey, that have become common during the last 25 years of rapid industrialization and labor migration. "Three areas of conflict are predominant in Gebze: the struggle for land and the allocation of municipal resources; the job market; and conflict arising from cultural differences. There are two dimensions of conflict, class cleavage, and ethnicity, both of which at least partly involve voluntary associations as organized interest groups. So not only is there conflict, but it is organized conflict with important political implications." (EXCERPT)
Rural-urban migration in West Africa.
"This paper considers West African rural-urban migration and associated labour markets from the perspective of the region's overall development since the Second World War. Three features of this process stand out--state formation during this century, both colonial and postcolonial; incorporation into the world economy through export of primary products in exchange for manufactures, and, increasingly, food and energy; and expansion of the home market without significant industrialization or agricultural mechanization....My questions are: How has postwar migration on such a massive scale been made possible? Can the current level of urbanization be sustained; and what is likely to happen to labour markets if it cannot?" (EXCERPT)
Law, human rights, and population policy.
The author reviews the objectives and impact of the Law and Population Program, which was administered from 1970 to 1978 by Tufts University in Boston, Massachusetts, and was established in order to relate law and human rights to population and family planning. "The lapse of more than ten years since the closing of the Law and Population Program at the Fletcher School of Law and Diplomacy affords an opportunity to place the program and its activities in perspective. Have the theoretical assumptions and bases underlying the program been justified? What impact, if any, have its activities had on population policies around the world? What lessons may be drawn for the future? These are questions which the present chapter seeks to address." (EXCERPT)
Labour migrants with a secure base: Bedouin of South Sinai.
"I argue that one of the outstanding features of labour migration is that in the long run, the cash income plays only a limited role in the economy. For labour migration takes place in conditions where employment is insecure, so that many efforts are made to provide greater economic security....I concentrated on a number of labour migrants and their households, followed their movements wherever they led, and explored their social interactions over an extended period. These events took place against a background of changing political, economic, and ecological conditions....The population studied were [the] Bedouin of South Sinai [in Egypt]." (EXCERPT)
Death notices and dispersal: international migration among Catholic Goans.
International migration among the Catholic population of Goa, India, is analyzed, with a focus on communication patterns and migrants' decision making. "I hope to demonstrate in this paper that...proactivity [defined here as the anticipation of and planning for events] played an important role in the global dispersion of Catholic Goans....In order to do this, the first section briefly describes some aspects of Portuguese colonialism, and the conditions in Goa which led to international migration. The second section examines how various labour markets arose outside Goa and the proactive mechanisms adopted by Catholic Goans to capitalize on new and recurring job opportunities. The third section examines the development and maintenance of international networks and their role in the organization of migration." (EXCERPT)
Rural-urban child fostering in Kenya: migration, kinship ideology, and class.
The author examines child fostering in Kenya. "Two types of exchange occur in different ways and for different socioeconomic reasons. The first type of fostering is where poor, rural peasants send their children to be fostered by kinspeople who are part of the urban elite. The second type occurs when poor, urban migrants send their children back to kin in the villages. Looking at the possible changes in the rate of fostering and the certain changes in the structure of fostering will yield insights into the interrelationships between rural-urban migration, class formation, and kinship ideology in modern Kenya." (EXCERPT)
Modern man's history: methodology, results and hypotheses.
The author outlines a genetic history of Europe and the world. Consideration is given to historical and genetic linkages among modern peoples, including a phylogenetic tree of 42 world populations; genes and archaeological records; and genes and linguistic classification. (ANNOTATION)
[Immunological polymorphisms and human migration: the history of 180,000 individuals]
Differences in the distribution of three major gene groups among the world's population are analyzed using data from a global sample of 180,000 individuals. The similarities in gene type among peoples are used to hypothesize the extent of historical migration. (ANNOTATION)
Dispersing dependants: a response to the exigencies of labour migration in rural Transkei.
The author examines the ways in which the dependents of migratory workers in South Africa respond to the general income insecurity that surrounds labor migration. "This paper considers the movement of people from one household to another. The practice of placing children in domestic groups other than those of their parents is examined as a response to the absence of children's guardians. The paper also looks at the ways in which people in a village in the Matatiele district of the Transkei bantustan deal with the exigencies of loss of a remittance income, considering how changes in household compositions over a two-year period are, at least in part, attributable to circumstances experienced by migrants in the labour market....The paper concludes by examining some of these problems, considering the implications of migration and changed residence for the individual's jural status." (EXCERPT)
Changes in the process by which young French women pass from adolescence to adulthood are examined using data from a retrospective survey conducted by INED in 1986. The survey included data on the life course of 2,193 women and 1,886 men born between 1941 and 1964. The primary focus is on changes over time in the age at which young people leave home, are first employed, become part of a couple, and get married. Consideration is also given to the age at which women have their first child. The author concludes that a consequence of these changes has been the development of a status for women apart from their spouses and a diminution of inequality between the sexes.
Enclave economies and family firms: Pakistani traders in a British city.
"In this paper I discuss the underlying processes generating the immigrant 'economic enclave', and examine the management of relations within the household and wider kin networks in the context of immigrant enterprise. My aim is to elucidate the way family, capital, and labour interrelate under conditions of both immigrant community growth and development, and family growth." The focus is on Pakistanis who have migrated to Manchester, England, since the end of World War II. (EXCERPT)
Alcohol use as a situational influence on young women's pregnancy risk-taking behaviors.
The purpose of this paper was to describe the use of alcohol and other drugs before the sexual experiences of 43 US white young women (14-21) whose intercourse resulted in unintended pregnancy. The study is both intercourse and descriptive and its intent is to determine whether, in cases where pregnancy occurred, if alcohol and other drugs were factors present at the time of unintentional conception, and the reasons cited for engaging in pregnancy risk-taking behaviors. Outcomes that emerged from the data gathered by questionnaires and 7 interview were that: 1) many of the women had been sexually active for a long time before becoming pregnant and were not using contraceptives; 2) interpsychic conflict existed between wanting to avoid pregnancy and unconsciously wanting to become pregnant; 3) the belief that they would not get pregnant (show the gap between contraceptive knowledge and actual practice); 4) situational influence was a significant finding which strengthened the argument that during times of major transition women are more vulnerable to pregnancy risk-taking behavior; 5) the role of parents as support systems--that is--not encouraging birth control; 6) combination of all factors. Alcohol and drug use, while not being sufficient to deter women from protecting themselves against pregnancy, may be significant among other causal factors. Young women need to know about contraceptive use and the physiology of female and male bodies. Health and sex educators need to include discussions about alcohol and drugs when developing teaching materials about sexuality and contraceptives. Also researchers and clinicians need to learn more about young people's risk-taking behavior to develop pregnancy- prevention programs tailored to their needs. (Author's modified).
1751 adolescent secondary school girls aged between 12-19 years were interviewed by means of self-administered questionnaire to determine their knowledge on reproductive biology, sexual behavior and its relationship to contraceptive practice in late 1986. 23.8% of all the girls had been or were sexually active at the time of the study. 94.5% of the sexually active girls had not or were not using any method of contraception, while the rest, (5.5%) were mainly using unreliable or risky methods of contraception. 1.7% of the sexually active girls admitted to having been pregnant at one time and had sought abortion. The majority of the girls displayed profound ignorance and misinformation regarding their reproductive biology and contraception. Their mothers played a minor role in imparting this knowledge, their sources of information being fairly unreliable. While 77.8% of the girls were against school girls having sexual relationships, 90.7% of them felt that all women (including school girls) should be given contraceptives to protect themselves from unwanted pregnancies. (Author's modified)
Sexually transmitted diseases as a gender issue: examples from Nigeria and Uganda.
In response to the high prevalence of sexually transmitted diseases (STD) in tropical Africa and 11,000 AIDS cases reported in 42 African countries with 3 of these countries ranking in the top 10, the authors reviewed 961 medical records of patients with sexually transmitted diseases from a teaching hospital in Northern Nigeria and current scientific literature and employed a pilot assessment of AIDS in Uganda to investigate gender differences associated with STD. Interviews with 100 of these patients revealed that 82.8% were male and 17.2 were females. Gonorrhea is most prevalent among males while candida, trichomoniasis, herpes, and chancroid are most common among female patients. 64.1% of the males were unmarried and 56.3% of female subjects. The highest represented age group included 20-24 years. Religion, ethnic backgrounds, and occupation are also reviewed. The pilot study in Uganda consisted of qualitative data collected from 1984 to July 1988. Ranked 3rd globally, Uganda is threatened by AIDS with 85% of the 15-39 age group infected. Also included in this pilot assessment is the consideration of public perception and the impact on health delivery services. Gender issues in this study include sex patterns in attendance of STD clinics, pelvic inflammatory diseases, infertility, and sexual harassment. Case studies are also included. Overall findings indicate that STD is a sexual issue for women who are at high risk by virtue of their professions, the consequences of sexual behavior of men, and limited access to treatment facilities. Policies necessary to improve this crisis include routine diagnostic and screening services, promotion of condom use, screening of AIDS for high- risk pregnant women, and governmental educational measures such as brochures, posters, and training seminars for health care workers.
Contraceptive use in the United States, 1973-88.
The percentage of couples using sterilization as a contraceptive method increased greatly between 1973 and 1982, and increased more until 1988. The percentages of couples on the pill decreased sharply between 1973 and 1982. The decrease did not continue between 1982 and 1988. Use of the condom did not significantly change among married couples, but increased sharply among never-married women. These findings come from the National Surveys of Family Growth, conducted by the National Center for Health Statistics. Cycle IV of this survey was done between January and August of 1988. 8450 women 15-44 were interviewed. Cycle III was done 1982; Cycle I in 1973. In 1988, 60% of the women were using contraception. 24% were using sterilization; 37% were using other methods. The number of contraceptors increased by 4.8 million between 1982 and 1988 (16%). Contraceptive use varies by the woman's age. The leading method in the youngest age group was the pill in 1982 and 1988, followed by the condom. In the oldest age group female sterilization was the leading method, followed by male sterilization and the condom. The proportion of never-married women who never had intercourse dropped from 38% in 1982 to 32% in 1988. Among currently married couples, surgical sterilization more than doubled from 1973 to 1988. Most of this was female sterilization. The proportion of couples using other methods declined. The increase in the percent using the condom was statistically significant. There was no significant change in the % using the pill among formerly married women between 1982 and 1988. IUD use decreased from 6% in 1982 to 2% in 1988. Black women were less likely than Whites to be using contraception. But among those Blacks who did use a method they were significantly more likely than Whites to use the 2 most effective female methods--sterilization and the pill. The largest increase in use of female sterilization occurred among the formerly married; from 398% to 51% in 1988. (author's modified)
Union of Soviet Socialist Republics.
The goal of the policies established by the Soviet Union are to meet, as much as possible, the growing demand of its people. Marxist-Leninist policies on population states that various facets of the society - economic, social, and cultural - are interrelated; and that each should not be studied separately but in reference to other parts of society that it affects. The Great October Socialist Revolution established a society with equal opportunity for all; women are equal to men in education and make up 51% of persons employed by the States. Concerning reproduction, the government protects the rights of the family and encourages maternity, while working to create conditions worth raising children in. However, that does not mean that the government does not support family planning. The government has established its 11th 5-year plan which will work to encourage technological advances and economic development, while still protecting the family. In 1981, the government adopted a resolution which encourages women to combine motherhood with employment. The government has also implemented policies which work to reorganize health care, limit the growth of large cities, develop small to medium-size towns, and advocate disarmament in pursuit of peace.
Use of family planning services in the United States: 1982 and 1988.
This preliminary report on the 1988 data from Cycle IV of the National Survey of Family Growth (NSFG) collected by the US National Center for Health Statistics. Compares 1988 figures with the 1982 Cycle III data. 8450 women 15-44 years old across the US were interviewed in 1988. 37% (1982) and 35% (1988) of the women had family planning visits in the previous year. 50% of the 20-24 year olds used family planning services in 1988 (the highest % group), whereas 25-29 year olds were the highest group in 1982. Among teenagers, 41% of the black women and 34% of the white women had a visit. Over 20 years old, the racial differences were not significant. In 1988, low and high income groups were equally likely to use family planning. In 1982, low income women were more likely to have had a visit. 64% of the women used a private doctor and 36% used a clinic (these are similar to 1982 rates). A significantly larger number of black women used the clinics than white in all age groups. Black teenagers use clinics more than white teenagers, however the differential decreased from 1982 (74% vs. 44%) to 1988 (65% vs. 61%). The race differential remained large for women 20 and older (e.g. for 1988, 62% of black and 38% of white women 20-24 years old used clinics). The amount of teenagers using a clinic has risen sharply from 51% (1982) to 62% (1988), whereas only 19% (1982) and 23% (1988) of women over 30 used clinics. Low-income women predominantly use clinics. More low-income white women used clinics in 1988 (56%) than in 1982 (40%). 70% of black women used a clinic for a 1st visit vs. 54% of white women in 1988.
Adolescent pregnancy: a medical concern.
Medical problems associated with adolescent pregnancy and motherhood in the US are common across cultural and racial boundaries. These problems are, however, exacerbated for the African-American adolescent. This article examines the importance of maternal and infant mortality, low birth weight, and the social implications of these for health practitioner. Inadequate pre- and post natal care are seen as more problematic for teenage parents than for older parents. Some reasons cited for the inappropriate use of medical care by adolescents are their contemporary life styles, the inaccessibility of health care, and their reluctance to seek prenatal care. (author's)
Reaching African-American male adolescent parents through nontraditional techniques.
Despite considerable attention in the literature give to African- American adolescent fathers by human service professionals, efforts to document how workers might reach out to them more have been few. Even less is available on how to reach African-American adolescent fathers through nontraditional techniques, for new approaches are needed. As a step toward alleviating this nagging gap in the literature, this article utilizes data from studies conducted in Tulsa, Chicago, Columbus, and Washington, D.C. to provide suggestions for reaching out to African- American male adolescent parents through nontraditional means. Major issues include but are not limited to the following: 1) needs of African-American male adolescent parents, 2) nontraditional techniques for reaching this group of parents, 3) planning the initial assessment meeting, including possible barriers to the process and factors that contribute to its success, 4) dos and don'ts for helping African- American adolescent fathers stay in treatment or in a counseling relationship, and 5) ways young African-American fathers may be helpful not only to themselves but also to mothers and their children. (author's)
[Induction of uterine contractions using Enzaprost F administered into the uterine cavity]
In a clinical trial carried out in 34 pregnancy women Enzaprost F 4 (prostaglandin F2-alpha) was administered into the uterus to cause uterine contractions in the 2nd and 3rd trimesters. The indications for the treatment were: 1. membrane rupture in 20 cases between the 21st and 26th weeks of pregnancy; 2. fetal death in 12 cases between the 24th and 34th weeks of pregnancy, and 3. induced abortion for medical reasons in 2 cases of primiparae in the 2nd trimester. Enzaprost was administered in physiological salt solution in doses of 2-5 mg with a total dose of 9-22 mg (average 18.5 mg). Contractions appeared within 15-30 minutes in groups 1 and within 20-30 minutes in groups 2 and 3. Abortions in the three different groups began 10.2, 11.5, and 6.0 hours after administration in primiparae and 7.3 and 8.2 hours, respectively, after treatment in groups 1 and 2 in women other than primiparae. Oxytocin had to be administered additionally in 3 cases in groups 1 and 2. The method proved to be safe and effective, side effects occurred in 6 cases (17.6%) consisting of cardiac pain, nausea, tachycardia, and increased systolic pressure.
A multitude of quiet tragedies.
Dr. Barbara Kwast was lecturer and midwife in community obstetrics in Ethiopia, before joining the World Health Organization in 1986. While in Ethiopia, she observed maternal mortality first hand and chronicles her observations in this article. All cases are true, with only names being changed. Covered are a variety of maternal deaths due to various causes such as tetanus, ruptured uteri, puerperal sepsis, peritonitis, and renal failure. All stories point to the tragedy of poverty, little education, and neglect in family planning throughout the third world.
[The problem of abortion in Polish gynecological literature in the second half of the 19th century]
""Artificial abortion is undoubtedly the most important type of operations carried out for saving the life of a human being by sacrificing another one," said A. Przystanski in 1871 and his opinion has not lost its validity since then. A representative collection of the views of Polish physicians about abortion in the second half of the 19th century is reviewed. At that time the problem was considered from a strictly medical-causal point of view and its legal, economic, and demographic ramifications were not taken into account. Swiecicki described 15 different reasons for artificial (induced) abortion and distinguished pre-term induced abortion performed for saving the mother's life and premature birth induced for the sake of both the mother and the child or for the child alone. Neugebauer described one case of artificial abortion in which warm water was injected into the vagina every 2 hours followed by the insertion of a compressed sponge into the oviduct, as no reaction occurred, resulting in expulsion of the fetus. L. Switalski in Cracow used elastic rubber balloons for the same purpose. The role of cesarean section to save the mother is also discussed.
[Contribution to studies on the model of the family]
Fertility data obtained in Wolbrom, Poland were utilized for the analysis of family models. During the period of 1877-1950 the average number of births per married couple decreased gradually from 7.71 to 3.00. Between 1881 and 1980 about 50% of all births occurred in families of 7-10 children. The analysis of the periods of 1877-1910 and 1941-1950 showed that the age of the mother of the first child was under 34, while the father's age was under 40. The age of the parents of the second child was 39 and 44, respectively, however, the upper age limit of mothers and fathers to whom children were born decreased by 5 and 15 years between the two periods. The number of births was the highest in the first 3 years of marriage (19% and 44% of all births fell in this range during 1881-1910 and 1945-1950, respectively). The average age of men getting married decreased, while that of women was increased (mean values of 28.6 and 24.4 years, respectively). Most people married during 20-24 years of age. The demographic changes that occurred were caused by socio-economic factors, e.g., industrialization, migration, improvement of living standards and health care, and culture.
[Population policy in some Asian countries]
In 1986 the population of Asia was estimated at 2.9 billion constituting 58% of the world's population on 20% of the world's territory. By the year 2000 the total population will reach 3-3.5 billion people. Fertility in China, the Koreas, and Singapore diminished by 40% between 1960-1965 and 1980-1985, and by 26-34% in Indonesia, India, Malaysia, the Philippines, and Thailand. In Malaysia, a pronatalist policy started in 1983 aims at attaining a population of 70 million by 2100. Social, educational, and health programs have markedly reduced mortality in Sri Lanka and South Korea between 1960-1965 and 1980-1985 and life expectancy exceeded 60 years in 1980. The figure for Burma, Indonesia, and India was 52-55 years for the same period. Bangladesh plans to reduce the birth rate from 5.8 children/woman in 1980 to 3.2 by 1990, while Thailand started a program in 1986 to increase it by 1.5%. Population distribution policies to alleviate urban congestion have been implemented in South Korea, Indonesia, Malaysia, and the Philippines. Immigration to Canada and the United States from Pakistan and South Korea have relieved internal population pressures. Almost half a million Koreans have migrated to 72 different countries between 1962- 1981. Successful population policies require the analysis of economic, educational, social, and cultural factors of demographics.
A new primate retrovirus, STLV-IIIAGM, has been recently isolated from healthy African green monkeys and is apparently nonpathogenic in its natural host. However, spontaneous infection as well as inoculation of STLV-IIIAGM into macaques induces a disease with clinical features that resembles human AIDS. Independent isolates of human retroviruses, serologically related closely to STLV-IIIAGM, have been obtained from healthy individuals (HTLV-IV) and patients with immunodeficiency (LAV-2FG and SBL 6669) from West AFrica. The latter have also been referred to as HIV-2 because, like HTLV-III/HIV-1, they may be associated with immune deficiency, or as West African human retroviruses because of their prevalence and probable origin from that region. The authors have molecularly cloned the STLV-IIIAGM genome and have generated probes from the gag-pol and envelope genes to analyze the genetic relatedness of these simian and human retroviruses. These results indicate that all these retroviruses are genetically closely related to one another, HTLV- IV and STLV-IIIAGM differing only by a few restriction enzyme sites while LAV-2FG and SBL 6669 exhibit greater polymorphism from HTLV- IV/STLV-IIIAGM. These data mirror the variable degree of relatedness among members of the 1st subgroup of human retroviruses, HTLV-III/HIV. (author's)
Market research for Australia's National AIDS Education Campaign.
Australia's National Acquired Immunodeficiency Syndrome (AIDS) Education Program seeks to raise the public's general level of knowledge of AIDS and its transmission through the presentation of clear, factual information and to motivate the public to avoid high-risk behaviors. In 1986, the National AIDS Education Program commissioned a market research survey of 4 population groups: adults, adolescents, homosexuals, and intravenous drug users. The largest of these surveys involved 1500 randomly selected individuals 16060 years of age. Survey findings indicated a high level of concern about the seriousness of AIDS (74% view the disease as likely to become an epidemic) and awareness of the major risk groups. Less clear was knowledge about how the AIDS virus is transmitted; 36% believed that casual contact, such as coughing or social kissing, could transmit the disease, and 24% thought that AIDS could be transmitted through public toilets. In terms of high risk behaviors, 5% of males and 4% of females reported anal intercourse in the preceding month, 14% of males had more than 1 sexual partner in the 3 months prior to the survey, and 5% of males had intercourse with a prostitute in the preceding year. Only 2% reported intravenous drug use, but 71% of the female drug users had shared needles in the past year. 44% of the male adolescents surveyed were sexually active, and 34% had had more that 1 partner. 74% of adult respondents had used condoms at some time, but only 12% reported current use. In contrast, 48% of the adolescent males and 62% of adolescent females were regular condom users. Overall, there was support for health education, more widespread condom distribution, and legalization of the sale of hypodermic needles as means of controlling AIDS.
In Africa, the design of educational campaigns to prevent the further spread of acquired immunodeficiency syndrome (AIDS) has been constrained by a lack of information about sexual behavior and sexual decision making; the fact that most researchers, educators, and the mass media are untrained in the area of human sexuality and inhibited in their ability to deal openly with related issues; and the highly political nature of the AIDS epidemic. The combined use of human sexuality training, focus group discussions, and social marketing offers a means of overcoming some of these constraints. This approach can be used by African health professionals and researchers to gain knowledge of AIDS- related high-risk sexual behaviors; by social researchers, social marketing experts, and health communications personnel to develop and test culturally appropriate media campaigns for high-risk populations; and by specific AIDS risk groups to understand the behaviors that place them at risk. The human sexuality training model proposed uses imagery and participants' memories of their own life experiences to develop the ability to discuss sexuality openly, without embarrassment or a judgmental stance toward alternative life-styles. Health professionals and program developers must be able to deal with a broad range of sexual topics if they are to design effective AIDS prevention programs. The focus group social marketing technique provides researchers with the social and psychological data they need to understand the sexual behaviors and attitudes of populations targeted for intervention. Such discussions are particularly important for the development of culturally sensitive AIDS educational campaigns that take into account the differing values of Africa's ethnic, tribal, religious, and linguistic groupings.
Hysteroscopy has been commonly used to evaluate infertile women. Problems with this technique have resulted in the discovery - especially of asymptomatic women - of polyps, adhesions, myomata, and septa. With the introduction of the Hamou hysteroscope, questions arose as to the possibility that identification of intrauterine lesions had diminished. This study compares the findings of hysteroscopy when performed with Dextran 70 with carbon dioxide used as the distention medium. The 1st group consisted of 508 women with primary infertility, 351 with secondary infertility, and 155 women requesting a reversal of a previous sterilization. The 2nd group consisted of 339 women, 164 with primary infertility, 118 with secondary infertility, and 57 requesting reversal of a previous sterilization. Incidence of uterine abnormality when Dextran 70 was used were 29% in women with primary infertility, 41% with secondary infertility, and 33% in those requesting a reversal of previous sterilization. The figures when C02 was used were 7.2%, 11%, and 6% respectively. Conclusions drawn were that the previous studies were both artificial and were a result of the technique of hysteroscopy and should be evaluated with caution.
A Group of European scientists held a workshop in Sestri Levante, Italy, September 28-30, 1976, proposing a more rational approach towards regulation and development of new medicines. The dual theme of the workshop was the influence of regulatory agencies on new medicines, and discussions on current medical research and discoveries. The scientists, while acknowledging the importance of regulatory agencies with regard to public safety and welfare, did question the agencies' objectives; they admit these objectives are well intended, but may, with the passage of time, have become too cumbersome. The group also suggests regulation may be interfering with the development of new medicines that could prove helpful to patients. These speculations are highlighted in detail, and reasons are given scientifically, administratively, and politically, why these interferences occur. Offered too are methods regulatory agencies could employ to alter this situation in favor of patients and communities as a whole. The report concludes that the public should be made aware that medicines are not, nor can they be, 100% safe. Public education is the only rational approach towards the development of new medicines.
Hepatic actinomycosis diagnosed by fine needle aspiration: a case report.
Examined in the article is the significance of fine needle aspiration (FNA) cytology in diagnosing actinomycosis infections. A 43 old woman, having worn a Saf-T-Coil IUD for 15 years, and with a history of actinomycosis organisms shown in cervicovaginal smears, developed hepatic actinomycosis 13 months after the IUD was removed. Smears showed inflammatory changes in the patient, actinomycosis, and an ovarian mass 5.1 cm. which was removed. Surgical exploration revealed an actinomycosis tubo-ovarian abscess, the principal lesion in this case. When the patient showed symptoms of PID, proper treatment and accurate recognition of pelvic actinomycosis may have prevented the development of the liver abscess. The nature of actinomycosis infection makes diagnosis difficult, as detection may not occur until the disease is too well advanced. FNA cytology is useful in detecting actinomycosis because the organism is so difficult to culture. FNA cytology also, because it provides more extensive sampling of purulent material, is a more accurate, speedy, and far more economical method of diagnosis.
The papers presented during the general session included in these proceedings cover several topics: the diarrheal disease process and new therapies; diarrhea as a nutritional disease; the effectiveness and costs of nonclinical interventions for diarrhea control; control and prevention of diarrheal diseases at the national level; and implementation issues. Concurrent panel summaries addressed the following: communications and social marketing; distribution and logistics; health personnel training; supervision and monitoring; evaluation and cost issues; and integrating oral rehydration therapy with other health activities. A summary of the clinical management seminar also is included. The key characteristics of successful national diarrheal disease control programs were identified as follows: a strong political commitment; clear strategy for the delivery and use of ORT in the home and in health facilities; adequate supplies of oral rehydration solution packets; special attention to communication activities oriented toward the needs of consumers; recognition of the importance of supervision; and a plan for evaluation.
Malnutrition and infection, which strike as many as 40,000 African children daily, through the use of basic health care measures. The 4 simple techniques are: growth monitoring, oral rehydration, breast feeding, and immunization (GOBI). It is a task of political and social groups to put present technology to work at a reasonable cost, and to help communities learn to apply them effectively at the local level. Change from an agricultural culture to an industrial one has caused upheaval, but through the development of knowledge and skills at the community level, hunger and disease can be controlled. GOBI training should focus on the changing roles of women, men, and children; changing environments caused by technological innovations, and creative parenthood. The community needs intellectual, emotional, and social skills to be able to take this responsibility. The imagery for GOBI should be symbols of reality and life familiar to the particular community. Training in GOBI strategies need specific expertise in oral rehydration, breast feeding, immunization, and growth monitoring. Child health care must be taken out of hospitals and care centers and put back into the community where a culturally appropriate holistic approach can be carried out.
Socio-economic determinants of fertility: an assessment of recent findings and their implications.
The influence of socioeconomic factors on marital fertility and its connection to population policies is the purpose of a recent UN study. It has been found that birth control can effect the rate of decline but not initiate reproductive change. Events over the last 30 years indicate that a decline in marital fertility once started in a population will continue much further. In Europe declines in fertility between late 1800's and early 1900's were significant with no association to the socioeconomic conditions. For example, England at the time was highly industrialized; Bulgaria on the other hand was mainly agricultural, clearly eliminating simple economic reasons. Life expectancy and education show a stronger relationship with fertility decline than economic factors, and are analyzed more. Declining child mortality can change population policies of governments and practices of parents where irreversible birth control dominate. There appear to be no definite socioeconomic barriers to fertility decline, since a decline has occurred in populations with poverty, illiteracy and subsistence agriculture conditions. The conclusion from previous evidence indicates fertility decline starts because of acceptance of major behavioral changes, i.e., birth control, which allow parents to prevent unwanted children. There seems to be little in the way that governments can influence levels of fertility by socioeconomic levels. Education, on the other hand, can effect fertility but has the drawback of a generational lag. In the immediate future, the promotion of birth control and the expansion of services for the less educated and rural people should offer the most progress.
Knowledge, attitudes and practice regarding infant feeding among mother substitutes.
With more women entering the workforce, the issue of infant nutrition has become more complex. Mother surrogates, or substitutes, are increasingly taking over the responsibility of infant care. 80 mother substitutes, aged 7-70, were interviewed in Jabalpur town, India, from October 1983-July 1984. Substitutes originated from nuclear families consisting of grandmothers, aunts, elder sisters, brothers, and servants. They were questioned concerning breast feeding, top milk initiation, feeding technique, and weaning. Results pointed to a variety of opinions on feeding practices and nutrition. 50% of younger mother substitutes and the majority of older, uneducated ones believed in initiating breast feeding from the 2nd day onward. 50% of young and 64% of older substitutes did not consider giving colostrum, and various reasons why are cited. 20% of all and 42% of highly educated substitutes were aware of the advantages of breast feeding. 65% of young and 60% uneducated did not know age of initiation of top milk. 45% advocated bottle feeding, with 25% preferring spoon feeding. With regard to "tinned milk" 40% did not use it, 25% were unaware of it, and of 30% using tinned milk, only 1/3 knew the correct technique of reconstitution. The majority of young and uneducated substitutes thought proper weaning age to be after 6 months. 50%, aged 21-40 years, believed in adding solid food from below 6 months. 90% of the young mother substitutes were against solids being introduced by the age of 4 months. A majority of the substitutes suggested weaning foods such as dal, rice, roti, and biscuits with a few considering tinned cereals as proper weaning foods. This response may point to the reason why protein and energy deficiency may be observed around weaning age in many infants throughout the 3rd world.
Obstetric practices and breastfeeding [letter]
Following the International Federation of Gynecology and Obstetric's recommendations on breastfeeding, a study was undertaken in Bombay, India to determine if the recommendations were being implemented. Mothers of infants less than 1 year old were interviewed from January 1, 1982 - August 17, 1982, then another 100 again from January 1, 1986 - June 15, 1986. All deliveries had been normal. 3 questions were asked concerning breastfeeding: 1) During pregnancy did the obstetrician give mothers advice on breastfeeding? 2) Were the baby and mother kept in separate rooms? and 3) When was the baby 1st put to the mother's breast? Results in 1982 indicated only 1 mother out of 100 was given prenatal advice on breastfeeding, compared to only 5 in 1986. In 1986, 25% of the newborns stayed with their mothers compared to 6% in 1982. Breastfeeding was initiated with 1 hour in 1%, 1-24 house in 28%, and after 24 hours in 71% of the mothers in 1982. 1986's corresponding figures were 4, 54, and 42% respectively. Although a favorable change in breastfeeding education was noticed within the 4 year span of the study, some results of the study were still disturbing. In Bombay, during the 1st half of 1986, 95% of the mothers did not receive any advice on breastfeeding from their obstetricians. 75% of newborns were kept from their mothers, and 42% were put to breast after 24 hours. More improvement in obstetric practices is recommended, with pediatricians cooperating more actively with their obstetric counterparts.
[Sensitivity of population projections to variations in hypotheses of population variables]
A series of estimations were determined on the basis of population projections conducted by the state of Sao Paulo for 1980/2000, especially for the region of Marilia. The component method correlating the trends of fertility, mortality, and migration was utilized. The 1st hypothesis assumes a constant fertility rate of 3.5 children/woman in 1980, the 2nd average decreasing rate of 2.4 children during 1995/2000, and the 3rd a major drop of the rate to 2.1 children by the end of the century. If mortality stays constant based on 1980 data, life expectancy will reach 63.81 for men and 70.37 for women. If it decreases slowly, life expectancy will increase to 66.99 and 73.92 years, respectively, by the last 5 years of the century. Constant, slowly decreasing, decreasing, and rapidly decreasing migration trends were also utilized. Decreasing mortality, fertility, and emigration yielded a population of 995,000 by 2000, and a drop of the dependent population (<15 and > 65 years of age) from 69-58 for 100 active persons. Constant mortality yielded 991,700, rapidly decreasing fertility yielded 971,300 with the drop of the percentage of youth to 29.8%, and negative constant migration yielded 657,400 with increases of > 65 and < 15 age groups. Fertility and migration variations affected both the volume and age of population, while mortality had no effect.
A 25 year study comparing undernourished and well-nourished girls found that malnutrition delayed menarche and delayed, but did not stunt, skeletal growth. The Birmingham, Alabama study followed 30 undernourished and well-nourished local white girls from approximately 4 - 19 years of age. The well-nourished girls' diets met the US Daily Recommended Allowances but the other girls' diets were deficient in nutrients especially Vitamin A, ascorbic acid, iron, calcium and animal protein. The girls' height was measured every 3 months, serial sequential roentgenograms were taken of their left hands and wrists every 6 months and the age of menarche of noted. The undernourished group's rate of skeletal maturation was significantly slower premenstrually than the others and the occurrence of menarche was closely related to skeletal maturation. Menarche was over 24 months later in the malnourished group at which time their skeletal maturation was similar to the group at the time of their menarche. The postmenstrual rate of skeletal maturation of both groups was similar. Asymmetry of maturation (the range from the most to the least advanced bones in an individual's hand) was higher in the undernourished group at the earliest age but declined in both groups with age. The well-nourished group reached zero asymmetry at age 18; the malnourished group about two years later. The mean height at maturity of both groups was not significantly different but the undernourished groups' greatest growth spurt was again 18-24 months behind the other group.
Household and community beliefs and practices that influence maternal health and nutrition.
A preliminary global overview of beliefs and practices at the household and community level in developing countries which influence maternal health, mortality and morbidity, from the viewpoint of what a project designer needs to know, is provided. Traditional, meaning cultural household and community beliefs and practices, particularly in rural areas, are the focus. Findings are presented in chapters entitled general reproductive health, traditional birth attendants, pregnancy, labor and delivery, postpartum, and lactation, with recommendations after each section. Eliminating traditional practices that are definitely harmful is essential. Examples are gender-related undernutrition and neglect, female circumcision, early childbearing, continued hard labor during pregnancy. Introduction of formal medical care or comparable techniques is recommended in certain circumstances, such as training of birth attendants, dietary supplements of pregnant and lactating women, and provision of safe abortion. Many cultural practices are harmless or even beneficial, and all need to be evaluated in context. To improve women's health in the long term, a global improvement of the underlying conditions, poverty and the inferior status of women, is vital.
[Acquired immunodeficiency syndrome seen in Africa]
The demographic data on AIDS in Africa, the possible means of tracking the disease, the most characteristic opportunistic diseases, and the frequency of the occurrence of Kaposi's sarcoma are detailed. According to World Health Organization data, there were 4583 AIDS patients in 41 regions of Africa on June 20, 1987. Uganda and Tanzania had the highest figures, 1183 and 1130 cases, respectively. AIDS in Africa is very unique both epidemiologically and clinically. Homosexuality is very rare, thus the ratio of AIDS-infected men and women is almost the same. Promiscuity is widely accepted. In Rwanda 27 of 33 prostitutes had lymphadenopathy and 88% had a positive reaction to the ELISA test. In Lusaka, Zambia 17.5% of patients tested in out-patients treatment centers and hospitals were AIDS-positive, mainly men aged 30-35 and women aged 20-25. In Kinshasa, Zaire 6-7% of clinically healthy citizens were AIDS-positive. In Kampala, Uganda 14.4% of blood donors were HIV-seropositive. In regions where serological analysis is not available, the clinical criteria given by WHO are decisive. In Tanzania prolonged asthenia proved to be most frequent. In AIDS patients treated in Europe often occurring opportunistic diseases are cryptococcosis, toxoplasmosis, candidiasis, tuberculosis, and cryptosporidiosis. However, pneumonia caused by Pneumocystis carinii is rather rare in Africa. In Lubumbashi, Zaire the most frequent lethal diseases are cerebro-meningitis cryptococcica and diarrhea choleriformis. According to the author's observations, possible viral transmission on the mucosa occurs in 38.4% of the patients. In Zaire the patients with endemic types of Kaposi's sarcoma were seronegative, but out of the 22 cases of Kaposi's sarcoma, atypical for Africa, 20 were AIDS-positive in Zambia, and 4 of the 17 endemic cases in Uganda were also positive. The perspectives of curing AIDS patients are disappointing because of the shortage of pharmaceuticals and lack of physicians.
[Demometric estimation of fertility function by age of women in Poland]
The empirical distribution of age-specific fertility rates in Poland during 1950-1985 and the choice of theoretical distributions to be used in simulation models for prognostical purposes are discussed. The arithmetic mean of the ages of child-bearing women in the given period was 27.33 with a standard deviation of 0.82. The mean age had been decreasing from 28.91 in 1950 to 26.35 in 1980 and remained almost the same until the end of the study period. Total fertility rate, on the other hand, had decreased from 3.68 in 1950 to 2.18 in 1974 and increased slightly afterwards varying between 2.30 and 2.40 in the last four years. The standard deviation of mean age decreased from 6.43 in 1950 to 5.33 in 1985. The statistical analysis of the empirical distribution of age-specific fertility rates lead to the following conclusions: 1. there was an expressed tendency of development in the parameters of the fertility distribution, and 2. the dynamics of the discussed parameters of distribution were strongly correlated. The following theoretical distributions were fitted to the empirical one: Pearson type-I, gamma distribution, and Maxwell distribution. The analysis of statistical parameters demonstrated that the Pearson type-I curve gave the best fit up to 1974 (fitted by Elderton's method). In the 1980's, however, the gamma-distribution gave the best results. Other different functions to be used in modelling the change of fertility rates under European conditions are also mentioned.
Fertility data from 49 Polish counties during 1978/79 and 1983/84 were analyzed. Fertility rates were 91.36% in the first period and 98.38% in the second among women between 15 and 49 years of age. The 20-24 age group had the highest fertility rate (216.62% and 243.79% during the above time periods, respectively). During 1978/79 fertility rates varied significantly depending on area: the lowest values were obtained in the county of Lodz 72.1% and the highest ones in the county of Novosad. The variation was the highest in the three oldest age groups (27-55%). During 1983/84 in the most fertile age group 178.21% the lowest, was observed in Warsaw county, and 326.98%, in the highest, in Bialskopodle county. Between the two periods average fertility increased in the most fertile group, while it decreased in the oldest age groups. In the territorial analysis 4 sets of factors were studied: 1. urbanization level and professional activity; 2. living and working conditions; 3. domestic conditions; and 4. educational and cultural level. Sets 1 and 4 were very significant in the two youngest age groups (15-19 and 20-24). The effect of domestic conditions was increasing between the two periods, but no evidence was collected on the effect of income on fertility. In the 30-34 age group determining factors were: the number of TV sets per 1000 inhabitants (within set 4, set 3, and then set 2). In the youngest age groups the variation of fertility rates among different regions was increasing, while in the oldest groups fertility stabilized. The above models adequately accounted for the spatial variations of fertility.
Plant contraceptives: translating folklore into scientific application.
There are hundreds of antifertility plants in as many countries around the world. The information on these plants can be traced to a number of sources. Books have been written on Indian, Chinese and other medical systems that refer to plants used for contraception. In almost all countries folklore exists regarding the use of herbs in birth control. In some cases the practice is passed down through families for generations. Tests indicate that there are possible antifertility properties present. Many travelers, including botanists, missionaries, scientists, and doctors, observed this use of plants. In various areas of the world this information may be lost if it is not recorded. Recent research shows hundreds of plants have been tested and given clinical trials. There are 11 plants tested with animals that show 100% anti- implantation activity. They are Aristolochia indica, Curcuma longa, Cuminum cymimium, Daucus carota, Embelia ribes, Ensete superbum, Hyptis sauveolens, Mentha arvensis, Podocarpus brevifolia, Polgonium hydropiper, and Sapindus trifoliatus. Other plants have given us belladonna, digitalis, cinchona, reserpine, carbenoxolone, and vincristine. Further studies and testing should lead to the discovery of some effective oral herbal contraceptives.
Exercise-induced changes in urinary water and mineral output during the menstrual cycle.
The secretion of water and minerals were evaluated in women during and after exercise in the menstrual, post-menstrual and pre-menstrual phases. In addition, effects of oral contraceptives (OCs) on these physiological factors is considered. The study participants consisted of 30 physical education students divided into 2 groups: the 1st were menstruating regularly, and the 2nd were taking an ultra-low dose OC on a 21 day cycle. The groups exercised on a treadmill for 18 minutes at increasing speeds and urine samples were taken 1 hour prior and upon completion of the exercise. Of the OC users, in the resting phase samples of minerals and creatinine were much lower than those of the general menstrual cycle values, and reduced levels of salts and water output occurred with exercise. Calcium and magnesium excretion rates were much lower for the OC users and the retention of water for pill users may effect the renal homeostasis. The non-OC users' resting flow rate was lower and sodium output much higher during the normal post- menstrual phase than during other parts of the cycle. These changes were not due to glomerular filtration rate and may impede maximal performance. After the exercise an aliguria and hyponatriuresis were most prevalent during the menstrual phase. The resting urinary output of calcium and magnesium were unrelated to normal estrogenic and progestagenic cyclic surges. The effects of mineral retention are unknown at this time.
Sterilization patterns in a maternity unit.
The Mt. Hope hospital built by the World Health Organization to assist in family planning and maternity services has used sterilization since 1981. In the study of 425 women who had surgical sterilization in 1984 40% were over 35 years old and 48% had 5 or more children. Roman Catholics made up 35%, Moslems 22.5% and there was an equal division between the 2 major ethnic groups of Trinidad. There has been a major effort to encourage postpartum sterilization following vaginal delivery where the patients would not normally return for sterilization; 209 patients or 3.2% have undergone this among 6,530. There were 66% married, 24.5% living together, and 9.5% single, divorced or separated. The main reason for the procedure was reaching the desired family size. This study indicates that voluntary sterilization has become a common and safe contraceptive procedure. It is most suitable for couples where pregnancy is dangerous and no longer wanted. Voluntary postpartum sterilization has not been accepted everywhere and in other studies many young single women who requested it in developing countries had regrets. In the United States it has grown from 3.4% - 7% in 1981. However, it is not as popular in third world countries where the women are in a high risk group for maternal health problems; and because of domestic pressure, they will return for sterilization, resulting in many undesired pregnancies.
Genetic variability in human immunodeficiency viruses.
The genetic polymorphism of the human immunodeficiency virus (HIV) has been established. In addition to the nucleic acid variations responsible for the restriction map polymorphism, isolates of HIV differ significantly at the protein level, especially in the envelope, in terms of amino acid substitutions and reciprocal insertions-deletions. In this investigation, molecular cloning and nucleotide sequencing of the genomes of 2 HIV isolates obtained from patients in Zaire were carried out. The 1st isolate was recovered in 1983 from a 24-year-old woman with acquired immunodeficiency syndrome (AIDS); the 2nd was isolated in 1985 from a 7-year-old boy with AIDS-related complex (ARC). The genetic organization of these isolates was identical to that found in other HIV isolates from the US and Europe, particularly in terms of the conservation of the central region located between the pol and env genes composed of a series of overlapping open reading frames. There were, however, substantial differences in the primary structure of the viral proteins, with env being more variable than the gag and pol genes. Alignment of the envelopes revealed hypervariable domains with a great number of mutations and reciprocal insertions and deletions. Overall, this analysis suggests that the African and American HIV infections have a common origin given their identical genetic organization. The sequence variability reflects a divergent evolutionary process, and the fact that the 2 Zairian isolates were more divergent than American isolates studied by others indicates a longer evolution of HIV in Africa. An essential research goal is to identify the HIV envelope domains responsible for the virus-cellular surface antigen interaction since an immune response against these epitopes could elicit neutralizing antibodies for use in a vaccine.
[Adnexal actinomycosis in a woman using an intrauterine contraceptive device (IUD)]
The case-study of genital actinomycosis in a 33-year old woman wearing a "Copper T200" IUD is presented. She was hospitalized and treated for lower abdominal pain and non-characteristic signs of adnexitis twice. Adnexectomy on the left side was performed to remove an orange-size cyst. Histo-pathological examination of a prepared tissue sample revealed a colony of Actinomyces. Following the operation the patient was treated with 3 x 500 mg Flagyl (metronidazole) 3 x 80 mg of Gentamicin im. The wound healed in 19 days after operation. This woman had worn the IUD continuously for more than 3 years, thus there was an increased risk of uterine lesions. The most frequent consequences of wearing IUDs for a long time are dysmenorrhea and endometritis and therapeutic approaches are detailed. Since its first description in the literature in 1857 actinomycosis has not been mentioned frequently. However, with the spread of IUDs, the number of actinomycosis-like cases has increased and this justifies the need for improved diagnosis. The frequency of actinomycosis occurring in women wearing IUDs ranges between 1.6% and 19.7%
[Risks of intrauterine contraception (IUD)]
During the last 5 years a decrease in the use of oral contraceptives has been observed alongside an increase in the use of IUDs; this may be because of the absence of systemic side effects in the latter. 332 women between 22-52 years of age with an average of 39.1 months of IUD use were studied; parameters were pelvic inflammation, bleeding, pelvic pain, expulsion, pregnancies, copper allergy, perforation, and extrauterine pregnancies. Inflammation was noticed more frequently in nulliparae and within the 1st year of use. The frequency of pelvic inflammatory disease (PID) was 2.1%; bleeding was 7.7% and the main cause of removal. It also seemed mostly related to progesterone-based devices. Pelvic pain seemed to be mostly associated with inflammation. Expulsion happens in the 1st weeks of use. The risk of pregnancy was 0.47%. Perforation was rare, but potentially fatal. There was only 1 case of allergy with itching rashes on the skin. No increase in extrauterine pregnancy was noted; in this study, 1/3 of ectopic pregnancies occur with progesterone-based devices.
[Kaposi's sarcoma. Clinical picture, treatment and prognosis. I. Clinical forms of Kaposi's sarcoma]
The clinical features of the 4 major forms of Kaposi's sarcoma, the classic, African, epidemic (associated with AIDS) types, and the one connected with immunosuppressive treatment are detailed. Kaposi's sarcoma (KS) makes up about .06% of all malignant diseases. 83% of all patients are above 40 and 45% are above 60 years of age in the classical form. They survive for an average of 13 years. 15-25% die due to the development of KS and in 1/3 concomitant malignant tumors appear. Until 1979 KS occurred most frequently in Equatorial Africa. Just like in its classical form, KS in Africa threatens men more than women (10:1 ratio). Taylor, et al. distinguished 4 different forms: tuberculated, rosette-forming, infiltrated, and lymphadenopathic. The first one is the same as the classical form. In the aggressive 2nd and 3rd forms the average age of patients is 25-40 years and more than 1/3 die within 3 years. The lymphadenopathic form occurs mainly in children under 16 without any apparent skin lesions. Its development is extremely rapid causing death within 1 year when untreated. In 1983 an especially aggressive case was observed in Zambia in which infiltrations appeared in unusual places. In 33 similar cases in Uganda 80% of the patients had HTLV-III/LAV antibodies indicating the presence of AIDS in this area as well. KS is induced by 9-10 months of immunosuppressive treatment, e.g, in organ transplantation, rheumatoid arthritis, etc. This form is more aggressive than the classical one, the ratio of men to women is 2.3:1 and more than 25% of the patients are under 40. In AIDS patients KS occurs in more than 30%, homo- and bisexuals are most frequently inflicted. The average age of patients in this epidemic form is 35 years (19-64). The most significant risk factors, the main clinical signs of KS in AIDS (pityriasis rosea and angiosarcoma), the most frequent opportunistic diseases are further discussed, and the immunological disorders of KS/AIDS patients are listed.
The 1st step of the President of Burundi's new rural development policy involves educating both peasants and personnel. An information and promotion campaign will need to focus on relevant themes to facilitate changing psychological and cultural attitudes. The general theme of this consciousness-raising campaign will be the consolidation of the village population. The goal is to influence the villagers to take responsibility. To participate effectively, the villagers need retraining, but the agricultural schools are inadequate to this task. Adult education may serve as a interim solution, with training sessions in the peasant's own environment. Cooperative community farming of some or all land would make it possible in suitable areas to introduce mechanization and consequently to increase productivity/hectare.
Appropriate technology for rural telecommunications.
The issue of rural telecommunications has been a concern of developing countries as well as equipment suppliers. The desire by many countries to develop these systems challenges the industry to provide telecommunication services to these remote areas. There are several alternatives including microwave or cellular, digital or analogue, and fiber optics or quartz regulated gateways. The important factors in developing these systems are reliability, compatibility with present technology, and cost. The demands of remote locations in rough terrain and severe climatic conditions must also be considered. Power may be a problem especially in remote locations where solar or wind energy might be used. There is a definite need for standardization of the equipment in these systems to facilitate parts replacement and cost control. The demand for highly reliable low power equipment to meet special requirements of the developing countries, is now more clear. Also the suppliers must provide proper training for technicians and engineers so maintenance can be done without supplier contracts.
Possible viral interactions in the acquired immunodeficiency syndrome (AIDS).
Interactions among viruses may be significant to the pathogenesis of the profound immunologic defects observed in acquired immunodeficiency syndrome (AIDS). Such interactions could include complementary immunosuppression, potentiation of infection by altered receptors or genetic complementation, phenotypic mixing, or genetic recombination. The abnormalities induced by simultaneous infection with cytomegalovirus of Epstein-Barr virus, for example, may be synergistic and suppression induced by 1 virus may permit replication of another virus to high titer. Given the alterations in cell-surface components during the course of a viral infection, it is possible that AIDS infection modifies the expression of histocompatibility antigens on lymphocyte membranes or viral receptors not normally available on a given cell become expressed during infection with a 2nd virus. An alternative, viral potentiation, occurs when 1 virus codes for a gene product required for growth of another, resulting in a greater virus yield that would be expected from either virus alone. Phenotypic mixing occurs when 2 enveloped viruses infect the same cell, and the genome of 1 becomes incorporated in an envelope composed of glycoproteins from the other. In genetic recombination, actual exchange of genetic information between viruses allows for the emergence of new viruses with altered biologic characteristics. Such recombination occurs with high frequency in the human retroviruses, probably during a phase of replication involving reverse transcriptase to viral DNA. To learn more about such interactions, viruses isolated from the blood and semen of AIDS patients should be analyzed for cell tropism, neutralization kinetics, and hybridization.
1988 annual report: Family Planning International Assistance.
In 1988, Family Planning International Assistance (FPIA) provided support to family planning programs in developing countries through USAID grant, cooperative agreement, and contract funds, supplemented by private contributions from foundations, corporations, and individuals. Africa claims the largest share of 1988 assistance value (43%) and the largest number of active projects (57). In terms of assistance value, Latin America followed with 34% and the Asia-Pacific region with 21%. On the other hand, the Asia-Pacific region placed 2nd in the number of active projects (45) and Latin America was 3rd (32). In 1988, Nigeria, Mexico, Bangladesh, Thailand, and Kenya received the most project assistance dollars respectively. 48% of all FPIA contraceptive clients resided in the Asia-Pacific region, 26% in Latin America, and 26% in Africa. In 1987, the majority of new clients chose oral contraceptives (OCs) or condoms. The IUD and voluntary sterilization were the 3rd and 4th most popular methods. FPIA provided contraceptive services to all regions at an annual cost/client of $4.63. The highest cost/client was in Latin American ($6.04) followed by Africa ($4.30), and the Asia- Pacific region (4.03). FPIA's 1988 objective for number of countries in which family planning related commodities were to be distributed was 55, but FPIA surpassed that and distributed commodities to 76 countries. Distribution of OCs exceeded FPIA's 1988 objective by 59% and distribution of condoms by 286%.
Indications for drug-induced abortion include clear sonographic proof of a deceased fetus and/or an immature cervix in connection with a incomplete abortion. Medicinal pretreatment is administered in order to reduce iatrogenic cervical injuries, to prevent cervical insufficiency in following pregnancies, and to reduce the risk of perforation during cervical dilatation. A combined application of local and systemic prostaglandin therapy is suggested to reduce labor pains and side effects. For this purpose, PGE2 in vaginal suppository, gel, or capsule form has been used, as well as PGE2 alpha, PGE1, and recently also synthetic methylester gel. The objective of the current study was to determine side effects and efficiency of local and time-lagged administration of systemic sulprostone for pregnancies with complications. 20 patients with pregnancy complications were given a capsule containing 500 mcg sulprostone (Nalador) before systemic administration of Nalador 250mcg + 500 mcg. They were then compared for 6 hours with 139 patients that were treated similarly with vaginal tablets PGE2 (Upjohn). Previously noticed gastrointestinal side effects were not present, except that vomiting occurred sometimes during labor- induced spontaneous abortion. With reference to the success of the pilot study with Nalador, no significant difference to local PGE2 vaginal suppositories was noticed. Since the success of cervical priming or abortion induction in the 1st/2nd trimester during pregnancies with complications is more related to the time of death of the fetus than to parity or other factors, a statistical statement is only possible with a larger study numbers. It is concluded that local administration of 500 mcg sulprostone does not result in greater side effects by any means than the administration of a PGE2 gel.
Acquired immunodeficiency syndrome (AIDS) offers a case study of the failure of the US public health system to launch effective responses to novel health emergencies. 7 years after AIDS was 1st documented in the US, the country is still without a plan to unite academia, the government, and the private sector into a coordinated effort against the epidemic. There has been inadequate attention to preventive education and strategic planning for providing health and social services under emergency conditions. At the center of these failures in crisis management has been the AIDS bureaucracy, particularly the National Institutes of Health (NIH) and the Centers for Disease Control (CDC). The author of this monograph, a program officer at the Alfred P Sloan Foundation, contends that the extreme nature of the AIDS epidemic so stressed the public health system that deficiencies that are ordinarily obscured have become apparent. Decision makers were immobilized by the lack of a clear cut division of responsibilities among local, state, and federal officials and the response to AIDS was undermined by suspicion, personal ambition, professional rivalries, political factors, and sensationalized publicity. This book analyzes the history of the AIDS epidemic, the evolution of public health and research agencies, the role of politics in determining funding priorities, and the public relations and communication aspects of AIDS. It concludes with a proposal for a national novel health emergency plan to facilitated the management of unexpected public health crises. Additional recommendations include: 1) centralization of responsibility for managing novel health emergencies to a federal official; 2) flexible budget authority and centralized finances; 3) central management of research; 4) strategic planning for short, medium, and longterm problems; and 5) the early initiation of health education.
[Therapeutic use of gonadotropin releasing hormone and its analogues]
The anterior pituitary gland requires periodic stimulation by gonadotropin releasing hormone (Gn-RH) in order to secrete the gonadotropins. Deficiency of Gn-RH leads in both sexes to functional disturbances which in females may produce chronic anovulation and amenorrhea. If administered continuously Gn-RH leads to desensitization of pituitary Gn-RH receptors and inhibition of luteinizing hormone (LH) and follicle stimulating hormone (FSH) secretion. The article reviews preliminary results of the administration of Gn-RH and its long acting agonists. Several authors have studied the effect of the Gn-RH agonists on the luteal phase in humans. On the basis of present experience there appears to be no applicability for Gn-RH agonists as postovulatory contraceptives. Intranasal administration of buserelin showed reliable inhibition of ovulation in 1 study although higher doses produced subjective and objective symptoms of estrogen deficiency (dry secretions, vasomotor phenomena, delayed danger of osteoporosis) and even at lower dosages a high rate of blood disturbances and the possibility of development of endometrial hyperplasia was noted. Administration of Gn-RH agonists as contraceptives for men produces reversible inhibition of spermatogenesis in steroid synthesis, but because of the lowered testosterone level it leads also to impotence and libido disturbances.
[Metabolic effects of contraceptive pills]
The side effects and health risks associated with contraceptive pills have been explained by the metabolic changes they produce. The steroids in them affect the metabolism of hormones, vitamins, trace elements, carbohydrates, proteins and lipids. The changes, however, are minimal, and the steroid content has decreased over the years. The liver toxicity of currently used pills is small. Serum amino transferase values need to be checked once during the 1st 3-6 months of use, although routine liver tests have been halted. Contraceptive pills cause fluid retention and weight increase because of the estrogens. Progestin increases the secretion of water and natrium. Osteoporosis, however, does not develop. Contraceptive pills do not cause diabetes, although blood sugar increases more than average during the glucose tolerance test. Some progestins have a poor anabolic effect. The ethinylestradiol pill increases the content of some liver-based proteins in the circulation. Smoking is an important risk factor because it increases changes in the content of coagulation factors and antithrombin III. The progestin component determines the effect of the pill on lipoproteins. Changes in the cholesterol and triglycerides have remained minimal, as the estrogen-progestin content of the pill has been decreased. A new product that acts antiandrogenically has been developed for contraception by those suffering from acne.
[A case of unusually long use of an intrauterine device (IUD)]
There are more than 60 million women wearing IUDs worldwide and 40 million of them live in the People's Republic of China. Yet the risks of using this contraceptive device have not been discussed exhaustively in the gynecological literature, and the published data are contradictory. The peculiar case a woman having worn an IUD for an extremely long period of time (48 years) without any harmful effects is described. The device was made of plastic by a Polish gynecologist before World War II. In addition to its historical peculiarity this case calls attention to the fact that wearing an IUD continuously for an extremely long period of time does not necessarily result in complications. Although Akait suggested that dysplasia and cancer of the endometrium were more frequent in such cases, Kracunovic and Opric found no pathological changes in the endometrium of women having worn IUDs for 45.2 months on the average. The gynecological literature is not replete with similar cases. Tapia, et al. described an IUD made of gold which was worn by a woman for 44 years. The proven effectiveness of IUDs to avoid unwanted pregnancies varies between 91.2 and 99.2%, as substantiated by this case, too.
[Vitamin C levels in trophoblasts from pregnancies terminated by spontaneous and induced abortion]
The correlation between the level of vitamin C and spontaneous abortion was examined on the basis of data obtained during the period May 1985- May 1986. The level of vitamin C in the trophoblastic tissue shows a linear increase up to the 40th day of pregnancy. It had been suggested that vitamin C may be synthesized and stored in the trophoblast. Vitamin C concentration was determined according to the method of Roe and Kuether in 20 trophoblasts after spontaneous abortions (test group) and in 20 trophoblasts after induced abortions (control group). The concentration values obtained were 211.4 + or - 64.36 mcgmol/1 in the test group and 211.4 + or - 73.79 mcgmol/1 in the control group. The differences between the test and control groups were statistically significant at and p 0.001 level in the t-test. there were no statistical differences, however, when trophoblasts were grouped according to the timing of abortions (weeks 7 to 9 and 10 to 12), residence of mothers (town, village), or seasons. Consequently, the conclusion is reached that the lack of vitamin C may be one of the causes of spontaneous abortions.
[Risks and benefits of hormonal contraception]
In Finland, 162,000 women used hormonal contraception in 1984. 90% of them were taking low dosage combination pills. The benefits of the contraceptive pill today exceed the risks, especially when compared with the risks associated with pregnancy. Several types of combination pills have been marketed, as well as the minipill that contains progestin. The combination pills are most effective, although subcutaneous capsules and hormonal IUDs are equally effective. Many benefits of present and past use of the pill have been found to result from stopping the ovulation and the additional hormones. The combination pill has the effect of lowering the incidence of pelvic inflammatory disease and ovarian/endometrial cancer by half. It also decreases functional ovarian cysts, ectopic pregnancies, dysfunctional bleeding, dysmenorrhea, premenstrual tension and benign mastopathia. Although the side effects are rare, they are serious even with use of the modern products: coronary infarction, thromboembolism and subarachnoid hemorrhage. Hypertension, gall bladder and cardiovascular diseases have also been reported. Smoking significantly increases the risk of coronary infarction. There are less serious side effects from the use of progestin, but its benefit-risk ratio is not as well understood.
[Pregnancy interruption and childbirth after contraception]
Birth control pills are considered the basic method of contraception after pregnancy interruption. If the pill is contraindicated, hormone capsules provide a good alternative. With 83% of patients, the 1st menstrual period after pregnancy interruption os ovulatory. After childbirth this usually occurs 50-60 days following delivery, providing the woman does not breast feed. Breast feeding delays ovulation by 6 weeks. Subcutaneous hormone capsules of levonorgestrel are considered very suitable for contraception after pregnancy, and have the added benefit of offering increased protection against infections. In the Finnish sample, 91.7% of subjects continued their use after 1 year, while only 73.9% in the comparison group continued the use of an IUD. Spontaneous expulsion of IUDs is reported as a problem. IUDs are recommended for contraception after childbirth if the woman breast feeds. They can be inserted 6 weeks after delivery. Risk of perforation is less if the device is placed later and the physician is experienced. Use of combination pills decreases production of milk and slows down the baby's growth. Breast gland enlargements have also been observed. Levonorgestrel capsules slow the baby's growth 4-6 months after birth, but this difference levels off in older age groups. Developing countries have obtained a lot of experience with depot- medroxy progesterone acetate, which increases lactation and does not alter the growth rate of children. However, the longterm effects of hormones on the baby are not yet known. Post-partum sterilization is becoming more common, although it produces a greater possibility of psychological reactions.
[Prevention of teenage pregnancy]
Because the sexual activity of teenagers has increased, birth control is important to emphasize in this age group. The success of pregnancy prevention can be measured by the number of abortions, which has remained relatively stable in the 1980s, following a decrease of 11-16% in the late 1970s in Finland. Use of condoms as a method of birth control has the added benefit of protecting against infectious diseases, such as chlamydia and AIDS. However, combination pills are the most recommended option for young people. Mini-pills and capsules tend to cause menstrual problems among teenagers. Use of spermicides and diaphragms appear to have little appeal with youth. The IUD is not a good method of prevention due to increased risk of infection. Post coital prevention should be included in sex education, but this is likely to be a very transient method. Health care workers need to emphasize confidentiality in activities related to prevention of teenage pregnancy. It would also be beneficial for schools to provide counseling as part of their sex education program.
[Prognosis of ovulation based on contraceptive methods]
Natural family planning consists of contraceptive methods that are based on prediction of ovulation, i.e. rhythm method, basal body temperature, symptothermal and Billing's ovulation methods. In industrialized countries about 10% of the population needing prevention utilizes these techniques. The fertile period of the menstrual cycle is considered as starting when cervical mucus appears on the external sexual organs, and as ending 3 days after the so-called "culmination day," at which time the possibility of fertilization is greatest, generally days 6-12 in a 28-day cycle. Changes in cervical mucus, basal body temperature, softness of the cervix, and such things as tenderness of the breasts and pain in lower abdomen, are used to determine time of ovulation. Natural family planning methods are quite troublesome, and the continuity of their use after 1 year is only 50-60%. Reliability of protection varies between 0.3 and 35%, depending on the particular variant used and the population adopting it. The biggest cause of failure is due to ignoring the rules. 24% of users find the long periods of abstinence uncomfortable. This type of prevention is best suited for women who have learned to identify their time of ovulation.
An IUD placed in the uterine cavity that secretes levonorgestrel (LNG) at the rate of 20 mcg a day has been studied over the course of 14 years. In this contraceptive around a Nova T stem, covered with a silicon membrane. 20 mcg levonorgestrel is sufficient to produce 10 mcg, even after 5 years duration. During its use the duration and amount of menstruation decreases significantly. Therefore, blood hemoglobin and iron content is decreased. In spite of the amenorrhea, studies have shown that production of estrogen and ovary function have been normal. Both fertility and menstruation return quickly after the contraceptive is removed, generally after five years of use. The LNG device has proven very reliable. The pregnancy index during the five years of study was 0.4, and at least some of the pregnancies were caused by spontaneous expulsion of the contraceptive. If the menstrual flow returns to normal, there is reason to suspect that the IUD has come out. Headaches and acne are listed as common side effects associated with this method. It is mostly recommended for women over 30 who are in stable relationships and who want their fertility to return. LNG prevention does not protect against infections. Therefore, education is important for successful use of this method.
Postcoital prevention is for women whose contraceptive failed or who experienced unprotected intercourse. This method is sought out more in countries having well developed family planning services and liberal legislation regarding abortion. Over 50% of those women seeking postcoital contraception are 16-25 years old. Although administration of large doses of estrogen and progestin have been utilized after unprotected intercourse, 2 other methods are recommended: Yuzpe's ethinyl estradiol and levonorgestrel combination or IUD. Estrogen and progestin treatments are no more reliable. A package of 4 pills, each containing 50 mcg ethinyl estradiol and 250 mcg levonorgestrel has made it easier for consumers. The contraindications of Yuzpe's method are the same as with any birth control pills. Teratogenic effects as well as pregnancies are possibilities. Of the women utilizing Yuzpe's method, 95% began to menstruate within 3 weeks. The method fails in 0- 2% of cases. Use of the IUD as a postcoital contraceptive is recommended when there are contraindications for the use of hormones, and when the women wishes for longer term protection.
The popularity of sterilization as a birth control method has increased over the past 20 years through better understanding of family planning and development of sterilization procedures that require only brief after-care. Female sterilization is approximately 99.5% safe, depending on the particular method used. Surgical methods include mini laparotomy and colpotomy, and are recommended if a pregnancy has occurred. Laparoscopy techniques are more advantageous with non-gravid women. These procedures can be performed under local anesthesia, and even on an outpatient basis. Coagulation of the ovarian tubes and mechanical clips have been utilized, although the latter have not produced good results. Intrauterine methods include injection of chemicals such as transvaginal quinacrine. Risk of death from complications is less that the cumulative risk from the use of other contraceptives. Such sterilization is considered permanent; it is most suitable for women in a stable relationship after they have had the planned number of children. Counseling is important in order to minimize poorly thought out decisions and later regret. (author's modified)
[Contraceptive coils and their problems]
Intrauterine contraception is characterized by reliability, ease of use and quick return of fertility upon removal. The life of the old Copper T was 3 years. Newer copper IUDs were developed to decrease the chance of pregnancy. Tolerance, however, was not increased. Pregnancy indexes with the newer intrauterine devices ranged from 0.3 - 2.1. Bleeding and pain are typical side effects of IUD prevention. The IUD can come out by itself because of poor placement or unsuitability of the uterus for this type of contraception. All IUDs, except ones that secrete hormones, increase bleeding and pain. Infection has been observed to be another problem, according to epidemiological studies conducted in the 1970s. Contributing factors are the shape of the device and its placement. Women with multiple partners have an increased risk of infertility. A tendency to develop venereal disease is a contraindication for IUD use. Studies regarding the higher incidence of ectopic pregnancy are controversial. Individuals affected by this usually are found to have had higher chlamydia antibody levels. Careful selection of user, counseling and follow-up are important for successful IUD contraception. (author's modified)
Interest in contraceptive devices has increased in recent years due to their safety and protection offered against venereal disease. Use of the devices prevents sperm from entering the uterine canal. Failure of a device is usually caused either because the contraceptive outside the uterus is wrongly positioned or because not enough active spermicidal ingredients were released before ejaculation. Mass production of condoms was made possible through utilization of latex rubber. Different color and shape alternatives have made condom usage more popular in developing countries. The diaphragm and its variation, the cervical cap, are treated with spermicide and then placed inside the vagina. Correct size of the contraceptive is an important consideration. Spermicides consist of active substances that kill sperm, as well as a carrier substance such as foam, ointment and jelly. The newest preventive device is the contraceptive sponge, which can stay in place for up to 36 hours. IN vitro studies show that effectiveness of condoms is 0.5-2.0 (Pearl's index). Combination use of diaphragm and spermicide yields a protection rate of 2-20 (life-table index), and spermicides 0.3-30.0. Risks associated with these methods include local irritation. It was believed that some spermicides increased rats of miscarriage, Down's Syndrome and other chromosomal abnormalities, as well as limb anomalies. Diaphragm use increases potential for urinary tract infections. Toxic shock may occur with some users of sponge and diaphragm. All the mentioned contraceptives protect from infection, and are most suitable for people who cannot tolerate hormonal preparations or IUD's, who are in a casual sexual relationship or nursing mothers or youth.
[Subcutaneous hormone capsules]
Contraceptive implants containing progestin have been marketed in Finland since 1984. The method utilizes 6 silicon capsules of 36 mg levonorgestrel that are implanted inside the upper arm under local anesthesia. Each capsule is 34 mm long and 2.5 mm wide. The capsules release 100 mcg levonorgestrel a day during the 1st 3 months, after which dosage decreases to a level of 30-35 mcg a day within 15 months. The rate of release remains the same for a period of up to 6.5 years. Some users experience no ovulation or an incomplete luteal phase. The level of estradiol varies, although FSH, LH and androgen levels do no essentially change. Cholesterol ratios remain unchanged, but the levels decrease somewhat. Blood coagulation problems due to menstrual problems, primarily frequent, irregular bleeding and spotting. Side effects such as headaches, weight gain, mood changes can be caused by the capsule, as well as the contraceptive pill. During implantation and removal there is a small (0.3) risk of infection. Teratogenic and mutagenic effects are unlikely. Studies have shown no pregnancies occurring in the 1st 2 years of use. The 3rd year, the cumulative rate has been shown to be 0.3, and for the 4th year 0.7. To a great extent, contraceptive implants are utilized by women who have had bad experiences with other methods, and who already have the desired number of children. This method offers much promise to those women in developing countries, and has been proven to be well tolerated there.
HIV infection and maternal and child health.
Collaborative studies to determine the consequences of pregnancy in HIV infected women have been begun in the last 2 years. Both HIV and HIV antibodies pass through the placenta, and 30-50% of infants born to HIV infected mothers are infected in utero. In developed countries it is feasible to screen pregnant women in high risk groups for HIV positivity. In developing countries, where heterosexual transmission is the main route of infection, there are no high risk groups, and it is not feasible to screen all pregnant women. Some data have shown that HIV infection in pregnancy is associated with intrauterine growth retardation, low birth weight, and high infant mortality. There is no evidence that cesarean section reduces infection in neonates, and it should not be performed on HIV infected women. By 1987 almost 1.5% of AIDS cases in the US were in vertically infected infants. In Africa also the main factor in HIV in infancy is vertical transmission. AIDS in infancy follows 1 of 2 distinct patterns: failure to thrive and death from Pneumocystis carinii pneumonia within the 1st year or else apparent health during infancy but death from opportunistic infections by age 3. HIV infection in childhood is uncommon and can usually be traced to blood transfusions or unsterilized needles used for vaccinations. Neurological symptoms often develop early in children. Breast feeding probably does not infect any infants who have not already been infected in utero, and in developing counties breast feeding is still the best assurance of total nutrition. Pooled, unpasteurized milk banks, on the other hand, represent an unnecessary danger, and milk donors should be screened. Since there is no evidence that routine immunization accelerates the course of HIV infection, and since mass screening is not feasible in developing countries, the World Health Organization recommends that routine immunizations be continued. Since the best protection from in utero HIV infection is the use of contraception, it is recommended that contraceptive regimens should be continued, but the use of condoms is recommended in addition. In India the 1st AIDS cases were found among prostitutes in Madras, and a nationwide serosurveillance program was implemented within 6 months. By October, 1987, 145 seropositive persons were identified, of whom 13 had AIDS. The main methods of minimizing in utero infection remain sex education, sterilization of instruments, and contraception.
It has been noted that following the procedure of vasectomy, blockage of the vas deferens exposes the immune system to reproductive tract antigens, an antisperm autoimmune response occurs. This has been found to occur not only in humans, but other species as well. In a previous investigation on this subject monoclonal antisperm antibodies were discovered after the fusion of myeloma cells with cells from the spleen of vasectomized mice. A study was conducted on the effect that monoclonal antibodies have on sperm function and in vitro fertilization. The monoclonal antibodies were developed from the spleen cells of BDF 1 mice, vasectomized for 12 weeks, fused with NS-1 myeloma cells. 7 hybrid cell lines secreting mouse antisperm antibodies were recloned. The supernatants and ascites taken from these cell lines were employed in the study; all of these clones were IGM. The results are as follows: the clones when introduced to sperm reacted to different parts of the sperm - 4 with the tail; the antibodies when exposed to tissue antigen had different reactions as well - Vx13 reacted to extracted antigens of both testis and epididymis, Vx4, Vx8, and Vx13 reacted to testicular and epididymal extracts and Vx4 reacted only to testicular antigens. 4 of the monoclonal antibodies had an effect on in vivo and in vitro fertilization when added to either the sperm or used as an immunization.
[Fate of subsequent pregnancies after induced abortion in primiparae]
Premature birth, a well-known result of induced abortion in primiparae, was studied on the basis of data obtained at the Institute of Gynecology and Obstetrics in Lodz during the period 1981-1985. The test group was comprised of 1494 births out of a total of 15,711 registered births that occurred prematurely. Another 390 births at term were selected from the rest of the cases to form the control group. 14.93% of the test group had had induced abortions as primiparae, while this ratio was only 7.95% in the control group. According to the results of the + - test this difference was statistically significant at the p 0.05 level calling attention to the harmful effect of induced abortion in primiparae (double risk of premature birth). During the process of induced abortion, the cervical orifice of the uterus is often mechanically hurt resulting in insufficiency, thus causing premature birth in the pregnancies that follow. It is mostly young women who are not appropriately cognizant of these facts of risks.
[Male sterilization -- a forgotten alternative?]
Over the last 20 years, some 20 million vasectomies have been performed in the world. In Finland and other Nordic countries, vasectomies are controlled by strict legislation. In 1970, "social reasons" were accepted as justification for sterilization. Sterilization is generally granted only after an individual has submitted an application to the National Board of Medicine requesting this. The performing physician may alone make a decision of sterilization if the applicant has reached the age of 30 and has 3 minor children. Vasectomy is a simple procedure that is usually performed under local anesthesia on an outpatient basis. On occasion, bleeding or pain may develop, which may require a period of recovery beyond the normal 2-day period. Sterility is likely if sperm analysis reveals a count of less than 125,000 ml of unmobile sperm. A recanalization occurs in 1% of patients, making necessary a repeated vasectomy. Sperm granulism increases risk of recanalization. This risk can be decreased by modification of surgical techniques. Possible complications resulting from vasectomy include atherosclerosis, pain and swelling around the testicles, and psychogenic impotence. Reversal of vasectomy is a more complicated procedure and leads to pregnancy in only 50% of cases. Vasectomy is a recommended method of birth control for those in a stable relationship and who already have the desired number of children.
[The origin of intrauterine contraception]
In this historical survey on intrauterine contraceptive devices the first types are traced back to Arabian times. However, the precursors of today's IUDs were pessaries developed during the 1860's and 1890's. Initially, they were used as elevators/regulators to correct the position of the uterus. Pessaries of different shapes became widespread as contraceptive devices in Europe at the turn of the century. Their popularity was accompanied by the appearance of side-effects: according to 1907 statistics there were 445 cases of uterine lesions and 45 cases of death occurred as a result of the use of a fungus-shaped pessary. The most frequent complications were endometritis, bleeding, purulent inflammations of the uterus, peritonitis, etc. The spread of pessaries was accompanied by strong criticism from gynecologists. Broc and Cruveillier proposed to exclude the device from practice at the Paris Academy of Medicine in 1854. A similar proposal was made at the Gynecological Section of the Society of Natural History of Austria in 1856. In the 1930's this type of device was replaced by the intrauterine loop invented by the gynecologist Grafenberg from Berlin.
Acquired immuno deficiency syndrome (AIDS). Its impact on blood transfusion services.
About 3.2% of worldwide cases of acquired immunodeficiency syndrome (AIDS) have been attributed to the transfusion of whole blood and plasma products. An estimated 66% of recipients of blood and blood products infected with human immunodeficiency virus (HIV) develop HIV seropositivity. This calls attention to the need to develop strict guidelines to protect clients of blood transfusion services. Toward this end, the International Society of Blood Transfusion has made the following recommendations: donors belonging to high-risk groups for HIV infection should be excluded from donating blood; blood and plasma products should be screened for antibodies to HIV through laboratory tests with demonstrated reproducibility and specificity; donors should be informed that their blood will be screened and procedures for confidential notification of any positive results should be outlines; it should be clearly stated on the label if a blood product has not been screened for HIV; and viral inactivation, including heat treatment, should be mandatory for the processing of all plasma products. Interns of the situation in India, the director of the Institute of Immunohematology in Bombay has made these recommendations: the general public should be educated about the fact that the donation of blood cannot lead to AIDS; an effort should be made to obtain blood products from volunteers rather than professional donors or blood banks; donors whose history includes risk factors for HIV infection should have their blood screened; confidentiality must be a guiding principle in all cases; all source material and final plasma products should be screened for antibodies to HIV; and all plasma products should be heat inactivated before sale.
Sera from patients with adult T-cell leukemia and asymptomatic carriers of human T-cell lymphotropic virus type I (HTLV-I) from widely separated areas of the world reacted strongly in a standardized quantitative enzyme-linked immunosorbent assay procedure with HTLV-I viral antigen prepared from a strain isolated in the US. There was a sharp differentiation of the values seen in the patients as compared with a normal population. Of the 35 acquired immune deficiency syndrome patients with Kaposi's sarcoma, only 2 were positive for HTLV-I antibodies in this test, and the distribution of the negative assay values in the other AIDS patient's sera was similar to that seen in the normal sera. Sera which contained extremely high levels of antibodies to other unrelated viruses (rubella virus, cytomegalovirus, and herpes simplex virus) all showed negative anti-HTLV-I results, in a pattern similar to the normal sera. Sera from patients with several autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, thyroiditis) as well as those with infectious mononucleosis or myeloma all showed the normal distribution of negative results, in spite of the presence of very high levels of the autoantibodies, etc., associated with their illnesses. (author's)
Kaposi's sarcoma and HTLV-III: a study in Nigerian adult males.
Sera from 37 Nigerian men with Kaposi's sarcoma were examined for evidence of infection with human T-cell lymphotropic virus type III (HTLV-III), cytomegalovirus (CMV), Epstein-Barr virus (EBV), hepatitis B virus (HBV), hepatitis A virus (HAV), and Candida albicans. For comparison purposes, sera from 30 patients with primary cell liver carcinoma and 150 health young adults were also assessed. The Kaposi's sarcoma patients were in poor general condition, with severe anemia and gross sepsis. In each case, cutaneous disease affected only the limbs-- a finding that is in contrast with the visceral organ involvement seen in most black African victims. The serologic testing provided clear evidence that tropical African Kaposi's sarcoma is not associated with HTLV-III infection; non of the 217 serum samples analyzed from the 3 study groups showed antibodies to this virus. A widespread pattern among the Kaposi's sarcoma and liver carcinoma patients was depression of peripheral blood monocyte chemotaxis and a diminished, delayed-type hypersensitivity reaction to tuberculin. All patients in these 2 groups demonstrated circulating antibodies to CMV, EBV, HBV, AND HAV. Candida albicans was isolated from 30 of the 37 Kaposi's sarcoma patients and all 30 liver carcinoma patients compared with none of the health controls. These findings suggest that endemic tropical African Kaposi's sarcoma is a different disease than the epidemic AIDS-linked Kaposi's sarcoma reported from the US, and it is probable that different etiologic agents are involved in each case.
Screening for seroprevalence of HTLV-III/HIV infection in high risk groups in Delhi.
Serum samples from a total of 1505 (826 males and 679 females) individuals belonging to various categories of Delhi based high-risk groups, such as those attending clinics which treat sexually transmitted diseases (n=700), prostitutes (n=348), jail inmates (n=325), drug addicts (n=26), blood donors (n=11), those clinically suspected AIDS cases (n=89), and those who underwent coronary bypass surgery abroad during the past 3-4 years (n=6) were screened for the presence of antibodies to HTLV-III/LAV/HIV virus. The commercial Wellcozyme AIDS ELISA kit was used and none of the serum samples tested positive for the HTLV-III virus. (author's modified)
Infection with human immunodeficiency virus (HIV), the causative agent of AIDS, is endemic in the general population of large parts of Africa, particularly in Central Africa. In the industrialized world (North America, Europe, and Australia) the infection remains largely confined to a number of specific high-risk groups (male homosexuals, intravenous drug abusers, hemophiliacs). Little is known about the spread of HIV- infection in Asia. Only a number of isolated cases of AIDS have been reported from Thailand, Japan, and some islands of the South Pacific. In order to evaluate HIV presence in Indonesia, we tested 247 sera from pregnant women living in the Bandung area. Sera were collected in the 1st trimester of 1986 as part of a prevalence study on HBV markers. Antibodies to HIV were determined by the Abbott HTLV-III EIA (Abbott Laboratories, North Chicago, IL). All 247 sera tested were negative for HIV antibodies. This strongly indicates that HIV infection has not yet been introduced into the population of West-Java, Indonesia. But a surveillance system for the infection should be started immediately, in order to be able to implement control measures. (full text)
Epidemiological correlations between African AIDS and AIDS in Europe [editorial]
By September 1985, 157 cases of acquired immunodeficiency syndrome (AIDS) had been diagnosed in Europe (primarily in Belgium, France, and Switzerland) among people originating from 22 African countries. These patients represented 10% of the total cases of AIDS reported as of that date in Europe. The majority of African AIDS patients living in Europe were heterosexual and originally from Africa's Equatorial belt. There are sharp differences in the epidemiology, virology, and clinical manifestations of AIDS in Africa compared to Europe and the US. African AIDS has largely affected young, sexually active men and women and children under 5 years of age; homosexual/bisexual activity and injections are not major risk factors, as they are in Europe and the US. While male to female transmission predominates in developed countries, Africa demonstrates evidence of efficient bidirectional transmission. AIDS retroviral isolates from Africa show greater genomic heterogeneity than those from Europe and North America. Moreover, retrospective serologic data suggest that the AIDS virus, or a related virus, has been present in Africa since the early 1960s and may have evolved from an animal predecessor. It is possible that co-factors, such as the existence of other sexually transmitted diseases or specific sexual behaviors (vaginal intercourse during menses, trauma during sex, anal sex), have contributed to the heterosexual predominance of African AIDS. Since the Africa AIDS pattern could represent the future profile of AIDS in developed countries, it is important to clarify the factors that promote heterosexual transmission and to take steps to prevent the spread of AIDS from limited high-risk groups to the general population.
HIV infection and tuberculosis in Turkey [letter]
Infection with human immunodeficiency virus (HIV) has been recently assigned as one of the leading reasons for an increase of tuberculosis in some populations. Whether a full-blown AIDS picture develops or not, immunodeficiency occurs among infected individuals soon after seroconversion to HIV infection. Data which have been obtained suggest that the immunodeficiency caused by HIV infection may reactivate M tuberculosis among populations which were widely infected with this bacterium (PPD positive). It is also suggested that HIV infection may be responsible for the increase of tuberculosis in these populations. The incidence of tuberculosis has risen in our country in recent years. It has been estimated that there are 10-12 million individuals infected with M tuberculosis and about 200,000 patients with active tuberculosis in Turkey. ALthough only a few cases of AIDS have been reported from Turkey (34 patients as of November 30, 1987), we have investigated 221 active pulmonary tuberculosis patients and 38 cases who had experienced tuberculosis within the last 5 years in order to find out whether HIV infection contributed to this increment. These individuals were from 58 of 67 provinces in our country. Anti-HIV antibody was screened by a commercial enzyme-linked immunosorbent assay (Abbott Laboratories). None was positive. This result has, at least at the present time, indicated that HIV infection does not contribute to the increase in cases of tuberculosis in our country and implicated that HIV is not an indigenous human retrovirus in Anatolia. (full text)
Nutritional beliefs among rural Nigerian mothers.
At Shao, a rural community in Nigeria, 730 women were asked to state their awareness of pregnancy symptoms and nutritional beliefs during pregnancy. Among the participants, 92.3% mentioned the stoppage of menstruation while 81.9% recognized breast enlargement, 16.2% considered nausea and vomiting, and 5.3% mentioned the darkening of the nipples. Specific foods of the protein rich meat group, particularly rabbit Oryctolagus capensis was avoided during pregnancy because of sociocultural beliefs. Energy-giving starch-rich food items were most frequently regarded as good for the body. Over 50% of the respondents considered the roots, the starchy food group, and the fruits and vegetables group as most nutritious during pregnancy. Only 38.8% of the respondents met the recommended weekly weight gain standard and 61.2% did not. It was recommended that a statewide classification of food taboos in Kwara State should be undertaken to assist the services provided by primary healthcare workers. The need to intensify health counseling in antenatal care clinics was highlighted. (author's)
Mortality data collected from sources other that a death registration system can validate the accuracy of the system, but this information is rarely obtained. Data on 1979 deaths among reproductive age women were collected in the 1981-1983 Reproductive Age Mortality Survey (RAMOS) in the governorate of Menoufia, Egypt, and compared with data on these deaths as recorded by the Egyptian death registration system. Although the distribution of the causes of death were similar, there were substantial differences between classification systems for deaths due to particular causes. Over 1/2 of the deaths classified differently by the systems were those assigned to circulatory disease on the death certificate. In contrast, there was a high rate of agreement between systems in the classification of trauma deaths. About 1/2 (52.4%) of cancer deaths had the same site-specific cancer diagnosis assigned by RAMOS. The % of deaths assigned to maternal causes was 3 times higher in RAMOS (19.2%) than on death certificates (6.1%). Reported mortality rates for this often-preventable cause of death have been substantially underestimated in national death registration systems. Such underreporting masks the need for additional prenatal care and maternal health programs. (author's)
Immunogenicity and safety of measles vaccine in ill African children.
A concurrent prospective study was conducted in Rwanda to compare the immunogenicity and safety of live, attenuated measles vaccine in both ill and well children. 518 children ages 8-19 months were selected from children attending the acute care and immunization services of 2 clinics. 267 ill children and 251 well children were enrolled and examined. Serological tests were performed on blood samples obtained before and 40 days after measles immunization. Among the 208 ill children and 215 well children who were seronegative at baseline and had unequivocal follow-up serological results, seroconversion rates were 81% and 80%, respectively. Side effects were modest and were equally frequent in the 2 study groups (15.4% among ill children vs. 15.1% among well children). These results support a change in measles immunization policy in developing countries with respect to immunization of children with acute illnesses. Such a change would make a great contribution to decreasing the enormous burden of measles in the developing world through increased immunization coverage. (author's)
Neonatology in the developing world. Part 1.
With proper nursing care and procedures, small hospitals in rural areas of developing countries can provide good neonatal care and achieve perinatal mortality rates comparable to those found at teaching hospitals. The 1st ingredient of adequate neonatology is the establishment of proper regimens for feeding, observation, and resuscitation of newborns. Even in areas where the majority of births take place at home, good neonatal care is possible as long as local risk factors are identified, all newborns are screened for these factors, and at-risk infants are referred for treatment. Factors that place infants at risk include birthweight under 2 kg or above 4 kg, delivery before 34 weeks' gestation, respiratory distress, severe birth asphyxia or trauma, jaundice, prolonged rupture of the membranes, infant not sucking or febrile, convulsions, congenital malformations, and maternal disease. 4 areas require special knowledge on the part of health personnel: the asphyxiated infant, hypothermia, hypoglycemia, and neonatal sepsis. Health workers must be familiar with proper resuscitation techniques, especially avoidance of excessive suctioning of the pharynx, and be alert to signs of hypoxic ischemic encephalopathy. Premature, small, asphyxiated, and sick infants are at greatest risk of hypothermia, a condition that can be prevented by drying and wrapping newborns immediately. Providers should be alert to signs of hypoglycemia in infants of diabetic mothers, large-for-gestational-age babies, the low- birthweight infant, and sick babies. To prevent sudden infant deaths, all sick newborns should be treated for neonatal sepsis.
Colombia: crusading efforts bring signs of progress.
Colombia, like many developing countries, has not committed resources to fight the AIDS problem. They have used the media for condom promotion and other sexually transmitted diseases. There have been 151 deaths caused by AIDS by the end of 1988; 344 cases are known, and 130 additional have tested positive to the virus. Health officials were reluctant to recognize the problem, thinking it was outside their country and that they would not be affected by it. Since then, they have tried to target high risk groups and educate them and assist with testing and counseling. There is a move to make the new drug zidovudine available, but few could afford its high price. The authorities have put transvestite prostitutes in jail and kept them for AIDS testing, but few woman prostitutes have been tested. Up until 1986, only 30% of the Red Cross blood bank supplies were being tested; now 80% are, although it comprises only about 40% of the total supply. Drugs are used heavily, but mostly smoked, in Colombia, yet there is some concern about increased use of needles. The majority of cases in Columbia have been homosexual and bisexual men, but prostitution among men and women is prevalent in large cities such as Bogota. Health officials state that education is the best deterrent, but must be perpetuated so people will be constantly reminded.
Two cases of genital actinomycosis caused by Actinomyces israeli are described. The first case of this type in a woman wearing an IUD was found in 1926. At the Institute of Gynecology and Obstetrics of the Medical Academy of Lodz there were two similar cases diagnosed during the period of 1954-1985. In the first case, a 31-year old childless woman was hospitalized with a cyst in the left adnexum and was treated with 0.5 g of streptomycin and 300 thousand units of procaine penicillin for 10 days. As sufficient improvement did not ensue, the cyst was surgically removed and administration of 0.5 g of streptomycin plus 300 thousand units of penicillin followed for 14 days. Examination did not reveal further inflammations. The woman died at the age of 63 due to insufficient cerebral blood supply. In the second case, a 29-year old woman with two children and no abortions was treated for actinomycosis. She had worn a ""Lippes""type IUD before the second birth for 3 years and a Copper T200-type IUD for almost two years after it. She was hospitalized with lower abdominal pain and fever of 39-40C. In the right adnexum a cyst caused by Actinomyces was found and removed surgically. Following the operation, the woman was treated with 2400 thousand units of procaine penicillin and 2 x 0.5 streptomycin per day, for 7 days. She left the hospital 13 days later in good condition. The literature of the changes of the endometrium caused by IUDs is further discussed.
[The experience of European countries in stimulating fertility through economic means]
Demographic trends in various European countries during the end of 19th and 20th century are reviewed with special emphasis on the historic changes in population dynamics. Transition from high birth rate and high mortality rate to low birth rate and low mortality rate led to a zero growth and even to a negative population growth. The decrease in birth rate is associated with the changes in the need to have children and with changes in the attitude of parents. The measures to stimulate birth rate are based on the assumption that parents want to have children but are prevented by socioeconomic factors. Birth rate can be stimulated by direct subsidies (1-time cash payments after the birth of a child, maternity leave, monthly bonus payments) or by indirect subsidies (loans for housing, medical care, education). 1-time cash payments vary from country to country and can amount to an average monthly salary. In the USSR, the amount of payment depends upon the income of the parents. All European countries provide for maternal leave (12-16 weeks). Monthly bonus payments for a 2nd child range from 1%-21% of an average monthly salary; the lowest payments are given in Greece and Spain and the highest--in Hungary. Countries with relatively low birth rate (Austria, Belgium, Luxembourg, West Germany, France, Holland) are characterized by the highest child payments, while counties with relatively high birth rate (Greece, Ireland, Spain, Italy, Poland, Portugal) have the lowest child payments.
Literature data on the mechanism of Laminaria-induced dilatation of the cervix uteri during abortion in the 2nd and 3rd trimesters are reviewed. Laminaria sticks are made of the stems of the algae Laminaria digitata or Laminaria japonica; the standard stick is 6-7 mm in length and 2-3 mm in diameter. Laminaria acts on the cervix uteri by applying the radial force and by removing water from the cervical stroma. One of the mechanisms of action of Laminaria is associated with the stimulation of synthesis and release of endogenous prostaglandins. The most widely used method of sterilization is gammairradiation of individually packaged Laminaria sticks. The thread attached to the proximal end of the stick simplifies its removal. Dilatation of the cervix uteri during 1st trimester requires insertion of 1-4-6 sticks for 6-12-16 hours. The methods of Laminaria insertion during the 2nd trimester vary depending upon the clinical situation. The major disadvantage of Laminaria is acute or spastic pain during insertion. Complications include migration of the Laminaria stick into the vagina or uterus and the risk of infection. Recently developed synthetic Laminaria have a number of advantages over natural Laminaria (guaranteed sterility, uniform shape, more rapid swelling, relative insensitivity to pressure). The most widely used synthetic Laminaria are manufactured from the polyvinyl alcohol (Lamicel, Merocel) and hydrogel polymer (hypan and Dilapan). Merocel and Lamicel are impregnated with magnesium sulfate providing for additional absorption of the fluid.
[Use of a synthetic cervical dilator in induced abortion]
A novel synthetic dilator of the cervix uteri used for abortion is described. The device is made of hydrophobic polymer polyacrylonitrile (trade name Dilapan) and is available in several sizes (3 and 4 mm in width; 55 and 65 mm in length). The device can be rigid of flexible (the latter is used for patients with abnormal cervical canal or atypical location of the uterus). The dilator is recommended for use in patients with pregnancy less than 15 weeks of gestation; the device can also be used for curettage in nonpregnant patients. Contraindications include acute, subacute or chronic endocervicitis, gonorrhea, or acute inflammation of the lesser pelvis. The dilator inserted into the cervix for 15-30, 30-60, 60-120, and 120-140 minutes provided a dilation of 6, 7, 9 and> 11 mm, respectively. Dilatation of > 15 mm could be achieved by leaving the device in for 24 hours. Simultaneous use of 2 dilators allowed a 20 mm dilation of the cervix in a shorter time. Clinical trials indicated an average dilation of 9.3 mm after 3-4 hours application. Approximately 4% of women experienced pain and 12% had spastic pain similar to that during menstruation. Comparative evaluation of the dilator and Laminaria Japonica showed the dilation of 8.3 to 10.3 mm after 2-4 hour applications of the synthetic dilator in 82% of the abortion applicants, while similar dilation after the use of Laminaria was achieved only in 44% of women. Complications following application of the dilator included infection, insufficient dilation of the cervix associated with use of the wrong size device, incarceration of the device in the cervix uteri, and breaking of the device.
A sensitive bedside urine test for human chorionic gonadotrophin in suspected ectopic pregnancy.
The use of high-sensitivity urine tests for the beta subunit of human chorionic gonadotropin (hCG) is recommended in cases where ectopic pregnancy is suspected to avoid unnecessary diagnostic surgery and hospitalization. However, variability in environmental conditions and interpretation by clinicians who lack training in laboratory technique are potential sources of error when such tests are used. The potential for such error with an ultrasensitive modification of the Tandem Icon urine test for hCG was assessed among clinicians at Johannesburg Hospital who lacked laboratory training but had clear written instructions. A total of 51 tests were performed by 10 registrars and 8 senior house officers. The Tandem Icon test was positive in all 6 cases of ectopic pregnancy in this series. There were 2 false-positive results, both of which involved patients with ovarian cysts. There were no false-negative results. More widespread use of this test is recommended given its acceptably low level of error. The reliability of the test could be improved, however, by the addition of illustrations to the instructions. In particular, the instructions should be modified to emphasize that a vague blueness without a clearly defined circular shape does not represent a positive result. This error appeared to have been the cause of the 2 false-positive readings encountered in this study
The Behrhorst Program: a model for primary health care.
The World Health ORganization committee on nursing training suggests changes toward programs which are community-focused, reasonably priced and easily accessible. From experiences in a program in Guatemala throughout the 1970's, a nurse has many strong beliefs as to what primary care should be. Death was only too familiar, where only 3 in 10 births survived, when Dr. Carrol Behrhorst started to work there. His purpose was to help the 4,000,000 indian natives change to a strong self reliant people. They could not respond to normal curative medicine for diseases since malnutrition was prevalent. To make changes, other considerations had to be addressed such as social and economic justice, land reform, agriculture development, birth control, malnutrition elimination, health education, and practical medicine. The program progressed and is now in the hands of local people, with a 125 bed hospital, a health care promotion program, women's family planning groups, agricultural development, and projects for safe water and sanitation.
[Breastfeeding in relation to knowledge and social support]
It has been suggested that every country undergoes 3 stages of development in its attitude toward breast feeding. The 1st or traditional stage is characterized by mothers breast feeding their children for a long time. The 2nd stage is a strong downswing in the popularity of breast feeding. The 3rd stage is a period during which breast feeding undergoes a renaissance. By 1979 about half of the mothers in Finland nursed their children for at least 6 months. In a study of 100 primiparae the 17-36 year olds (mean 24.7/) completed 4 questionnaires in the period from delivery up to the termination of breast feeding. In no case did this period exceed 5 months, at which time 60% of the women were still lactating. Age correlated significantly with the desire to nurse longer as did support received from the child's father, although support from health services sources was more significant. Mothers with higher work status had significantly more knowledge of breast feeding before nursing began and nursed significantly longer than women with lower work status. Women who nursed at least 5 months had significantly better expulsion reflex during delivery, did not need additives to mother's milk, and had a more positive experience with nursing after 3 weeks than women who nursed for a shorter time. Women who nursed for a longer period also had significant difference in the experience of nursing as an expression of contact and as an expression of sexuality.
[Acquired immunodeficiency syndrome (AIDS) in the African environment]
The characteristics of AIDS in Africa differ sharply from those in North America with respect to diagnosis and epidemiology, and in a clinical sense. The study of 78 patients treated in Kinshasa, Zaire during the period of October 1983-July 1984 yielded the following results: 159 out of a total of 1051 hospitalized patients were suspected of having AIDS, and there were 78 proven cases (54 of them died). The average age of 40 women and 38 men was 27 and 31 years, respectively, and the ratio of married people was 35% and 74%, respectively, with a lot of men living in polygamous relationships. In the first stage of the disease weight loss appeared in 100%, recurrent diarrhea in 83.3%, significant loss of strength in 75.6%, febrile conditions in 68.3%, and skin lesions in 58.9%. The ratio of men to women was 5:5, since heterosexuality and polygamy prevailed. Cigarette smoking was the main addition, thus drug addition per se did not appear as a risk factor. Blood transfusions occurred frequently (for instance, in malaria), but hemophilic patients receiving lyophilized preparations were rare. Haitians visited in fairly large numbers after the 1960's propagating the risk of AIDS. Black Africans accounted for 100% of cases. The number of concomitant, opportunistic diseases in AIDS patients in Zaire were: 34 cases of tuberculosis, 32 cases of candidiasis, 30 fungal infections, 21 Herpes labialis and/or genitalis, 19 cases of dermal and cerebral cryptococcosis, 12 cases of cryptosporidiosis, 9 cases of Kaposi's sarcoma, 5 cases of Herpes zoster, 3 cases of aseptic cerebral infections, 3 cases of coccidiosis, 2 cases of toxoplasmosis, and 1 case of pneumonia (Pneumocystis). Tuberculosis, cryptococcosis, cryptosporidiosis, and toxicosis were more frequent opportunistic diseases in Zaire than in the U.S.A., while pneumonia caused by Pneumocystis and Kaposi's sarcoma were relatively rare.
Using high pressure liquid chromatography (HPLC), the antiprogestin RU 486 and 2 of its metabolites (N-mono-demethyl RU 486 and propargyl RU 486) were measured in plasma and follicular fluid of 21 women requesting laparoscopic sterilization. Pretreatment of the women involved ovulation induction with clomiphene and HCG. RU 486 (100 mg) was administered orally and 1 hour later, blood samples were drawn. 34 hours later, at laparoscopy, samples of both blood and follicular fluid were collected. During the 34 hour period, the average plasma level of RU 486 decreased from 1.93 mcmol/1 to 0.91 mcmol/1; i.e., by approximately 50%. The latter concentration of RU 486 was not significantly different from that found in follicular fluid (0.79 mcmol/1). The monodemethyl metabolite exhibited significantly higher plasma levels (3.09 mcmol/1) than RU 486 1 hour after administration. 34 hours later, these levels had decreased to 0.92 mcmol/1; i.e., by 70%. In follicular fluid, the levels of the monodemethyl metabolite (1.76 mcmol/1) were significantly higher than those of RU 486 (0.79 mcmol/1). Because of background noise, only approximate values were established for the propargyl metabolite. These were 0.67 and 0.40 mcmol/1, respectively, in plasma and 0.42 mcmol/1 in follicular fluid. The results indicate that RU 486 and 2 of its major metabolites can readily cross the blood-follicle barrier of human preovulatory follicles. (author's)
Serum levels of pregnancy-associated endometrial alpha2-globulin (alpha2-PEG), the major secretory protein of the endometrium during the late luteal phase of the menstrual cycle and early pregnancy, were measured serially during normal menstrual cycles and in women taking various combined oral contraceptives (OCs). Pill users were also sampled on an individual basis. Endometrium from women taking the combined OC was examined immunohistochemically using a monoclonal antibody to alpha2-PEG. Levels of alpha@-PEG in the menstrual cycle sera showed consistent changes following the luteinizing hormone peak, with a greater than 3-fold increase between basal levels at midcycle and those in the late luteal phase. Serum levels of alpha@-PEG in the pill users remained at basal levels throughout the cycle, regardless of the progestogen in the formulation. This finding was noted in serial and individual samples from both monophasic and triphasic preparations. However, there was evidence of induction of alpha2-PEG production at the local endometrial level when immunohistochemical staining was employed at various stages of the pill cycle. This suggests that serum levels of alpha2-PEG may not necessarily reflect local endometrial production of the protein. These observations are discussed with reference to the proposed value of serum measurement of this protein in assessing relative progestogenic activity upon the endometrium. (author's)
Tubal desterilization through exclusive laparoscopy.
The 1st case of tubal reversal after use of the Yoon ring by way of exclusive laparoscopy is discussed. Yoon ring tubal segment excision was performed with CO2 laser and coelioscopic scissors, after mesosalpinx hemostasis by ornithine-vasopressin infiltration. Tubal anastomosis was managed with biological glue on an intraluminal guide which was pulled out after 48 hours. Follow-up hysterosalpingography 3 months later showed perfect tubal patency. This case proves that complete tubal reversal by exclusive coelioscopy is possible. At present, this procedure is restricted to only 1 tube during coelioscopic evaluation, preserving, in case of failure, the chance of microsurgery either on the contralateral tube or even on the previously operated one. The advantages of such a technique are those of coeliosurgery; no laparotomy, shortened hospitalization and minimal postoperative adhesions. Since this 1st case, others have been performed. It is still too early to appreciate the results in terms of intrauterine pregnancy. (author's)
Efficacy of the antiprogestin mifepristone (RU 486) prior to prostaglandin termination of pregnancy.
49 patients undergoing midtrimester extraamniotic prostaglandin (PG) termination of pregnancy were studied. 20 patients acted as controls and received the standard hospital regime. 29 patients received the same regime, but in addition were given a single 200 mg oral dose of the antiprogesterone, mifepristone (RU 486), 24 hours prior to PG infusion. The dose of PG required and the induction to abortion interval in the mifepristone-pretreatment group was significantly reduced. Complication rates were similar in both groups. Mifepristone is a safe and useful adjuvant therapy in midtrimester PG termination. (author's)
[Clinical experience with a gossypol-releasing IUD]
Gossypol-releasing IUDs were put on clinical trial from May 1983-August 1985. 501 users were followed for 1, 3, 6, 12, 24, and 34 months; 8 cases were lost. The clinical results showed that the cumulative continuation rate was 72.9%, expulsion rate was 20.1%, pregnancy rate was 4.6%, removal on bleeding/pain was 1.6%, and removal for other medical reasons was 0.5%. The side effects of pain and menstrual blood loss (MBL) were significantly less than that of the silicon rubber IUD, stainless steel ring, copper V IUD. MBL measured on the month before IUD insertion and 1, 3, 6, and 12 months postinsertion showed that the increase in MBL after insertion of the gossypol IUD was less than that after the insertion of other IUDs. 100% of the users were found to have decreased MBL at the 12th month of gossypol IUD use. (author's modified) (summary in ENG)
Lack of efficacy of pyrimethamine prophylaxis in pregnant Nigerian women.
New studies on the suppressive and curative effects of the anti-malarial drug pyrimethamine in pregnant women from Ilorin, Nigeria showed both ineffective prophylaxis and suppression, and parasite resistance. The drug has been used in pregnant women because of its effectiveness in suppression of asexual forms of malaria infections due to Plasmodium falciparum, its long half life and its safety. 1st a group of 88 pregnant women infected with only P falciparum received 25 mg pyrimethamine weekly for 4 weeks and parasites were counted on blood smears. 67% retained parasites by Day 7, and 60% by Day 14. All were treated with curative doses of chloroquine. A 2nd group of 71 pregnant women were first treated for malaria parasites with 2 doses of chloroquine, 25 mg/kg, in 300 mg tablets, followed by weekly pyrimethamine 25 mg for 10 weeks. All subjects and controls were given iron and folic acid supplements to take daily. 24% developed parasitemia during the 10 weeks of the study, compared to 30% of the controls. The mean intervals to development of parasitemia, and the geometric mean parasite density in blood did not differ significantly. In 6 of 10 in vitro tests of parasite resistance to pyrimethamine, parasite growth was uninhibited, compared to 22 of 23 tests for resistance to chloroquine. In vivo and in vitro tests correlated well for pyrimethamine resistance. The results also indicated that primigravidae, who are more likely to harbor malaria parasites, were also more likely to fail in parasite suppression with pyrimethamine treatment. Thus pyrimethamine is not expected to reduce incidence of premature and low birth weight infants due to malaria in this area.
[Renal lesions in patients infected with human immunodeficiency virus]
Potential involvement of the kidneys in AIDS is illustrated by the case histories of 2 patients (56-year old man from Central Africa and 64-year old man from Caribbean islands). Diagnosis of AIDS was made on the basis of immunoenzyme detection of HIV antibodies. The 1st patient had proteinuria and mild creatinuria. Ultrasonic examination indicated glomerulonephritis. The 2nd patient was seen with acute retention of urine, marked elevation of the urinary levels of urea, creatinine and potassium requiring hemodialysis. Ultrasonic examination showed normal kidneys, tumoral formation in the bladder cavity, and prostatic adenoma. These findings were indicative of acute kidney insufficiency associated with bladder tumor or prostatic adenoma. These findings indicated that the patients with AIDS can develop kidney pathology associated with immune complex disease, water-electrolyte imbalance, or nephrotoxic effects of drugs.
The clinical duration of vecuronium was measured in 2 groups of postpartum patients undergoing elective tubal ligation. 10 patients received no premedication and 10 others received ranitidine 150 mg orally the morning of surgery. The mean duration of action vecuronium was 57.2 +or- 9.9 minutes in the unmedicated patients and 54.0 +or- 12.9 minutes in the ranitidine treated patients. These values were significantly greater than the mean value for nonpregnant control patients (35.3 +or- 8.4 minutes) but indistinguishable from the mean value for cimetidine pretreated patients (63.0 +or- 17.6 minutes) reported previously. The combined results of the previous and present studies provide convincing evidence that the clinical duration of vecuronium-induced neuromuscular blockade is significantly longer in the postpartum patient and independent of cimetidine or ranitidine pretreatment. (author's)
Influence of menstrual cycle on serum cholinesterase.
This study examined whether the variability in cholinesterase (ChE) values among and within women may be attributed to a phase of the menstrual cycle and/or circulating progesterone concentration. Blood was drawn from 21 female subjects once a week for 8 weeks and analyzed for ChE activity and for progesterone concentration. Women ranged in age from 25-55 years and 5 used exogenous hormones (oral contraceptives [OCs]; estrogen supplements, or progesterone therapy); 1 woman became pregnant during the study. There was a significant positive correlation between ChE and progesterone values only for the 2 women taking OCs although there were large weekly variations within individuals (CV; 4- 32%). Age significantly affected ChE values with 36-40 years having the lowest values and 30-35 year olds the highest. This variation in serum ChE probably is due to the influence of some sex steroid but, in women, there is not a direct 1-to-1 relationship between the enzyme and progesterone. However, when interpreting ChE tests used to monitor exposure of women to pesticides, age and hormone intake must be considered in order to avoid false positive results. (author's)
A double-blind clinical trial of prostaglandins (PGs) for cervical ripening prior to vacuum aspiration for termination of early pregnancy in primigravidae was carried out in 68 patients with 6-11 weeks gestation. The patients were randomly treated with either 1.0 mg of 15- methyl-PG F2alpha methyl ester vaginal suppository or a placebo suppository. A mean cervical dilation to 6.6 mm was achieved with minimal side effects in the PG group as against 4.3 mm in the placebo group. The 15-methyl-PG F2alpha methyl ester suppository technique seems to be effective, safe, and simple in ripening the cervix for termination of early pregnancy in primigravidae. (author's)
Psychological profile of dysphoric women postabortion.
Women who identified themselves as having poorly assimilated the abortion experience were surveyed using a demographic questionnaire, the Beck Depression Inventory (BDI), and the Millon Clinical Multiaxial Inventory (MCMI). 81 surveys were returned from the sample of 150 women. 17% (n=12) of the women had had multiple abortions. Women with multiple abortions scored significantly higher on the BDI and also scored higher on the borderline personality subscales of the MCMI. Besides multiple abortions, other risk factors for postabortion dysphoria identified in this study were premorbid psychiatric illness, lack of family support, ambivalence, and feeling coerced into having an abortion. (author's)
Contraceptive practices of patients referred for colposcopy with an abnormal cervical smear.
This study examined the contraceptive practices of 100 patients referred for colposcopy because of an abnormal cervical smear. At presentation, 49% were using oral contraceptives (OCs) but 94% had taken the pill at some time. 8 of 10 patients using barrier methods relied on condoms; in at least 7 of 8 cases, an abnormal cervical smear preceded condom usage. Thus, the method of contraception used when cervical neoplasia develops may differ from the method used when the patient presents for colposcopy. Although consistent with previous studies suggesting that the incidence of cervical neoplasia is increased in women taking OCs, the risk of neoplasia is more likely to be explained by the degree of exposure of the cervix to an infectious carcinogen or to the immunosuppressive effects of seminal plasma. The authors suggest that future studies of the epidemiology and natural history of cervical neoplasia should include a detailed contraceptive history. (author's)
Report on the evaluation of Indonesia country programme.
A mission team evaluated the UNFPA supported country program in Indonesia for 4 weeks in 1988. The team found that country program staff had progressed greatly towards institution building and had sufficiently upgraded its capacity, both primary goals in the design of the program. On the other hand, the evaluators observed that the program did not sufficiently emphasize or consider women's issues, except a project for income generation among women's acceptor groups. No comprehensive record of income generating programs exists, however, and should be developed. 4 population dynamics research projects involved improving individual and institutional capability to conduct research in development and implementation of population policies. In addition, the program also supported training programs and computer equipped resource centers at 2 university centers. The team noted, however, that research and analyses should also be conducted using the available primary data, e.g., census data and annual surveys. Even though the 2 projects in strengthening family planning management and operations research have basically achieved their goals, they need to foster linkage between the 2 and to include gender issues in their designs. Indonesia has been successful in delivery of family planning services through community involvement and women's group. Nevertheless, some areas of improvement include development of a transport policy to continue and expand family planning services and investigating the potential for NORPLANT production in Indonesia. In terms of education and communication, the program has satisfactorily focused on motivating couples and youth to use contraceptives. Yet it needs to know its target audiences better so as to develop more effective materials and presentations.
Receptor study on contraceptive steroids.
Binding constants of levonorgestrel for rabbit uterus, pituitary and hypothalamus, and inhibitor constants versus progesterone, testosterone and estradiol were computed. The inhibitor constants (Ki) of norethindrone, levonorgestrel and progesterone on progesterone receptor binding in rabbit uterine cytosol were calculated: 2.3, 0.84 and 0.81 nM respectively. Inhibition of binding of levonorgestrel to uterus, pituitary and hypothalamus cytosols of estrogen-withdrawn rabbits by estradiol, testosterone and progesterone was subjected to Scatchard analysis. Levonorgestrel binds to progesterone receptors > androgen receptors > estrogen receptors in decreasing order. Binding constants (Kd) for these three tissues were 194 for uterus, 41 for hypothalamus, and 11 nM for uterus, respectively.
Antiprogestational effects of RU 486 in the rabbit uterus and human uterine endometrium.
The binding constants of RU-486 with progestogen receptors in rabbit uterus and human endometrium were estimated both at equilibrium at several temperatures, and compared to several other steroids, and to ATP-sepharose; and inhibition of induction by progesterone of estradiol dehydrogenase, estrone sulfotransferase and aromatase in human endometrium was investigated. Rabbit uterine cytosol was incubated with or without a 200-fold excess of inert steroids at 0-4, 20 and 37 degrees C.. RU-486 binding did not persist at 37 degrees. Binding of medroxyprogesterone acetate, norethindrone and progesterone was stable at 0-4 and 20 degrees. Estradiol and dehydrotestosterone moderately inhibited binding, progesterone and norethindrone strongly inhibited binding, but dexamethasone and cortisol had little effect on binding of RU-486 to rabbit progestogen receptors. RU-486 had a strong binding coefficient in human endometrium and rabbit uterus. Progesterone, norethindrone and medroxyprogesterone acetate induced a 2-4-fold increase in estradiol dehydrogenase and estrone sulfotransferase enzyme activities in proliferative, but not in secretory endometrium. Aromatase activity was stimulated in both phases. RU-486 reduced the degree of induction of all 3 enzymes in proliferative endometrium. These results suggest that RU-486 acts at or after nuclear translocation in human endometrium.
Passive immunisation of children with bovine colostrum containing antibodies to human rotavirus.
One of the main reasons for hospital admission of infants and young children is infectious diarrhea usually caused by a rotavirus infection. Infants can also acquire rotavirus in hospital neonatal and pediatric wards; the infection can also be transmitted to adult members of the family. The most protection against rotavirus is the presence of an antibody in the lumen of the small intestine. However, both adults and children can be immunized against rotavirus through the ingestion of an antibody containing a modified rotavirus. A study was conducted on 120 children, aged 3 - 15 months. The aim of the study was to produce a preparation of bovine colostrum with a high antibody titre against the 4 known human rotavirus. 65 of the children were placed in a control group, while the remaining 55 were placed in a treatment group. A colostrum was produced by introducing a vaccine containing all 4 human rotavirus into 25 pregnant Freisian cows. The colostrum was then administered to the children, orally. Stool specimens were collected before admission, during the study and after discharge. The result of the study are as follows: 14% of the control group (9 of 65) acquired rotavirus during the study; 8 of the 9 patients probably acquired the infection on admission to the hospital. None of the treatment group were infected.
As an administrative and advocacy organization, the Family Planning Association of India (FPAI) is concerned with providing family planning services and accurate information to the public. Both governmental and non-governmental agencies such as the FPAI are alarmed the country's high growth rate, presently 2% per annum; India's present population is expected to double in 35 years. At present, there is an acceptance of family planning, however, it is up to the FPAI to encourage people to utilize family planning. The focus of the FPAI is to increase an individual's accessibility to family planning clinics. In 1988, the FPAI provided family planning services to a total of 216,752 new acceptors. Though a majority of FPAI clinics can be found in urban areas, the organization has worked to extend its service reach to a number of rural areas. In addition to improving its service capabilities, surveys on the FPAI showed an overwhelming satisfaction with the services provided by the clinics. Education of the Indian people has included focusing on encouraging male participation in family planning, promotion of birth spacing among young Indian couples, training community volunteers to work in the rural areas, and providing programs and projects in the communities and schools to reach young students and/or other Indians unsure of family planning. In addition to its other services, the FPAI has provided consultation services to other health-oriented NGO's, field training for its community volunteers, medical training for Indian doctors and nurses, management training for FPAI staff, and research and evaluation of the impact of family planning on India. The president of the FPAI has attended numerous international conferences and received national and international awards for the FPAI's outstanding service.
Annual report, July 1987 - June 1988.
The Taiwan Institute of Family Planning enters the 2nd year of its "2nd Intensive Family Planning 4-year Plan". The aim of the Institute for the 1988-89 year is to provide contraceptive services to the public, improve public education on family planning and contraception, improve accessibility and health care delivery, increase and improve research and evaluation of population growth and family planning acceptance among the population. Between the years 1987-88, 664,397 family units were recruited for family planning. IUDs had an acceptance rate of 54% of the total acceptors, the Pill and condoms were 2nd and 3rd choice, respectively. The process of sterilization has begun to gain among the Taiwanese, with vasectomies and tubal ligation being the most widely used form of sterilization. In rural areas, there has been a greater accessibility to family planning centers with the introduction of mobile clinics and supply depots. Couples in remote areas are encouraged to accept sterilization and incentives are paid to voluntary workers who refer couples to family planning centers. The government of Taiwan has worked to improve education by providing pamphlets and booklets to newlyweds and physicians, telephone services, family planning programs in work areas, schools, and the military, advertisements in various forms of mass communication, and special activities and educational material for those who are unable (housewives) to gain the information elsewhere. The government has also set up training programs to help in the improvement of health care delivery. This past year the Institute set up a population research studies in an attempt to understand the reasons for an increase in induced abortions and means to control adult diseases.
Improving nutrition in India. Policies and programs and their impact.
There have been a number of studies done on malnutrition in India. However, few if any have studied the distribution of nutrition levels by region, age, sex and/or social status. Nutritional programs in India have been greatly influenced by studies of Indian nutrition levels at a nation-level or state-level. The results have been a 10% fall in poverty. However, to have a full impact on poverty in India, it is necessary to understand all facets of Indian society. Regionally and socially, families influenced by the "caste" and tribes system have been found to have a lower caloric intake than regions not influenced by these systems. Despite the implementation of government nutrition programs, there has been no increase in the caloric intake of the ultra- poor. However, some increase was shown in regions were there was greater accessibility to publicly distributed food, quality of food, and economic performance of the state. In the case of children, data on prosperous states showed that 1/2 of the children were suffering from nutritional deficiency; in poorer regions, the rate was higher. In India, it is a common practice that the males of the household eat before females; the results are a higher rate of nutritional deficiency among females, especially among very young girls. 2 approaches have been advocated in dealing with improving nutrition levels: the Applied Nutrition Program and the Public Distribution System. The Applied Nutrition Program (APN), implemented during the 1950's worked to provide food to school-aged children and pregnant mothers. An updated program of APN can be found in the Integrated Child Development Program (IGPD) which works to feed the more vulnerable groups of India. The Public Distribution System works to improve households access to food--at reduced prices.
Approaches to reducing infant mortality in southern regions of USSR are outlined. Middle Asia and Kazakhstan comprise 16.7% of the USSR population; the birth rate in this region is 34-39/1000, and the birth interval is < 2 years (often, < 1 year). Infant mortality rate is > 25/1000 births; more than 46% of children die during the 1st year of life. In the structure of infant mortality, infections and respiratory diseases are dominant. The peak of infant morality occurs during the summer (July-September). Special surveys indicated an unsatisfactory state of health of pregnant women associated with nutritional deficiency, observance of certain religious customs, and occupational exposure to agricultural chemicals. The adopted program for the regions with high infant mortality consists of the following priority measures: family planning and birth control; improvement of the health of women of child-bearing age; nutrition of pregnant women; breast feeding for mothers with young children; strict adherence to the labor laws for working women; improvement of the social and legislative assistance to a family; improvement of the system of outpatient care facilities for large families; development of a system of emergency care; carrying out social, hygienic and medical measures of control of intestinal and other hospital infections; drastic changes in the methods and style of educational campaign; campaign against harmful customs; development of the system of medical genetic care and prenatal diagnosis; improvement of the training of medical personnel.
The Indonesian Ministry of Health and its Diarrheal Disease Control Program (CDD), in cooperation with the US Agency for International Development, contracted a US firm to develop and administer a training program for computerized management information systems. The goals are to use a 2 phase approach consisting of training program development and then field implementation. The objectives of the training phase are to assess computer training requirements of CDD at the central and provincial level, to develop courses, and to create practical application exercises. In phase 2, the objectives are to train the staffs of the central and provincial CDD offices, to use application exercises to apply the training, and to evaluate the computer literacy levels and make recommendations as to future information systems for the CDD. The course will be 3 weeks long and focus on an introduction to the IBM PC, DOS/Norton, maintenance, a data collection program, data input, and a computer workshop. The course will train staff to operate a microcomputer system, how to use PC-DOS and Norton Utilities, and how to perform preventive maintenance. Also, they will learn to use a data collection program, to classify and format data for input, to input data, do data modification, print verification reports, and back up and transfer data to disk. The consultants will evaluate each trainee and give a report on their progress. They will make recommendations on the future requirements of the CDD, on its information needs, computer usage, and personnel development.
AIDS education: evolving approaches.
Despite a proliferation educational initiatives in the campaign to prevent the spread of AIDS, there has been little systematic evaluation of programs to produce high-risk behaviors or communication across scientific disciplines and among researchers and community organizers. It is clear, however, that understanding of the modes of transmission, attitudes, beliefs, and motivations in high-risk groups is as important as scientific knowledge about the AIDS virus itself. This type of "insider" knowledge can be gained only through reliance on local sources of information. Some of the most effective campaigns have begun on a pragmatic, small-scale level, integrating AIDS prevention messages into existing networks. In Nairobi, prostitutes have become persuaded to use condoms through appeals to their commitment to their children and their need to continue to provide economic support to other dependent family members. A community group in California conducts AIDS education among poor migrant Mexican women in laundromats, where the women have time to talk away from the inhibiting influence of their husbands. The aversion-type of educational model 1st used in AIDS educational campaigns, with its emphasis on creating a fear of AIDS and a sense of vulnerability to it, has been replaced by models based on positive reinforcement and social support for behavioral changes. Campaigns in the gay community that stress the need to "love carefully" out os a sense of individual responsibility and community are examples of this more positive approach. Respect and self-esteem, a sense of family and community responsibility, and a belief in nondiscrimination against those with AIDS have now emerged as the building blocks of effective AIDS prevention programs.
Transplanting fetal tissue: how ethics and emotions interact.
The matter of the use of fetal tissue has aroused considerable controversy and calls for more dialogue among legislators, scientific researchers, and ethicists. In terms of the transplant of human organs, there is public confidence that the legal system and the ethics of the medical profession will combine to protect against abuse. The emotionality that surrounds fetal tissue transplants reflects divided opinion on the issue of induced abortion. There are, moreover, specific concerns regarding the specific abortion procedure to be used (dilatation and evacuation is the safest abortion method for the pregnant woman, but the most damaging in terms of fetal tissue conservation), the right of the mother to donate her fetus, and the definition of death, particularly in the case of anencephalic fetuses. A nonviable fetus may survive for a time ex utero while transplantable material deteriorates. Regulations have not yet been developed to provide guidelines for such situations. Others are concerned that the need for fetal tissue, as in the case of Parkinson's disease, will create an industry much like surrogate motherhood in which poor women will be exploited to bear fetuses for the wealthy. While pro-abortion proponents are able to justify their views on the grounds that a fetus in pre-human, the fact that fetal tissue can be used to benefit a living person makes this central argument more difficult to maintain. Given the challenges that fetal tissue transplantation poses to concepts of life, personhood, and protection of young life, it is certain to remain a controversial and emotionally laden issue in the years ahead.
CMS challenged on (pro-choice) Resolution 23P [letter]
In 1989 the Colorado Medical Society voted (Resolution 23P) to oppose interference by federal and state government in a woman's decision to undergo an abortion. The author, a Colorado physician, makes it clear that this policy is not reflective of his position and reflects the increasingly pragmatic, utilitarian, and self-serving perspective of the medical profession. Abortion, fetal tissue transplantation, infanticide, living will, assisted suicide, and euthanasia have created deep divisions in perceptions of the origins and meaning of human life. More reflection is necessary before the medical profession issues policy statements on these complex issues. Support for abortion sets a dangerous precedent. If the life of the unborn can be terminated because it is unwanted or the quality of its life is diminished, this same logic can be extended to justify medical murder at other stages of human life. Moreover, the logical implication of regarding abortion as a medical intervention is to define pregnancy as a disease and the fetus as a parasite.
Feces obtained from 1163 children (including 66 newborns) were analyzed in parallel for the presence of rotavirus particles using 2 enzyme- linked immunosorbent assay kits. The kits had been formulated by the WHO Collaborating Center for Reference and Research on Rotavirus (WHO- ELISA kit) and by DAKOPATTS (DAKO-ELISA kit) to be suitable for use in laboratories in developing countries. These kits were evaluated in laboratories in Burma, Chile, India, Mexico, Pakistan, Sri Lanka, and the United Kingdom. Comparison of results obtained indicated that the DAKO-ELISA had an overall sensitivity of 97% and a specificity of 97% relative to the WHO-ELISA. In individual laboratories, the DAKO-ELISA (K349) kit had a sensitivity in the 90-100% range and a specificity of 85-100%. The kit showed a sensitivity of 100% and a specificity of 98% in assays on feces obtained from newborns. The authors conclude that the DAKO-ELISA is as sensitive and specific as the WHO-ELISA for the detection of rotavirus antigen in feces. (author's)
Antifertility and hormonal properties of certain carotene sesquiterpenes of Ferula jaeschkeana.
7 terpenes were isolated from rhizomes of the plant Ferula jaeschkeana Vatke, and tested for antifertility, estrogenic and anti-estrogenic activity and estrogen receptor binding activity in rats. The plant is related to Ferula assafoetida, the gum of which has wide use in traditional medicine, including a reputation as an emmenagogue, abortifacient and uterine stimulant. The sesquiterpenes were isolated by methanol extraction and silicon dioxide column chromatography. Compounds were administered orally, by macerating in gum acacia and suspending in distilled water, and compared to ethinyl estradiol. 3 of 7 carotane sesquiterpenes prevented pregnancy in rats when given orally on Days 1-7, and 1 compound was effective in a single oral dose on Day 1, at 5 mg/kg. The 3 compounds had estrogenic, but not anti- estrogenic, effects in ovariectomized immature rats. In a competitive protein binding assay using dextran coated charcoal, the 3 compounds exhibited 5.75%, 0.75% and 0.01% relative binding affinity for immature rat uterine cytosol estrogen receptors. Since only 1 compound showed both in vitro binding and estrogenic activity, the others probably were metabolized to active substances. Possibly the estrogenic activity of these compounds explains their anti-implantational activity.
The authors measured levels of cow's milk-specific (CM) antibodies of immunoglobulin classes G, A, and M by enzyme-linked immunosorbent assay in plasma of 198 healthy infants; a variable number of samples taken at birth and at age 2, 4, 6, 9, 12, and 28 months were available (altogether 765 samples). The rise in the level of IgG CM antibodies was highest and most rapid in infants exposed to CM formula before the age 1 month. The level fell by 9 months, but rose again by 12 months. This 2nd rise was attributable to the introduction of dairy milk. Partially breastfed and fully weaned infants had similar levels of IgG CM antibodies. The levels of these antibodies was unaffected by the infants' own atopy, their heredity for atopy, and the umbilical serum level of IgG CM antibodies. IgA and IgM CM antibodies were absent at birth. Their levels increased similarly in exclusively breastfed infants and infants fed CM formula. The authors conclude that plasma IgG antibodies to cow's milk are increased by early weaning and by consumption of unmodified cow's milk. Production of plasma IgA and IgM antibodies to cow's milk is stimulated even during exclusive breastfeeding. (author's)
The course of human papilloma virus infections is unpredictable. Some cervical lesions regress, some persist, and some evolve toward cancer in situ. The factors governing their course remain unknown. 61 women with cervical lesions caused by human papilloma virus infections were monitored to assess the possible role of oral contraceptive use in the progression or regression of their lesions. 30 of the women used combined OCs, and 31 used another contraceptive method or no method. The women were all seen at a hospital in Grenoble, France, or in the office of 1 of the authors. After an initial Pap smear, colposcopy, and biopsy, each woman was followed for at least 6 months without treatment, after which the development of the lesions was assessed through a 2nd Pap smear, colposcopy, and in 36 cases a 2nd biopsy. During the 6-18 months of follow-up, the contraceptive method was not changed. 4 women in the OC group used standard dose and the rest used low-dose formulations. 10 women in the control group used IUDs, 4 were sterilized, 3 used condoms, 6 used spermicides, and 8 used no method. The average age was 27.1 for the OC group and 1.29 for the control group. The 2 groups were similar in average age at 1st menstruation, age at 1st intercourse, smoking, and for the other characteristics studied. There was no statistically significant difference in the development of lesions between the OC group and the control group. Lesions regressed in 30-35% of cases, persisted in 46.6-51.2%, and became worse in 12.9-23.3%. None of the 4 women using standard dose OCs had a regression of their lesions. Use of condoms or spermicides did not appear to favor regression of lesions. Among 7 OC users whose lesions became worse, 5 were smokers and the smoking status of 1 was unknown.
[The vascular risk of oral contraceptives: reality and mechanism. I. Risk evaluation]
The vascular risk of oral contraceptives (OCs) was not discovered until specialists noted a sudden increase in vascular accidents that had previously been rare in healthy young women. The risks were confirmed by largescale epidemiological studies in Great Britain and the US. Relative risk is the ratio of the rate of complications of women using OCs to that of nonusers. The excess risk or the number of cases attributable to OCs is the difference between the number of cases observed in the 2 groups and is usually expressed in terms of 100,000 woman-years. Estimates of risks may be obtained by case-control or retrospective studies using hospital records to compare OC use among women with vascular complications to those without. Prospective studies follow population groups using and not using OCs to compare their development of complications over time. Case control studies allow a sufficient number of cases to be assembled in a short time to calculate relative risk, but they provide no data on absolute risk and are subject to biases inherent in the mode of recruitment of sick persons in a program not designed for the purpose. Prospective studies permit assessment of both relative and absolute risks but they are long and costly since they deal with infrequent events. The risk of OCs can also be evaluated by assessing the evolution of female mortality over the years. In France and the US, mortality from pregnancy and related causes has been in decline since 1950, but the decline in obstetrical causes has been compensated by an increase in deaths attributable to contraception, and especially OCs. Cardiovascular complications are responsible for most of the increased mortality in OC users. The mortality risk differs according to the location of the complication. Venous thromboses and pulmonary emboli are not significantly associated with high mortality in OC users, but myocardial infarcts are about 4 times more frequent in OC users and half are fatal. The overall frequency of infarcts attributable OCs is estimated at 67/100,000 woman- years after age 35. Cerebral vascular accidents have a relative risk of 2 for ischemic accidents and 4-6.5 for subarachnoid hemorrhages. The number of deaths from cerebral vascular accidents attributable to OCs is estimated at 37/100,000 woman years. Few studies are available on morbidity due to OCs. The most frequent complications are superficial or deep venous thromboses, with or without pulmonary emboli. Their relative risk varies from 4-11 according to the study. Morbidity risks for thrombosis and other complications are increased by presence of predisposing factors. Beyond divergences related to methodology, the results of epidemiological studies have tended in the same direction and the risks established during the 1970s have persisted for the most part despite use of lower dose formulations.
AIDS and the doctors of death. An inquiry into the origin of the AIDS epidemic.
A physician and cancer researcher challenges the "official" view of the medical establishment that AIDS is a result of a new virus that emerged in Central Africa in the 1950s. His skepticism that an infectious agent could be capable of attacking only 1 small segment of society, such as young white homosexual men in Manhattan and San Francisco--led him to the theory that AIDS was a man-made cancer deliberately introduced into stigmatized communities as a variant of germ warfare. The researcher's perspective was developed through conversations with another physician, Robert Strecker, who maintained that the "new" AIDS virus was bioengineered by splicing or mixing together 2 different viruses, most likely visna virus and bovine leukemia virus. According to Strecker, this recombined virus was systematically introduced into the homosexual population through experimental hepatitis B vaccine trials conducted in New York City in the 1970s among gay volunteers. Within a decade, the majority of men in these trials had died of AIDS. Similar vaccine trials were conducted among volunteers recruited from sexually transmitted disease clinics for gay men in San Francisco, Los Angeles, Denver, St Louis, and Chicago. Understanding of this phenomenon is linked to knowledge of the politics of cancer, the medical establishment, and AIDS. A political view of the epidemic suggests that AIDS is the product of a racist, homophobic society that has used science to create socially acceptable means of the mass extermination of undesirable social groupings. Moreover, the author posits, as long as the research establishment and technical journals remain house organs of this politicized science, the origins and cure for the AIDS epidemic will remain obscured.
Nausea, vomiting and the efficacy of post-coital contraception. Reply [letter]
Although it is possible that nausea and vomiting after PC4 implies a high serum estrogen level, there is no scientific evidence to substantiate this idea. Indeed, there have been no studies to determine whether the nausea experienced by some women, who take the combined pill for regular contraception, results from high estrogen levels or enhanced end-organ sensitivity to estrogen. Incidentally, at the Margaret Pyke Center we do not routinely provide anti-emetics with the Yuzpe method because they are relatively ineffective against estrogen-induced nausea, and are potentially teratogenic should the method fail. If a patient informed me that she had vomited within 2 hours of taking PC4 and I considered her risk of pregnancy to be high, I would provide her with 2 further tablets or consider inserting a coil. (full text)
[Professional violations of the law by paramedical personnel and their prevention (2)]
Criminal offenses committed by allied medical personnel in USSR are briefly reviewed with special emphasis on criminal abortions and theft of narcotics. According to Section 116 of the Criminal Code of the Russian Soviet Federative Socialist Republic (RSFSR), abortion can be carried out only by persons who have a special medical education (physicians); abortion performed by allied personnel is punishable by imprisonment for up to 2 years. The only exception to this law is a real danger to the life of a pregnant woman. The accused has to have an intent to perform an illegal abortion and has to be paid. One of the causes of illegal activity of allied medical personnel is insufficient knowledge of the existing law. Continuous education of allied medical personnel, assurance of pregnant women of the confidentiality of legal abortion, and improvement of health education among women (especially in rural areas) would reduce the incidence of criminal abortions performed by allied medical personnel. Criminal Code provides responsibility for the illegal manufacturing, purchasing, storage, transportation and selling of narcotic substances. The theft of narcotics by medical personnel is punishable by imprisonment of up to 10-15 years.
[The role of the midwife in decreasing the number of abortions]
Midwives do not play an apparent role in family planning and in avoiding unwanted pregnancies. Nevertheless, they should pay more attention to this problem, primarily in the case of women who are less knowledgeable about family planning. Induced abortion should not be a means of family planning since it has many harmful consequences. Different means of contraception have been known for centuries, but the social movement for ""birth control"" dates back only to the 19th century. The International Society of Family Planning was organized in the 1950s, while the idea of birth control in Poland arose only in 1956. Before the amendment on abortion was added to the Polish constitution, the annual number of illegal abortions was about 300,000. In the era of legal abortions it is the task of physicians and midwives to propagate other means of family planning. Induced abortion results in complications in 2%-5% when carried out in the first 6-7 weeks of pregnancy, in 5%-10% in weeks 8-12 and in 20% after the 13th week. One of the most frequent complications is psychogenic. Among the women involved in a study conducted by Kokoszka, 104 out of a total of 500 women reported for a follow-up examination. Disturbance in orgasm occurred in 45 cases, decrease of sexual desire in 48 cases, reduction of sexual drive in 73 cases, and nervousness in 14 cases. The risks of induced abortion are ranked as 1) sexual nervousness 2) clinically diagnosable pain 3) general and organic nervousness. W. Poltawska adds the following. Psychological complications: depression and feelings of guilt, aggression and auto aggression, and prolonged changes in personality.
Vaccine for control of fertility.
A review of the prospects for use of vaccines in contraception covers immunization against sperm, emphasizes chorionic gonadotropin, and touches on gonadotropin releasing hormone. Sperm are programmed as non-self, and animals can be rendered aspermic by breaking the epididymal barrier or by local injection of BCG. This technique is effective in management of farm animals such as bulls and buffalos to induce temporary infertility. In contrast, most reproductive hormones are not naturally immunogenic, and several cross react with other hormones or tissues. Another result of recent trials with beta-hCG is that less than 100% of immunized human subjects respond with acceptable titers to block fertility, possibly because of genetic differences. Use of polyvalent vaccines and carriers may improve performance in this case. Although clinical trials have not reached the level of testing for efficacy, theoretically hCG vaccines present the obstacle of requiring a very high affinity to overcome the high binding coefficient of the hormone for its receptor. Specificity has also been a problem for hCG vaccines, since intact hCG produces 10-50% cross-reaction with hLH. Recently it was reported that the carboxy-terminal peptide cross reacts with pancreatic tissue, but no toxic effects have appeared in long-term primate studies with the peptide. Three types of hCG vaccines have been subjected to initial Phase 1 trials with acceptable results in most cases. Vaccines against semi-synthetic GnRH may possibly find therapeutic uses in treatment of prostate or breast cancer.
Oral contraceptives: a reassessment.
The risks and benefits of the newer oral contraceptives are evaluated, considering cancer, teratogenicity, drug interactions, cardiovascular risks, and carbohydrate metabolism. Oral contraceptives confer the lowest mortality risk of all contraceptives, except sexual abstinence, in all women under 30 and in nonsmokers through age 40 in developed countries. In less developed countries where maternal mortality can be as high as 5-10%, the risks of even nonmedically supervised oral contraceptives are dwarfed. The pill protects against ovarian cancer even after the pill is discontinued because it suppresses ovulation, and endometrial cancer because it blocks estrogen receptors. The relationship of oral contraception to breast cancer is still in dispute, but no good evidence exists for increased risk, especially with new low- dose pills. There may be a slightly increased risk of cervical cancer, although it is difficult to separate out other risk factors co-existing in pill users, such as earlier sexarche, more partners and more frequent screening. The incidence of pelvic inflammatory disease, functional ovarian cysts and ectopic pregnancy is reduced by pills. There is only 1 report of increased incidence of congenital heart disease in infants whose mothers took pills during pregnancy. Drug interactions are common, and must be managed by the physician. Among currently popular pills, only the norgestrel and levonorgestrel-containing multiphasic pills are said to decrease HDL2 and impair glucose tolerance, because they are androgenic enough to overcome the low dose of estrogen.
[Epidemiology of infections caused by human immunodeficiency viruses HIV-1 and HIV-2 in Ivory Coast]
A study of antibodies to HIV1 and HIV2 has been performed among selected groups in the Ivory Coast from January-December 1987. In total, 2578 serum samples were examined. A seropositivity to HIV1 and/or HIV2 was observed in the following groups: 32 (2.4%) of 1334 healthy subjects among the general population from 5 different areas; in 9 (3.6%) of 246 pregnant women; in 58 (12.3%) of 471 blood donors; in 72 (34.3%) of 210 female prostitutes; in 23 (35.3%) of 65 patients with sexually transmitted diseases; in 21 (35.6%) patients with chronic renal insufficiency; and in 98 (50.7%) patients with severe pulmonary tuberculosis. Among the 313 HIV antibodies carriers, the frequency of HIV1 infection (6.7%) was higher than HIV2 infection (2%). However, 3.4% had a double seropositivity to both HIV1 and HIV2. (author's modified) (summary in ENG)
[AIDS in the Republic of Niger (letter)]
The scope of the AIDS epidemic in Africa is known and its consequences are predictable. The Sahel regions seem less affected than those of Central Africa but the epidemiologic data remains fragmentary. The serologic markers of HIV infection have been assessed at Niamey, Niger, since early 1987 by the immunoenzymatic method (ELISA, Elavia Pasteur) and confirmed by the Western blot technique. Of 39 AIDS patients, 5 were children: 1 boy of 10, a homozygotic sickle cell patient who had undergone multiple transfusions, and 4 infants (3 boys age 2, 4, and 10 months and 1 girl of 4 months) all born to mothers with AIDS. AMong 34 adults, 25 (73.5%) were men (average age 39 years) and 9 (26.5%) were women (average age 29 years). 11 of the 39 dies during hospitalization. The Western blot technique applied to 30 of the 39 disclosed HIV-1 infections in 17 cases, HIV-2 in 9 cases, and HIV 1 and 2 in 4 cases. The 4 with both infections died less than 1 month after hospitalization. All patients denied drug addiction and homosexuality. 2 women reported they were prostitutes. But 26 of the patients including 25 men reported they had had extended stays in neighboring countries of West Africa (especially Ivory Coast). HIV infection thus exists in the Niger Republic. The gravity of the clinical signs confirms the diagnosis of AIDS and its often advanced character. In the context of Niger, the unspeakable taboos. It is likely that occasional, unreported prostitution plays a role. The risk of contamination during a prolonged stay in a neighboring region is not manifestly perceived by the patients, who do not hesitate to report their moves. This explains the strong male predominance; it is almost exclusively males who leave Niger to seek employment in an economically active region. As to the risk of accidental transmission during transfusion, it has been considerably reduced by the systematic screening of the blood supply. (full text)
Infertility represents a major public health problem in sub-Saharan Africa. In parts of Cameroon, Gabon, Zaire, and the Central African Republic, 20-40% of women aged 50 years and over are childless. Tubal damage is a major factor in female infertility in this region. Laparoscopic examination of a series of Kenyan women revealed that tubal occlusion was the main cause of primary and secondary infertility in 73%. Disorders of ovulation contribute an additional 20-30% of infertility, while coital problems account for 3-4%. Gonococcal infection is the key etiologic factor in tubal damage in female infertility patients and may also play an important role in male infertility. There is recent evidence, however, that infection from other micro-organisms, most notably Chlamydia, is increasing in significance as a result of its association with pelvic inflammatory disease. Postabortal sepsis and puerperal pelvic infections represent additional causes of fallopian tube damage. It has been estimated that a gynecologist working in a public institution in sub-Saharan Africa may spend up to 70% of his time managing the infertile couples. Moreover, the expensive diagnostic procedures and treatments involved in such cases are diverting health funds from areas such as child health and family planning. Thus, it is important to plan health education campaigns and condom use promotion to prevent the sexually transmitted diseases that are responsible for most infertility.
Transformation of hepatic cell adenoma to hepatocellular carcinoma due to oral contraceptive use.
Unlike the proven causal association between oral contraceptive (OC) use and hepatic cell adenoma, the link between OCs and hepatocellular carcinoma remains speculative. The case history of a 53-year-old US woman suggests, however, that hepatic cell adenomas may transform into hepatocellular carcinoma. The patient, who had used Ovral continuously since 1966, presented in 1985 with vague abdominal pain and a palpable right upper quadrant mass. Computed tomography revealed a 12 x 8 cm mass in the right hepatic lobe and 2 small lesions in the left lobe. Serum alpha-fetoprotein and ferritin levels were normal and tests for hepatitis B were negative. A needle biopsy of the right lobe mass indicated benign hepatic adenoma. OC use was discontinued and the patient was examined at bimonthly intervals. Although she continued to report vague pain, there were no significant changes in radiologic findings or levels of alpha-fetoprotein over the next 18 months. At the 18-month follow-up visit, the alpha-fetoprotein level showed an increase to 227 mcg/L and had risen to 2300 mcg/L by the 30-month follow-up visit. At this time, computed tomography showed slight enlargement of the right lobe mass and inhomogeneity, while biopsy revealed sclerosing hepatocellular carcinoma. This is the 3rd case reported in the literature in which there is evidence of a transformation of hepatic cell adenomas into hepatocellular carcinoma in longterm OC users. Thus, the premalignant potential of hepatic cell carcinomas in OC users should be considered by physicians who follow such cases.
Sterilization: Canadian choices.
Tubal ligation, which requires the use of general anesthesia and hospitalization, is more costly to the health care system than vasectomy and also associated with a higher rate of major complications. This reality suggests that policy makers may want to take steps to generate greater acceptance for vasectomy. To gain information on current trends in vasectomy and tubal ligation, a questionnaire was sent to Canada's 10 provincial health care organizations on the number and type of sterilization procedures performed in 1976-88. During the study period, the rates of tubal ligation surpassed those for vasectomy in all provinces except Quebec in 1986 and Newfoundland from 1982-86. There were indications, however, that vasectomy is steadily gaining in acceptance. The rate of tubal ligation declined from 18.1/1000 in 1976 to 13.1/1000 in 1988 while that for vasectomy increased from 6.9/1000 to 9.6/1000 in the same period. In 1986, Quebec's tubal ligation rate dropped to intersect with the rising rate of vasectomy, a pattern that can be expected in other provinces in the years ahead. Another indication for the promotion of vasectomy is the cost and safety of sterilization reversal. In Vancouver in 1986, the total cost of vasovasostomy was $1500-2500 compared with $2500-3500 for reversal of tubal ligation. Choice-oriented tubal ligation still constitutes a perhaps needlessly high proportion of sterilization procedures in Canada and other countries. Reasons for this include women's stronger motivation to avoid unwanted pregnancy, the greater apprehensiveness on the part of men about procedures involving the genital organs, and the desire for a safe, effective, and convenient contraceptive methods that don't require reliance upon a male partner.
Micro and female condoms stalled in move to market.
A male microcondom and a latex vaginal pouch received clearance for marketing from the US Food and Drug Administration (FDA) in 1988 under a regulation that permits products "substantially equivalent" to those already on the market to bypass standard safety and efficacy trails. However, the National Women's Health Network then petitioned the FDA to rescind this clearance pending proof of pregnancy prevention and protection against sexually transmitted diseases. At a special hearing in March 1989, an FDA advisory committee agreed with the National Women's Health Network that the products were in fact class 3 devices requiring full premarket testing. The male microcondom fits over the head of the penis and is held in place by adhesive strips. The women's coalition has argued that it is misleading to term such a device a condom in that it does not have the proven ability to prevent pregnancy and sexually transmitted diseases associated with traditional male condoms. The National Women's Health Network is more positive about the potential contribution of the vaginal pouch, which covers the entire genital and rectal area with a latex panty that has a pouch that fits into the vaginas. The FDA has not made a final determination on this matter, but is expected to agree with its advisory committee that these barrier methods do not fall under the "substantially equivalent" rubric. By law, the manufacturers could market these 2 products, but would have to submit clinical data within 30 months.
Promoting condoms for AIDS prevention: ten lessons learned from family planning programs.
The 20-years-plus experience of family planning programs in promoting acceptance and increased effective use of condoms offers 20 lessons for programs aimed at preventing the spread of AIDS: 1) in areas where family planning programs are not well established, only a minority of women of reproductive age will be familiar with condoms and basic information about their benefits must be provided; 2) given widespread incorrect use of condom (e.g., not using a condom with every act of intercourse or putting on the condom after intercourse has started), careful instructions in proper condom use are necessary; 3) condom acceptors must be provided with motivational counseling and support during the 1st month after acceptance, when drop-out rates are highest; 4) although condom breakage occurs at a rate under 2%, clients should be warned of this possibility and have extra supplies available; 5) positive attitudes on the part of health care providers toward condom use have a positive effect on condom acceptance, satisfaction, and continuing use; 6) condom sales increase when this method is easy to find and purchase; 7) since men are the primary decision makers about family planning and make most condom purchases in developing countries, AIDS programs should direct promotional campaigns directly at men; 8) communication and shared responsibility between sexual partners serves to enhance effective condom use; 9) the mass media plays an essential role in educating potential condom users and changing negative attitudes; and 10) a modest charge for condoms does not deter use, except among the very poor, and in some cases actually increases demand.
First amendment challenges to the use of mandatory student fees to help fund student abortions.
The use of mandatory student registration fees to fund abortions at public colleges and universities has met numerous challenges on the basis of 1st amendment rights to freedom of religion and association. Students have argued that this practice forces them to subsidize, and thereby condone, a position on abortion that may be contrary to their personal beliefs. School officials, on the other hand, have maintained that this student health service is religiously neutral and consistent with educational objectives. An analysis of recent federal court decisions suggests that the challenges of anti-abortion student activists are becoming increasingly successful. The students' assertion that the fee program infringes on their freedom of association has some basis in the US Supreme Court Abood v Detroit Board of Education decision, which recognized that requiring nonunion teachers to give financial support to political causes with which they disagreed violated their constitutional right to free association. To date, however, the Abood decision has not been expanded beyond the political arena. Other Supreme Court decisions--Sherbert, Zorach, and Yoder, for example--have noted the potential conflict between following one's religious beliefs or giving up those beliefs in order to qualify for a public benefit and accommodated the plaintiffs with relief from such coercion. The ideal alternative would be to balance the need to operate schools for the benefit of the entire student body and the 1st amendment guarantees of anti-abortion students. 1 possibility is to allow students to withhold the portion of their registration fee that is devoted to health services and disqualify them from using that service; another is to guarantee that abortion services will be funded from sources other than student registration fees.
Re: "Potential for Bias in Case-Control Studies of Oral Contraceptives and Breast Cancer" [letter]
A reassessment of 6 statistical studies that examined the association between use of oral contraceptives before 1st term pregnancy and breast cancer shows a definite trend toward increasing risk with duration of use. The 6 studies were conducted in the U.S., Sweden, New Zealand and England. 2 of the studies showed a significant, consistent increasing risk with duration of use. All compared users to never-users. 3 of the studies that looked at pill use before first pregnancy indicated significant increasing trends with duration of use. Some of these studies included controls that had not used before 1st pregnancy, but had used pills afterward. The U.S. study had never-users as controls. The highest relative risk, from Sweden, appeared in women less than 40 years of age. The most distressing finding was the increasing degree of risk over time, from the 1970s to cases diagnosed in the 1980s.
Clinical use of oral contraceptives administered vaginally: a case report.
Effectiveness in cycle control and plasma steroid levels were monitored in a woman with promyelocytic leukemia being treated with chemotherapy, given 2 combined oral contraceptives given vaginally. The 18-year old woman had been taking an oral contraceptive containing 50 mcg mestranol and 1 mg norethindrone during the 3 months since she began treatment for leukemia. After recurrence of leukemia, she developed acute hemorrhagic mucocitis and inability to swallow while on cytosine arabinoside, daunorubicin and etoposide. She was administered 2 of the same oral contraceptives daily per vagina, and her withdrawal bleeding continued to be suppressed for 6 weeks while receiving transfusions for aplastic marrow. Compared to 10 normal women taking 30 mcg ethinyl estradiol and 100 mcg norethindrone, the patient's plasma level of radioimmunoassayed ethinyl estradiol was comparable as to concentration and peak time. Her level of norethindrone was lower, with the highest level measured at 12 hours, compared to a peak at 2 hours in women taking one pill orally.
Oral contraceptives, breast cancer, and lactation [letter]
The correspondent is displeased with the choice of confounders used in the recent British case-control study on oral contraceptive use and breast cancer, especially the use of "ever" or "never" breastfeeding. In young women, many variables have been shown to be associated with risk of breast cancer, such as timing of pregnancy, duration of breastfeeding, method of ending pregnancies, height, weight at puberty, exercise, social class, education, religion, tubal ligation, pelvic surgery, contraceptive use, and irregular periods. Long lifetime duration of breastfeeding seems to protect against breast cancer, while brief breastfeeding appears to increase risk. Since women desiring oral contraception are discouraged from breastfeeding and given lactation suppressants, while those wishing to breastfeed are discouraged from taking combined pills, we might suspect a spurious increase in risk of breast cancer in longtime combined, but not progestin only, pill users.
The benefits of combined oral contraceptives.
The benefits of combined oral contraceptives are put into perspective, considering their effectiveness as a contraceptive, actual risks for breast, ovarian, endometrial and cervical cancer, and effects of reproductive and other body systems. Combined oral contraceptives are the best contraceptives available except for injectable progestogens, therefore they an reduce the risk of maternal mortality by at least 5 in nonsmoking western women, or over 100 in developing countries. No data are available on mortality risk of the presumed safer low-dose pills. Pills reduce ectopic pregnancy to virtually nil. They decrease the risk of endometrial cancer, and of ovarian cancer for up to 15 years after use. Although they protect against benign breast disease, both fibrocystic disease and fibroadenoma, which are risk factors for breast cancer, it is unsettled whether pills affect breast cancer incidence. Cervical cancer risk may be slightly higher. Functional ovarian cysts requiring surgery are cut about 10-fold; corpus luteum and follicular cysts are also reduced. Fibroids are decreased in proportion to duration of use. Pelvic inflammatory disease rates fall 50% during use. Chlamydial infections have not fallen in pill users, but it is not known whether sexual activity is a factor. Combined pills cut abnormal uterine bleeding by about half, reduce the incidence of iron deficiency anemia and of premenstrual tension. Seizures related to menses also are controlled. Some studies find a reduction in rheumatoid arthritis. Most of the cardiovascular complications of pills are thought to be dose related. Since today's pills contain approximately the same dose as a whole cycle of the original pills, it is expected that these risks will be greatly reduced, especially with better screening of candidates that is now the rule.
Oral contraceptives and stroke. [Reply] [letter]
A reported case of unexplained stroke in a young woman with history of migraine while taking an low-dose oral contraceptive suggests that epidemiological studies are correct when they find high risk of stroke in pill users. The occurrence of carotid dissection, asymptomatic mitral valve prolapse or patent foramen oval in some cases of pill- associated stroke in young women, does not exonerate the oral contraceptive as being the ultimate cause of the stroke. If any of these conditions are found, they only provide a mechanism for the pill to cause the stroke. It is still true that oral contraceptive drugs must be discontinued in case of migraine or other stroke risk factors.
Toxic effects of atenolol consumed during breast feeding.
A case of atenolol toxicity in a newborn who was normal except for physiologic jaundice is reported. The term infant was born vaginally with an Apgar score of 9-9 and weight of 3140 g. but was kept in hospital because of bilirubin levels reaching a maximum of 15.1 mg/dl. On Day 5 she developed cyanosis and bradycardia, with a rectal temperature of 35.5 degrees C. All other findings were normal, but poor perfusion continued until Day 8. The baby was treated with iv ampicillin and gentamicin until cultures came back negative. When it was learned that the mother had been taking atenolol (Normiten) for postpartum hypertension, while breastfeeding, samples of milk and the infant's blood was taken, and breastfeeding was discontinued. Within 6 hours the infant was clinically normal. Assays of milk and serum by high pressure liquid chromatography showed levels of 469 ng/ml in milk and 2010 ng/ml in the infant's serum 48 hours after breastfeeding had been stopped. At 72 hours the level in the infant's serum fell to 140 ng/ml, or a half-life of 6.4 hours. Atenolol is widely used for hypertension during pregnancy: this report suggests that it may not be safe during breast feeding.
The association of maternal age, quickening, physical symptoms of pregnancy, and other socioeconomic and medical factors with maternal- fetal attachment was explored using questionnaires and clinical data. 80 pregnant women, both primigravidas and multigravidas from a Nebraska clinic participated, filling out the Cranley maternal-fetal attachment scale and the Leifer pregnancy symptoms checklist. Having experienced quickening, and intensity and frequency of fetal movement were significantly correlated with attachment (p<0.0001). Having has an ultrasound scan and having planned the pregnancy were significantly correlated (p<0.01). Income was inversely correlated with attachment (p<0.05). Neither maternal age nor pregnancy symptoms had any relationship with attachment.
The effect on father-infant interaction of demonstrating the neonatal behavioral assessment scale.
Aspects of paternal-infant interaction, involvement and ratings of their infant's behavior were compared in fathers who had or had not observed administration of the Brazelton neonatal behavioral assessment scale to their 2-3-day old infants. 44 1st time fathers who had attended prenatal classes and delivery of their children were assigned alternatively to 2 groups. The Brazelton inventory was administered on the 2nd or 3rd postpartum evening. Their interactions with their infants were videotaped and coded according to a schedule, 8 weeks later at home. Paternal attitudes, caretaking activities and perception of difficult temperament in the infant were taken from questionnaires. The only significant differences noted were in quality of father-infant interactions (p<0.01) and in father's perception of unpredictability in their infants (p<0.01). The control infants had significantly less eye contact (p<0.01).
Uterine perforation and use of the Multiload IUD.
An exhaustive review of the English literature on uterine perforations with the Multiload IUD, including a computerized search back to 1975, book chapters, meeting proceedings and reprint files was conducted. Only 1 perforation in a total of 8252 Multiload insertions was found among those reports giving clear data on perforation rates. Thus the overall perforation rate was 0.12/1000. It occurred in a woman 6 weeks postpartum. The rate is significantly lower than the WHO's published overall rate for copper IUDs, 0.7/1000. Case reports of 4 other Multiload perforations were also found, 3 by Multiload 250s and 1 an unidentified type of Multiload. Possibly the reason for the lower rate of uterine perforations with Multiload is that it is inserted by the withdrawal technique, and although it required more force to insert than many other IUDs, the pressure needed is about half. Multiloads also come in several sizes.
The effect of a triphasic oral contraceptive based on norethindrone on fasting glucose, oral glucose tolerance (OGTT), and insulin response was tested in 20 women before and after 18 months of use. The pill, Ortho 7-7-7, contains 35 mcg ethinyl estradiol in 21 tablets, and 7 tablets each with norethindrone 0.5, 0.75 and 1.0 mg. Subjects were their own controls; radioimmunoassays of insulin were performed at the same time for each woman's 2 tests; and results were analyzed as matched pairs. Fasting glucose significantly decreased from 74.0 to 68.1 mg/dl (p<0.02). Values for the OGTT were not significantly different. Plasma insulin levels during the OGTT differed significantly only at the 1 hour time point: 66.0 mcU/ml compared to 45.5 before taking the pill, although a trend of lower fasting insulin and higher insulin response was noted at all other points. The total insulin values, summed over 5 samples were 184.6 before, and 226.3 after the pill (n.s). The results were considered reassuring: norethindrone evokes only weak effects on carbohydrate control.
A study comparing a gestoden triphasic formulation with a fixed combination OC.
A triphasic oral contraceptive containing gestoden was compared to a combined fixed dose pill containing desogestrel in a total of 27 women whose selected lipoproteins, liver functions, and blood coagulation factors were assayed at 0, 3, 6 and 12 months of use. Blood samples were collected between Cycle 14-21, and analyzed at University of Padjadgaran, Bandung, Indonesia. Gestoden pills contained 50 mcg gestoden and 30 mcg ethinyl estradiol (EE) for 6 days, 70 mcg gestoden and 40 mcg EE for 5 days, and 100 mcg gestoden and 30 mcg EE for 10 days. The combined pill contained 150 mcg desogestrel and 30 mcg EE for 21 days. Total cholesterol increased for both groups, significantly at 3 and 6 months for desogestrel. HDL decreased at 3 months on gestoden, but increased at all other points or both drugs. Triglycerides did not change significantly. LDL increased at 3 months, but fell below baseline at 12 months for both pills. The liver functions assayed were total protein, albumin, total bilirubin, and gamma-glutamyl transferase. All varied within normal limits, mostly with no significant differences. Blood coagulation factors examined were ACT-prothrombin time, euglobulin clot lysis time, anti-thrombin III, and Factor VII. Only Anti-thrombin III increased significantly, at 6 months on desogestrel, and at 12 months on gestoden. The coagulation effects are the most clinically important findings, but here they indicate a balance between clotting and fibrinolysis.
Pharmacy dispensing practices for Sudanese children with diarrhoea.
In order to study the dispensing practices of Khartoum and Khartoum North pharmacies with respect to the management of infantile diarrhea, a Sudanese woman presented pharmacists with a brief description of an infant with acute diarrhea. 63 pharmacies were visited; only 3 (5%) recommended oral rehydration salts (ORS) alone. An additional 4 pharmacies (6%) recommended ORS plus either an antimicrobial agent or a physician visit. 39 pharmacies (62%) recommended antimicrobial therapy alone, 9 (14%) recommended a physician visit alone, and 7 pharmacies (11%) had no available treatment. On the average, antimicrobials cost 4 times more than 2 packets of ORS. In order to increase pharmacists' recommendation of ORS, health professional training may be required, perhaps in association with dispensing subsidies. Increased public awareness of ORS should also be encourages. (author's)
The efficacy of oral rehydration solutions containing glycine and glycyl-glycine in addition to the WHO formula, adjusted to maintain osmolality, was compared in 32 male infants under 12 months of age with diarrheal dehydration. Addition of certain amino acids and dipeptides has been reported to enhance the absorption of sodium in dehydrated children. The solution give to 16 test subjects contained 60 mmol glycine/1 and 30 mmol/1 glycyl-glycine in a WHO ORS solution with glucose reduced from 111 mmol/1 to 89 mmol/1, keeping the total osmolality at 379 mOsm/kg. The WHO solution given to 16 controls contained 90 mmol/1 sodium, 80 chloride, 20 potassium, 10 citrate and 111 glucose with a total osmolality of 311 mOsm/kg. The test group had more episodes of diarrhea, 10.3 compared to 8.0 in controls, during the 1st 6 hours of rehydration. 2 controls and 3 test babies required intravenous rehydration. The results did not indicate any improvement gained by addition of glycine and its dipeptide.
How to communicate about AIDS: steps in developing a successful project.
Unless acquired immunodeficiency syndrome (AIDS) prevention campaigns are designed to meet the needs of the targeted population and systematically evaluated, they may fail to bring about the desired behavioral changes. The content and form of AIDS education and communication programs will vary from country to country, but a 5-step project development process is generalizable. The 1st step involves an exploration of the situation--the problem, the intended audience, campaign goals, the most effective medium, and potential allies. Step 2, design of the project, is based on the information gathered in step 1 and includes a consideration of the media, materials, and resources to be used; operationalization of objectives; administrative decisions such as the budget, schedule, and necessary personnel; a dissemination plan; and the development of message concepts for pretesting. In step 3, materials are pretested on members of the target audience, revised, and pretested again until they are easily understood by and acceptable to over 80% of the sample. In step 4, the plan is put into action (final materials are produced and distributed) and project activities are monitored. Step 5, project evaluation, analyzes data collected through the monitoring phase and uses this information to redesign the next stage of the campaign.
Structural changes in human cervical mucus.
Crystal patterns of cervical mucus were observed by electron scanning microscopy in 6 normal women and in women taking oral contraceptives, on Days 5, 11, 14 and 21 of the menstrual cycle. The pills contained 500 mcg norgestrel and 30 mcg ethinyl estradiol (Indian Drugs and Pharmaceuticals Ltd., Hyderabad). Mucus was obtained by aspiration from the cervical canal, smeared and dried at room temperature, and plated for scanning microscopy without fixation. Spinnbarkheit and ferning was noted to increase on Days 11 and 14 in normal cycling women, but rose slightly between Day 5 and 11 and then remained constant in pill cycles. On the scanning microscope, mucus from cycling women was characterized by fern patterns on Days 11 and 14. On Day 11 a rounded, parallel, grooved backbone with flattened branches on only 1 side was observed. The distance between sub-branches was consistent at 3.33 mcm. On Day 14 sub-branching lessened, but branching was commonly located on both sides of the backbone. The distance between sub-branches ranged from 3.75-5.0 mcm. The width of the main backbone was wider than on Day 11, from 6.25-11.25 mcm. In women on the pill, no ferning appeared: mucus remained thick, viscous and tenacious, with no crystalline structure.
Intra-uterine device failure: relation with drug use.
A retrospective case-control study examining medication incidence in women with failure of IUDs was conducted by questionnaires mailed to French physicians. Doctors who entered their patients in the study were self-selected in response to extensive advertising, and knew the nature of the hypothesis being tested. 228 physicians and 35 hospital obstetrics and gynecology departments provided 717 cases and 717 controls. The cases differed from controls in age, mean 31.1 vs 34.2 yrs, gravidity, 2.9 vs 2.4, and births, 2.1 vs. 2.0, respectively. Also, Multiload Cu 250 was used more often by failures and ML Cu 375 more often by controls. Cases took medication more often than controls, 46.5% vs 40.8%. Anti-inflammatory drugs, antibiotics and hormones, particularly progestins, were the individual drugs that differed significantly (p<0.001). Aspirin remained significant for the failure group even after dissociation. Potential bias due to lack of blinding and selective recall was discussed.
[The contraceptive effectiveness of morrhuic acid suppository]
The spermicidal effect of morrhuic acid has been studied. Up to now, the morrhuic acid vaginal suppository for contraception has been used in 1746 women; i.e., 16,073 woman-months of suppository use. There were 1354 subjects who continued to use morrhuic acid suppositories for 1 year. The cumulative 12 month life table pregnancy rate was 10.1/100 women and the morrhuic acid suppository method pregnancy rate was 4.8/100 women, corresponding to an effectiveness rate of 95.2/100 women. The gross cumulative termination rate/100 women was 27.3, giving a continuation rate of 72.7/100 women. This suppository is suitable for contraception among all fertile women, especially for those newly married, menopausal, or breastfeeding. Morrhuic acid vaginal suppository is a safe, simple, and effective contraceptive method well- accepted by women. (author's modified) (summary in ENG)
Social, biological, and political considerations on fertility in Arab populations.
In analyzing fertility in the Arab countries, crude birth rate, total fecundity rate, and age specific fertility rates were measured. The data was obtained from United Nations, UNICEF, and the World Bank. In the early 1980's 13 of the countries had birth rates 40/1000. The majority of countries showed a decline in their crude birth rate (CBR) between 1960-83, except Somalia, which increased. The United Arab Emirates (UAE), Tunisia, Lebanon, and Kuwait, had the largest CBR decreases, followed by Morocco, Egypt, and Saudi Arabia. The global fecundity rate (GFR) shows the number of expected births a woman lives through her reproductive period, having children at the prevailing rate for each age. The GFR in these countries is much higher than those of non Moslem countries in the area. Results show that the fertility of Arab countries are in a gradual decline, but remain high, and many have a CBR over 40/1000. In the last 20 years Saudi Arabia, with the largest population of oil producing countries, has had a decreasing CBR. It is not in agreement with its high GFR, but this can be attributed to the large number of immigration workers in the country. The UAE showed a decrease in CBR from 46/1000 to 27/1000, the largest decrease in these countries. This decline coincided with the economic development due to oil production. Kuwait had a 25.5% decrease in CBR but less than Tunisia and Lebanon. The fertility decline in Kuwait intensified in the middle 1970's; the decline in northern Africa began in the late 1960's. There were declines in birth rates in the North African countries in the early 1970's except for Tunisia. The rapid declines in fertility can be attributed to the countries' socioeconomic and political situations.
The 1988 Nigerian population policy.
The population of Nigeria is one of the fastest growing rates in the world at 2.5-3.5%/ year. The estimated population was 101.11 million in 1987 and by 2015 is projected to be 280 million. Nigeria was the 10th most populous country in 1985 and by 2025 it would be 4th. The average number of children for each woman is 6-7 and the death rate is 16/1000. A recent government policy has restricted women to 4 children. 47% of the population is under 15 years of age. Goals of the government include reducing the growth rate, improving the standard of living, and balancing the population distribution between urban and rural areas. To do this they will need to promote awareness of their population situation to all citizens, educate young people on family planning, and to enhance development in rural and urban areas by slowing the migration to the cities. Most Nigerians view this policy as discriminatory against women, and ineffective in curbing present growth in population. Religions including Catholicism, Islam and some Christian groups do not promote birth control. Although many groups oppose this policy, most realize that the country is over populated and that with the present economic situation, a reduction in growth is needed. A more acceptable policy would restrict Christians, who marry only 1 wife, to 4 children and Moslems, who can have up to 4 wives, could have only 1 child/wife or 4 children for the man, in each family. A better method would be to encourage 3 children/family because of the young age structure in the population. Even if the fertility would decline to 2 children/family there would be substantial growth for many years to come.
Global warming: can we avoid catastrophe?
Atmospheric scientists have continually debated the effects of pollution on changing the global climate and the increasing number of natural disasters. Scientists can not prove that the global warming process has caused these events. They do know that burning fossil fuels and depleting forest lands release gases that change the heat balance in the atmosphere. These gases make up less than 1% of the atmosphere but trap large amounts of heat near the earth's surface. Projections estimate a warming of 3-9 degrees fahrenheit by the year 2030 and a warming of 1- 1.5 degrees has already been observed. These increases could effect agriculture production in the US and other mid-latitude regions. The more serious effects would be felt by the low coastal areas and islands as the seas rise, from the thermal expansion of the water and melting ice packs. There could be as many as a billion people affected by a 1-2 meter rise in the world's oceans. There are 4 major parts to a strategy in reducing the possibilities of a rapid climate change. The most important is to greatly increase the efficiency of energy use by getting the most work out of every unit of fuel used. Next the emissions caused from biotic sources must be reduced by slowing the rate of deforestation. The most dangerous chlorofluorocarbons must be eliminated and the mix of fuels from carbon based ones like coal to natural gas must take place. In the long term, a change to fuels that do not emit carbon dioxide into the air like solar, wind, hydro, biomass and nuclear power must be accomplished.
Finding ways to stem the tide of deforestation.
In the 1980's we were losing 100,000 square kilometers of tropical rain forest per year, and today we are losing over 130,000 square kilometers due to general degradation. The greatest losses have occurred in Brazil; other countries include Bolivia, Ivory Coast, Burma, Thailand, Malaysia, Indonesia and more. By stopping the excess logging and cattle ranching almost 1/2 the problem would be solved. Such as in the Brazilian Amazon where the population is 147 million, and is projected to be 239 million by the year 2020. The economic imbalance, with the top 10% of the people having the larger share than the other 90%, and 10% of the land owners having more than 50% of the land, contributes to the problem. In 1 area, the use of extractive reserves, is producing higher income than cattle ranching and agriculture, and preserving the forest. Deforestation contributes to the greenhouse effect; reforestation of 3 million square kilometers of lands in the tropics could counterbalance this. It would cost $12 billion/year for 12 years to complete the project. If the present rate of deforestation continues we could lose 1/3-1/2 of all species in these forests. This implies that a priority should be to identify all critical areas within tropical forests, so that conservationists can use their scarce resources most efficiently. The most productive ways to slow deforestation needs to be determined, and evaluation of the goods and services generated, so that forests can be exploited in a rational and sustainable way. The areas of biodiversity should be identified, enabling us to preserve millions of threatened species efficiently.
The future of women's health -- the family planning clinic.
The prospects for the clinical specialty of family planning services in the Manchester-Sheffield region of the U.K. are discussed under the headings of service provision, teaching and research, stressing the advantages of centralized services. Centralized services have the advantages of better access, more convenient hours, anonymity, larger throughout which improves staff expertise, and cost effectiveness of equipment and facility usage. The trend toward centralization has allowed more medical specialization as well as targeting of client needs. Large centers can charge fees to doctors attending training sessions to become certified by the Joint Committee on Contraception, and can provide more then 1 physician for consultations. They can recruit subjects for research because of larger numbers of clients. In the future, family planning clinics will probably broaden their services to include other types of well women care such as hormone replacement therapy and AIDs counseling. Hormone replacement therapy is highly cost effective in preventing osteoporotic hip fractures, although its benefits will not appear until 20 years later. Some issues in management of family planning clinics include the inefficient redundant budgeting system, the need for a single national body to recognize professional competence in contraception practice, and the fact that most FP doctors only work part time.
IUD's are used by more than 60 million women around the world, and with the new copper releasing types, low pregnancy rates and high usage is prevalent. The IUD requires little user participation and once fitted can remain in place up to 5 years. It is most effective in pregnancy prevention but does have some side effects including ectopic pregnancy, pelvic inflammatory disease (PID), pain, blood loss, and anemia. There has been recent interest in how IUD's work by religious and political groups opposed to abortion and fertility regulation. One of the key questions is whether the embryo reaches the endometrial cavity at the same rate in non-IUD users as it does in IUD users. Research indicates higher losses of embryo in non-IUD users, but it is inconclusive. PID is one of the most serious infections women can have, and can be caused by insertion of IUDs. Dalkon shield use had a higher risk, and copper devices have a lower risk of PID occurrence. If a woman gets pregnant with an IUD in place, the chances of an ectopic pregnancy are from 2.9%- 8.9%, and this condition results in 10% of the maternal deaths. The type of IUD can effect the chances of ectopic pregnancy and copper releasing IUD's with larger surface areas seem to carry the lowest risk. IUD's do not protect the user from HIV infections, but whether they are more likely to develop and transmit the disease faster is not year determined. There are problems with doctors getting malpractice insurance for IUD fitting, making them unavailable in 1987. Since then a new copper T-device is being marketing in a limited way. Research will improve IUD's and develop new ones that will be safer and more acceptable.
The impact of legalized abortion on adolescent childbearing in New York City.
The liberalization of the New York State abortion law has had a major impact on teen birth rates in New York City. In the period between 1963-87 there has been a drop in the level of black teen births of 18.7% and white teens 14.1%. This research uses a time series analysis of monthly data over a 25 year period. The analysis was limited to white and black teens since ethnicity was not recorded on birth certificates until 1978. 2 approaches were used, both including the Box-Jenkins time series analysis. The 1st method fitted an autoregressive integrated moving average model, to project the number of teen births that would have been expected without legalized abortion. The 2nd method used intervention analysis to measure the change in the monthly level of births between the pre- and post-intervention series. The results indicate, a dramatic reversal of 7 year upward trend in 1970-71 for blacks, and for whites, a level trend dropping substantially in 1970-71 and continues to drop until 1986. The evidence also indicates that early childbearers tend to have more unwanted children than those who delay pregnancies. There is little evidence showing the availability of abortion acting as an alternative to birth control. The examination of statistics on teens who have children shows they will have less schooling, lower salaries, more marital problems, and be dependent on public assistance more than those who delay childbearing. The children of these teens will have more health and emotional problems than others.
The cesarean delivery rate can be safely reduced in a developing country.
The cesarean rate and outcomes were compared for 2-year periods before and after introduction of guidelines for resorting to abdominal delivery in cases of dystocia, fetal distress, previous cesarean section and breech presentation, in the Gweru Provincial Hospital, Zimbabwe. The guidelines for diagnosis implemented in September 1984 were briefly: a trial of labor with artificial rupture of membranes and oxytocin infusion for 6 hours in case of suspected dystocia; a trial of scar in case of single previous cesarean section; prolonged bradycardia <100 bpm or repeated decelerations to define fetal distress; a trial of vaginal breech delivery for those with normal pelvis and estimated fetal weight <4000 g. After introduction of the guidelines, cesarean section fell by 50% from 16.8% to 8.0%, especially for dystocia and previous cesareans. Maternal mortality declined from 202-57/100, 000 births, and perinatal mortality fell from 71.9-56.2/1000 births. The instrumental delivery rate increased from 1.0 - 1.9%; the use of oxytocin rose from 3.4 -17.4%. While numbers of stillbirths remained constant, Apgar scores of infants delivered by cesarean for fetal distress averaged lower, suggesting a higher threshold for intervention. The success rate for trial of scar rose from 72.9 to 88.4%. It is likely that tighter management was responsible for the improved outcomes with lower cesarean rates achieved here.
Contraceptive practice among women seeking legal abortion in the Scottish Highlands.
There has been a large increase in legal abortions in England in the last 10 years. The cause can be partially attributed to the decline in use of various contraceptive methods, particularly pills and IUD's. the statistics presented pertain to patients seeking abortion in the Scottish Highlands and include single and married women from 15-40 years of age. Of these women, 80% had 1st trimester abortions, and the other 20% had abortions between the 12-18 weeks of pregnancy. 25% were married, 13% divorced or separated, and 62% single. 64% of these women did not use any birth control method at the time of the unwanted pregnancies, and 74% were under 27 years of age. Fill failure occurred in 19% of cases and condom failure in 10%, with the remaining failures attributed to IUD's, caps, and diaphragms. Other factors causing increased numbers of abortions are economic conditions and reductions in family planning clinics. In this area local doctors are the main source of family planning information and services. Since most of these cases are young unmarried women, the need for better access to family planning education and birth control is obvious. The number of women of all ages not using contraceptives shows a need for reevaluation of family planning services for all age groups.
A study was conducted in Thailand to discover the prevalence of antibodies to HTLV-1 in patients suffering from chronic progressive myelopathy, multiple sclerosis (MS), myopathy and in HIV-seropositive intravenous heroin abusers. The aim of the study was to discover whether or not patients suffering from diseases with symptoms similar to tropical spastic paraparesis associated with HTLV-1 antibodies had the antibodies present in their serum. 35 patients were used in the study, 9 suffering from myelopathy, 11 with multiple sclerosis, 5 with myopathy and 10 HIV-seropositive intravenous heroin abusers. The symptoms of the 9 patients suffering from progressive myelopathy included stiffness and/or numbness in the extremities. It was concluded that these 9 also suffered from spastic paraparesis. A diagnosis of the patients suffering from MS was confirmed by a study of the patients' histories, and a diagnosis of the 10 HIV-seropositive intravenous heroin abusers was confirmed by Western blot. The serum of the 35 patients were tested and the results showed that HTLV-1 antibodies were not found in the serum of the 35 patients. More sensitive measures, such as in vitro enzymatic gene-amplification techniques, however, might show a connection between HTLV-1 and chronic neurological diseases. This study has shown that causes other than HTLV-1 antibodies maybe responsible for diseases such as chronic progressive myelopathy. In the case of spastic paraparesis, nutritional deficiencies and toxins have been considered as causes.
Diarrheal diseases continue to be the major causes of death for children in 4 Western Pacific Region nations: the Lao People's Democratic Republic, Papua New Guinea, the Philippines, and Viet Nam. They are also among the most frequent childhood illnesses in 18 of 35 countries and areas of the region. Many children die because physicians, health workers, and mothers do not know that oral rehydration therapy (ORT) is the single most effective treatment for diarrhea. All too often, older or hospital based physicians prescribe antidiarrheal drugs or antibiotics. ORT can successfully treat 90-95% of acute diarrheal cases. The oral rehydration salts (salt, glucose, sodium bicarbonate, and potassium chloride) are mixed with potable water so the child with diarrhea can drink it. The mixture replaces the water and salts removed from the body during diarrheal episodes. The 1st Diarrhoeal Training Unit (DTU) of the WHO Global Diarrhoeal Diseases Control programme in the region was found in Manila, the Philippines in December 1985. Its purpose continues to be the provision of hands-on training for health professionals in hospitals to convince them that ORT is effective. In 1988, 12 DTUs existed in such countries as China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines, and Viet Nam. They will soon also operate out of medical, nursing, and midwifery schools. Even though 60% of the population in the Western Pacific Region has access to ORT packets, too many mothers still do no use them to treat their children with diarrhea. Further, they do not know that they should continue to feed them. In 1988 in the region, an estimated 50,000 children lived who would have died without ORT.
[Vaginal tablets, pills, and intrauterine devices. Study of their comparative pathogenicity]
The spread of sexually transmitted diseases caused by bacteria or viruses has added a new requirement to contraceptives: that of protection from infection. A comparative study was undertaken of genital tract pathogenicity containing benzalkonium chloride. Because Pharmatex vaginal tablets do not lubricate or modify the vaginal mucus, they are acceptable to many pill and IUD users. Benzalkonium chloride is the most powerful known spermicide, but has no systemic effects. Acceptability of Pharmatex was good among most users and increased over time as they became more practiced. Subjective tolerance was good except in 4% of women who complained of a sensation of vaginal heat and 8% whose partners experienced a postcoital burning sensation of vaginal heat and 8% whose partners experienced a postcoital burning sensation. Objective tolerance was excellent. No evidence of sexually transmitted disease was seen in 202 users over 4470 cycles except for 2 cases of Candida. 4 cases of vaginal infection due to E. coli and 1 due to Proteus were also observed. 60 of the 202 women were nulliparas and the other 142 had a total of 255 lives births. The duration of use ranged from 3-48 months. The average age of patients was 31 years. 18 were under 20 at the start of the study, 38 were 20-29, 60 were 30-39, and 86 were over 40. 8 had used no method previously, 90 had used IUDs, 48 pills, 18 condoms, 12 spermicidal ovules, 8 the temperature method, and 18 withdrawal. 3 pregnancies were observed, 1 in a women of 22 after 3 months of use and 2 in women of 26 and 28 after 12 months of use. The Pearl index was 1.74 for the 1st year and .81 at the end of the 4-year study. The results for vaginal tablet users were compared with those of 100 IUD and 100 OC users. The average age was 25 years for OC users and 35 years for IUD users. 55% of OC users and 62% of IUD users experienced vaginal infections of some type during the study compared to 7% of Pharmatex users. The high rate of infection among OC and IUD users raises the question of whether the sample is representative. The preventive power of benzalkonium chloride is however confirmed.
A consultant's report on implementation of plans for an Information Center on Diarrheal Diseases and Child Survival within the Philippine Department of Health (DOH), conducted by Technologies for Primary Health Care (PRITECH), is presented. The users of the data base will be DOH staff and physicians and nurses in training. Other related information sources include the DOH Library, the Field Epidemiology Training Program information facility, the DOH Center on Diarrheal Disease newsletter Dialogue on Diarrhea, and the U.S. Naval Medical Research Unit. The consultant recommended that more time be allowed to set up and become operational, a total of 2 years. The Center should be located within the new DOH Library as a sub-collection. The PRITECH Information Center's procedures, resources and monthly Technical Literature Update should be utilized. Rather than use costly online searching, the Center should rely on CD-ROM discs, perhaps doing occasional online searches at NAMRU or HERDIN. An advisory committee should be appointed. The Center should see that Dialogue on Diarrhea is distributed to Regional Resource Centers. Nominal fees for services should be charged where appropriate.
Zambian population policy and the Integrated Family Planning Project.
In his speech at the 2nd African Conference on the Integrated Family Planning, Nutrition and Parasite Control Project (PANFRICO) held in Lusaka, Zambia on March 7-13, 1989, Zambian president, Kenneth D. Kaunda stated that rapid increase in population severely affected socio- economic growth in Africa. He also stated that adolescent pregnancies inhibit the contribution of women in Africa to socio-economic development. As adolescents have little knowledge of or access to family planning, this increases the rate of maternal and infant mortality. Lack of data available to young people, in addition to lack of data on the trends of young people, have increased the government's ignorance of present situations and the adolescent ignorance of family planning. Personal and religious beliefs have also interfered with implementing radical programs which would encourage adolescents to seek family planning. In order to overcome these obstacles, attention needs to be focused on the 4 following area: providing family education and family planning counseling; provide educational and employment opportunities as alternatives to adolescent pregnancy; increase population awareness of fertility related problems facing teens; and providing all types of support for programs aimed at young women. Counseling is the most popular and widely accepted service provided by family planning organizations, through counseling and distribution of educational material more couples are expected to be reached. Welfare support and employment opportunities may help women space their births while keeping down infant mortality rates. In Africa, Zambia, as well, population rates have far out grown socio-economic development. Governments have responded by stepping up family planning efforts by integrating family planning organization with health ministries.
The distinctive aspects of adolescent pregnancy in the U.S. are reviewed under the rubric of the "new morbidity": illnesses caused by social and life-style conditions. Quantitative trends in adolescent pregnancy are reviewed with statistics such as the annual U.S. Pregnancy rate for girls under 15, 5/1000, 4 times as high as Canada, the only other Western nation with a rate over 1/1000. Other countries pinpoint teen pregnancy, not sexual activity, as the key problem. Some social factors that have increased teen pregnancy are earlier menarche, increasing poverty, more single parent households. Determinants of sexually activity can be classed as individual, family and developmental. Individual factors include economic disadvantage, lack of opportunity and hopelessness and other problem behaviors. Family factors include race and female head of family. Development factors include pre- operational thinking, which prevents future planning and may require experience with sex to learn about it, and egocentricism, which implies an imaginary audience and the personal fable that "it will never happen to me." Teen pregnancy entails the medical risks of higher maternal mortality, cephalopelvic disproportion, anemia, toxemia and hypertension, resulting in prematurity and low birth weight. Social detriments are associate with teen childbearing, such as lower educational achievement, lower lifetime work accomplishment and income, larger families, cognitive delays in child development, lower school success and emotional problems for the child and higher risk for neglect and abuse. The cost of just Aid for Families with Dependent Children, Food Stamps and Medicaid for adolescent headed families is over $16 billion per year. The current administration has approached the problem by cutting funds, teaching the immorality of abortion, reducing the contraceptive availability and recommending teenage abstinence. The most effective programs in the U.S. are comprehensive school-based clinics.
Reversal of sterilization in women over 40 years of age: a multicenter survey in the Netherlands.
Cases of all women over 40 attending 9 Dutch centers offering microsurgical tubal surgery for reversal of sterilization from 1987- 1988 were reviewed. 78 cases met the criteria of minimum 4 cm of healthy tube, and normal basal body temperature, semen analysis and postcoital testing. The patients' ages ranged from 40-45, mean 41. There were 38 pregnancies after surgery: 35 intrauterine and 3 ectopic, an initial pregnancy rate of 45% intrauterine pregnancy. 26 normal term births and 9 spontaneous abortion resulted. 7 of the women who miscarried and 1 of those with ectopic pregnancy subsequently bore term babies. Thus the overall live birth rate was 44%, in comparison to 66% among the total population of reanastomosis cases in these 9 centers. The total abortion rate, 26%, is similar to that seen in women over 40 from the general population. The mean duration to 1st pregnancy was 5.5 months. Best results were seen with women sterilized with rings or clips. A trend in successful pregnancy appeared in younger women.
Aspects of health care systems in general, such as accessibility, equity, contacts per capita and organization and the system are discussed in view of planning for utilization, rather than planning personnel and facility input. All societies need a sick are and preventive care system with easy access. Equity is necessary, especially for primary health care interventions. Equity is determined by cost, distance and social status. Most developing and many developed countries can best provide this by having more than one separate health care system, one for the insured, and another for the uninsured. The overall contact rate per capital averages 4 or more annually for the insured, but less than 1 per year for others, which effectively means that half of the population is not in the health care system. Improved coverage is best attained at the lowest level, the rural/community health sub-center. Developing countries generally lack good data on health care system utilization. Cost-effective choices in planning for health care require information on utilization of care and actual unit costs of services. The view often expressed that health services are underutilized in developing countries is inaccurate: the insured do utilize care when it is accessible and decently provided.
Health-care delivery for children of school age.
The 1st study on school children was conducted in the early 19th century in the United Kingdom; however, the 1st school health services was not created until a century later. In 1929, medical officers were appointed in Nigeria and Uganda to create the 1st health service devoted to maternal, child and school services. During the school years, a child is exposed to a variety of dangers and illnesses. The main objectives of school health services are to detect child illnesses, maintain child health, teach the child healthy habits and respect for its elders and for authority. Currently, the majority of the Nigerian population is composed of school-aged children, thus deserving of priority health attention. However, a large portion of the children who should be in school are not. Recommendations include appointing 1 school physician to supervise health services in and out of schools; appointing experienced community nurses to implement health care in schools at community, local, or village level; designating special teachers to teach health care science in the schools; and appointing a group to implement health services outside of the school. It is recommended that all school children undergo comprehensive medical examinations, discovery of any defects should be directed to the appropriate specialist. It is also recommended that societal facets such as environment, nutrition and food hygiene and social problems of children should be investigated and reviewed.
Maternal and child health care refers to services administered to mothers and children, it administers to women of child-bearing age and children from infancy to adolescence. Priority is given to mothers and children since they are considered the most important members of society and make up the majority of the population. Maternal and Child Health (MCH) embraces different aspects of medicine in an attempt to promote the health of this particular group. Pre-conceptual care of women is advocated, to ensure that they are in good health before conceiving. During pregnancy, antenatal care is recommended as being within the best interests of the mother and fetus. Antenatal care may include 1 or more of the following: group health education administered by a nurse or midwife; history taking and examination; identification of high risk patients; treatment; individual health education for high risk women; and/or immunization. Women who work are encouraged to report to clinics to receive antenatal care. They should not be allowed to endanger themselves in work. Women should also be allowed maternity leave. Natal care is necessary for the continued health of the mother and child. Maternal mortality is 1 of the fatalities of pregnancies. The causes of maternal mortality are: hemorrhage; abortion; ruptured uterus; and/or factors attributed to anesthesia. Prevention of maternal mortality includes good antenatal care, early treatment and diagnosis of mothers during pregnancy, the training and provision of more midwives and doctors, and improving nutrition. Postnatal care includes examination and immunization of the baby and family planning counseling for the mother. Planning and developing an MCH programme includes identification of the problem, evaluation of resources and alternatives, setting of objectives, and yearly evaluations of the program.
Control of sexually transmitted diseases.
The most common disease affecting mankind today are sexually transmitted diseases (STDs). There is a high prevalence of STDs in Africa. STDs such as venereal syphilis and gonorrhea, common in urban areas, are now becoming prevalent in rural areas due in part to industrialization and better transport. The diagnosis and treatment of STDs are poor. There are few specialized clinics in many rural and urban areas to self- medication and/or the consultation of chemists, herbalists and quacks. In some developing countries, the public has easier access to antibiotics than in developing countries. Self-administration of antibiotics may affect a symptomatic cure but not a bacteriological cure. The results are that the person believes that he/she is cured and returns to their regular lifestyle, perhaps further spreading the disease. Suggestions for developing control programmes include: providing free facilities for diagnosis and treatment, these facilities would be provided in all major urban areas; providing competent screening and contact tracing of all patients; implementing legislation to encourage the treatment of STDs; and providing health education in an attempt to dispel or help change sexual traditions and misconceptions.
Liposarcoma of the cord presenting at vasectomy counselling.
A case of liposarcoma, a rare malignancy of lipoblasts derived from mesenchyme, in a 36-year old man applying for vasectomy is described. The subject reported nagging scrotal pain for 14 years. Examination revealed a soft mass above the left testis, thought to be an epididymal cyst. During exploration under general anesthesia, a partly encapsulated fatty lesion was found encircling the testis and the cord. The tumor was dissected and excised. Some parts of the tumor resembled a vascular lipoma, others contained multivesiculated primitive cells and hyperchromatic multi-nucleated and granular lipoblasts. The man was treated with left radical orchidectomy with high ligation of the cord 10 days later, and biopsies of lymph nodes, retroperitoneal fat and skin were taken for examination. He has remained recurrence free for 4 years by CT scans. This case dramatizes the need to consider paratesticular tumors in any case of a mass found in a vasectomy candidate.