Tanzania Demographic and Health Survey 1991/92. Preliminary report.
The preliminary report of the Tanzania Demographic and Health and Survey, 1991/92, provides background summary and survey methodology, and separate results for the male and female questionnaires. A more comprehensive analysis is expected in 1993. Female results covered characteristics, fertility, family planning (FP), fertility preferences, maternal care, breast feeding and supplementary feeding, vaccination of children, and treatment of children's diarrheal disease. Men's results included characteristics, FP, and fertility preferences. Sampling clusters were used in rural areas with a fixed number of regional households in a 3-stage sample design. Results were available for women from 20 mainland regions and Zanzibar. Men's results pertain to the nation and urban and rural areas. 96% of the sampled women and 88% of the men completed interviews. Basic data indicate that 60% of the women are <30 years, 97% live on the mainland, 6% in the Dar es Salaam region, 18% in urban areas, and 73% in rural areas. 61% have attended primary school; 34% have no education. 25% have never been marries. 66% are currently married of which 30% are polygamous. The total fertility rate (TFR) for 1989-91 was 6.3 vs. 6.9 in 1978. TFR in rural areas was 6.6 vs. 4.0 in Dar es Salaam and 5.5 in urban areas outside Dar es Salaam. 80% were aware of at least 1 FP method, usually the pill, condom, or female sterilization. Almost 50% knew of at least 1 traditional FP method. 90% of those knowing a method also knew a source. 25% have ever used and 10% are currently using. 7% use a modern method and 4% a traditional one. Women in urban areas or with higher education tended to use modern methods. 33% obtained a modern method from a government hospital and 24% from a government dispensary. 21% wanted no more children. 42% wanted birth spacing of 2 years. Only 50% used a trained health worker during delivery. 90% had received tetenus toxoid shots and some antenatal care. 98% of children are breast fed for at least 1 year. 71% of children 12-23 years received all vaccinations. 4% of the children had diarrhea within 24 hours of the survey of which 66% received oral rehydration. Contraceptive knowledge is higher among women. 45% of men ever used FP. 23% used periodic abstinence, 19% withdrawal, 14% condoms, and 11% the pill. 22% were current users (4% the pill) 15% want no more children. 35% want birth spacing of 2 years.
Double-edged limit of total fertility rates.
Total fertility rates are estimated for 46 countries including China to exemplify the method which uses upper and lower bounds. The positive growth rate, the negative growth rate, and zero growth rate are indicated for the countries. The theorem for a double-edged limit to fertility is proven and a description of the formulas given. Countries with lower fertility than the lower bound of the critical fertility rate and negative growth rates are the US, Japan, United Kingdom, France, West Germany, Australia, New Zealand, Canada, Sweden, Norway, Cuba, Finland, Denmark, and Mauritius. Low income countries with a fertility higher than the upper bound and with positive growth rates are China, India, Pakistan, Bangladesh, Egypt, kuwait, Chile, and Malawi. Countries where there are zero growth rates are Romania and Yugoslavia. China has had a slowing of the natural growth rate, but the population is still increasing and fertility must be reduced to below 2.1. The double-edged limit is not the same as replacement level, but depends on age distributed mortality rates. The continuous model employed used partial differential equations with boundary conditions to characterize the dynamic effects of the changing age and size structure of the population. The assumptions are that 1) if the real total fertility rate (TFR) is > the critical fertility rate for a long period of time, the total population size will be increasing exponentially without limit and the natural growth rate will be greater than 0; 2) if the real TFR remains smaller for a long time, then the population decreases exponentially and the natural growth rate will be below 0; and 3) if the real TFR is equal to the critical fertility rate, then the population will be stabilized at a constant defined by the initial population state and natural growth will approach 0. China's TFR has been higher than the critical fertility rate even in the 1980s, and natural increase rates remain high. This method is useful for family planning policy making.
A model for midwives -- support for ethnic breast-feeding mothers.
In England, migrant women from the hilly, tea-growing province of Sylhet in northeast Bangladesh who later moved to Tower Hamlets in London's East End borough were less likely to breast feed their infants at 3 months than were the prior generation living in Sylhet (27% vs. 98%). In the late 1980s, 37% of infants delivered by midwives from the LOndon Hospital were Bengali. The Sylheti mothers did not begin breast feeding until the 3rd day. They believed the colostrum to be harmful so they discarded it. Almost 50% gave their infants formula during the 1st week postpartum. The mothers believed that the English people expected them to bottle feed. The longer they lived in the UK and were exposed to its midwifery services the less likely they were to exclusively breast feed. In Bangladesh, friends and family provided food and drink for mothers and relieved them of their domestic duties during the postpartum period, but moving 6000 miles away into a new culture broke those bonds. They were often isolated and poor. Unfavorable conditions existed in Tower Hamlets thus making artificial infant feeding even more dangerous. The maternity unit of the health authorities in Tower Hamlets had 4 Sylheti maternity aides. It used breast-feeding promotion materials in Bengali developed by the Health Education Authority's Asian Mother & Baby Campaign. 2 Bengali midwives also provided health education for the Sylheti women. The health authorities' midwives worked with Bangladeshi community groups. Midwives could organize a culturally acceptable and postnatal and community support system for Bengali mothers to reduce bottle feeding, if they were to choose to do so.
Philosophical ethics of ending life: abortion.
A philosophical ethical discussion is given to support the notion that "right to life" and "right to choose" views of abortion are problematic, and a moral policy is required that provides subtlety, justice, and mercy. Philosophical ethics is defined as the passion of the mind to seek the noble insights of reason and logic and to affirm gratuity and caring impulse. There are formal ethics and impassioned ethics. The formal categories find abortion acceptable. Other ethics emphasize condolences. It is simplistic to say that abortion is always right or always wrong. The demands of philosophy for consistency and the law for uniformity must conform to the human dimensions of subtlety. Reason and produce in the public arena suggest that different situations are related to the appropriate use of abortion. Value and disvalue can be assigned to given cases to balance basic principles of kindness or justice or freedom. Groupings might take the form of 1) "strongly advised" for abortion in cases of incest, child rape, and cases of profound genetic defects, or where pregnancy or delivery is life threatening. 2) Abortion is "permissible but not obligatory" is cases of coercive out of wedlock pregnancy, of physical or mental risk to the mother, or moderately severe genetic or congenital defects. 3) Abortion is "permissible but discouraged" in illegitimate pregnancies and mild and treatable genetic accidents (cleft palate, harelip). 4) Abortion is "proscribed" for reasons of convenience, sex selection, an population control. The final choice should be made by the mother and the father, together with medical and pastoral counsel. The law should define but not criminalize unless the case is proscriptive. Thus the sanctity of life can be sustained.
Patterns of first marriage in Finland and Hungary: a comparative study.
Throughout Scandinavia and most of Western Europe the structure of families and households is changing; nontraditional family forms such as consensual unions and 1-parent families are on the rise. Traditional families have not changed in Eastern Europe. The aim of the paper is to compare the nature and background differences between East and West Europe by examining period measures of 1st marriages and nuptiality patterns in Finland and Hungary. Change in the age structure and intensity of 1st marriages is examined through the classic life table method for cohorts born between 1945-70. There was some variation in nuptiality tables due to data classification differences. Social and demographic factors which accompany the marriage changes are taken into consideration. In Hungary, modernization meant the transfer from the agricultural sector to the industrial without change of rural residence while in Finland the change was concurrent with the movement of the rural population to urban centers. In Hungary, therefore, it was easier to preserve traditional habits an features of the people's lives. Several other factors contributing to the historical patterns in Hungary are the high proportion of marriages arising out of pregnancy and the high value of marriage. Period and cohort indices of 1st marriage show that both countries are experiencing a decrease in the total 1st marriage rate, but Hungary is lagging 10-15 years behind Finland. The proportion of women ever married y age 50 is estimated to decline from 95% to 90%. Marriage age is still low in Hungary. For men, there has been a shift not just in timing of marriage as for women but also in the overall level of marriage. The cohort changes in Hungary mary be due to economic difficulties in beginning a family or preventing marriage entirely. Cohabitation in Hungary among the young is not common. Future trends in Hungary are uncertain; in Finland a similar pattern of radical change in society and economic uncertainty resulted in large emigration and unemployment for young people. Further research is needed on the social, cultural, and economic features of marriage in Hungary in order to understand the basis for the traditional patterns.
The development of family structure in Finland in 1960-1987.
Statistics on family structure in Finland usually exclude cohabiting couples. This paper provides, for the 1st time, statistics on family structure by family types based on a new method used by Statistics Finland in identifying families in the 1990 census. Family statistics are generated for 1981 and 1987; the changes in family structure by type are described. The method is described in the appendix. family is defined as persons of any age living with their parents. Over the past 100 years, the extended family of several nuclear families bound together by kinship has been replaced by the nuclear family of mother, father, and children. The modernization process has affected family cohesion. Social structural changes have contributed to the undermining of family cohesion. Key factors are the increasing proportion of people working as paid employees, changes in industrial structure, an the importance of the emotional bond for marital stability. There is an imbalance in the forces strengthening vs. undermining family cohesion in favor of undermining forces. The theories of Louis Wirth characterize urban life styles as producing formal, superficial contacts and as decreasing primary contacts. Official control replaces immediate social control. The cause is not as Wirth proposed. The spreading urban life style reflects the changes in the industrial structure, the division of labor, and the increased prevalence of paid employment. Families in 1987 constitute 50.6% of all families, and married couples without children around 24%. The trends between 1960-87 are visually represented for married couples with children, married couples without children, unmarried couples with children, unmarried couples without children, mother with children, and father with children. The number of unmarried couples grew rapidly during the 1980s; the growth rate in the number of families slowed and the number of families out of household or families (63.7% in 1960 vs. 61.4% in 1987) or total population has slowed. Most households are still families (82.9% of total population). Age factors are not related to the decline. The number of families with children dropped steeply from 65.4% in 1960 to 47.9% in 1987. Conditions for beginning a family were unfavorable. Family policy had little impact. Family growth was highest in municipal regions with 150,000 population.
Summer of 1989 surveys of 16-24 year old tourist workers and 16-24 year old residents in Torbay, England revealed considerable unsafe sex practices among respondents. They showed a strong association between leisure life styles (frequenting public houses and nightclubs) and unsafe sex practices (multiple partners and low levels of condom use). The health authority then developed a pilot prevention program to evaluate tourism-oriented approaches to increase awareness among youth about the risk of infection from unsafe sex and the need to always practice safer sex. They attempted to appeal to the youth's sense of humor. Health educators decided to focus on party nights and presenting safer sex messages to the youth at each of the 6 nightclubs. In August 1990 for 3 weeks and after 1 week of publicity about the program, 23 trained peer informants went to the public houses and nightclubs on party nights to speak to the youth about safer sex and to distribute information packs and t-shirts. It was easier for them to speak with the youth at public houses because it was very noisy at the nightclubs. TV stations broadcasted the party nights throughout southwestern England. Nightclub disc jockeys hosted safer sex quizzes and other games using promotional materials (posters, t-shirts, leaflets, stickers, and balloons each with the common logo). The peer informants believed the party night events were beneficial. They even had fun. Community members asked the health authority to help with other safer sex promotions. After the pilot program, the family planning clinic in Torbay could not keep condoms in stock for the 1st time ever. Even though the health authority could not determine whether the youth practiced safer sex after the program, the pilot program probably increased awareness of the risk of sexually transmitted diseases and HIV/AIDS.
Multilingual health education tapes project.
The success of Thailand's 1985 malaria education cassette tapes project motivated the Highland Development Program to produce tapes in 6 tribal languages on family planning, maternal and child health, nutrition, and disease prevention. Staff produced tapes using a drama or radio magazine format as a series of short features with music and sound effects. Scriptwriters consulted villagers, broadcasting professionals, research workers, and health officials to tailor messages to the various hill tribes. They tried to avoid conflict between traditional and modern concepts and to minimize distrust of government services. The scriptwriters used basically short, grammatically simple sentences, and colloquial Thai to simplify translation. The staff tried to recruit literate, adult, native speakers of the target languages with some experience in health education in their own languages. Obstacles encountered with translation included some languages used an uncommon alphabet or translators did not know their own alphabet. The program backtranslated the scripts to assure the accuracy of the messages and the appropriateness of the words used. Backtranslation revealed deficiencies in the translated messages. Altering the meaning of technical terms tended to be simple mistakes, words with multiple meanings, and exaggeration of problems and/or solutions. Translators also sometimes failed to adapt cultural ideas to those of their tribes. For example, some persons translated all possible misconceptions about a disease yet the tribes did not have all the misconceptions. As of early 1992, recording, pretesting, distribution, and follow up had not yet taken place. The staff should meet with a recording studio to coordinate production including technicians and translators identifying means to communicate. Staff should be aware of signs of poor translation which they may have missed earlier and surfaces during recording. Pretesting should occur among literate and illiterate members of target ethnic groups. Field officers should watch how villagers react after hearing the tape.
Immunization: full coverage the aim.
In November 1988, nursing students at Khon Kaen University in northeast Thailand conducted a baseline survey in 16 villages before a retraining program for village health workers began. It consisted of a 1-week intensive training program and meetings between officers and village health workers. The goal was to achieve full immunization coverage for children under 5. After retraining, the workers implemented their health education and immunization recruitment programs with a refresher course 4 months later. The nursing students conducted a follow-up survey in June 1989 so researchers could compare the effects of the 8 intervention villages with data collected in the 8 control villages. The intervention indeed brought about improvement in immunization coverage, mother's and health worker's knowledge, and health worker participation in program planning and coordination in the case villages. For example, full immunization coverage among children under 1 increased from 65% to 89% while in the control villages it remained at 56%. It also increased among children over 5 (30-81%) but in the control villages it only rose slightly (23-31%). The percentage of mothers who were very knowledgeable about infectious diseases increased from 1% to 8% yet in the control villages it decreased from 2% to 0. Mothers with high level of knowledge about immunization was higher in the 2nd survey in both groups, but the increase was greater in the intervention villages (12-33% vs. 14-21%). High level of knowledge about infectious diseases among health workers grew considerably (3-72%) in the case villages but in the control villages it decreased from 10% to 2%. In addition, health workers in the case villages improved their contact with health officers but not those in the control villages (47-64% vs. 70-36%). Program participation increased in the intervention villages (11-36%) but fell in the control villages (22-13%).
Smaller health areas for a better service.
Despite Sudan's commitment to primary health care, considerable health system weaknesses still existed in the late 1980s. For example, the health system was still operating under the organizational structure established by the former colonists and most of the allocated funds supported hospitals and salaries. The communities did not participate in primary health care activities and instead depended on official and outside funding. Lack of leadership and management support for health workers in the villages were perhaps the leading factors explaining the weaknesses. Its district-based system collapsed in the late 1970s due to population growth, transport problems in these large districts, creation of urban and rural councils to conduct administrative and decision making functions, separation of preventive and curative services (preventive services under local governments and curative services under the Ministry of Health [MOH]), decline in the national economy and in political commitment to health, increased numbers of physician specialists, and reduced numbers of physicians willing to go to rural areas. The MOH joined with Gezira University in Wad Medani, Sudan to develop a new health care policy. The National Council for Health adopted the new policy in December 1987. It decentralized the health system into 175 health areas around rural hospitals or health centers. Each area had a health area management team. The new policy was based on primary health care, community participation, and sound managerial processes. Since there was no clear national implementation plan, the regional health authorities tried to implement the new policy. Few regions did so successfully. Thus Sudan suggested that each region first implement the policy in 2-3 areas. Health workers would learn some lessons from this phase which they can apply to expand the system.
Birth kits for safe motherhood in Bangladesh.
In the late 1980s, the Christian Commission for Development in Bangladesh developed and field tested a simple, affordable birth kit to sell to pregnant women in rural areas. It hoped the kits would reduce neonatal tetanus mortality. Interviews with traditional birth attendants and focus group discussions with women of childbearing age and with men's groups made up the 1st phase. These activities allowed the Commission to decide upon the design, contents, and logo of the birth kits. The bright red and blue box with a logo of a breast-feeding mother contained a plastic bag to protect the contents which included soap, 2 pieces of gauze, a polythene sheet, and the autoclaved items of 3 cord ties and a new razor blade. Pictures on a pretested, folded panel were used to convey directions on how to use the kits. The Commission conducted field trials in 5 rural areas by giving the kits to women in their last month of pregnancy and interviewing them within 1 month of delivery. They tended not to understand that the polythene sheet was to be used as a clean surface. The researchers redesigned the kit accordingly. They conducted more field trials to validate the original results. They also test marketed 3000 prototype kits with a goal of covering 50% of expected births. Each kit retailed for 10 taka. The cost had been as issue, however. >58% of the kits were sold. Most people bought their kits from women's groups. The commission next planned to scale up kit production to meet existing demand. They redesigned the box to reduce costs. They intended to have local women assemble the box which would be <33% cheaper. They proposed to initially limit promotion efforts to posters, pamphlets, and maybe rickshaw broadcasts.
The program for the prevention of rheumatic fever/rheumatic heart disease (RF/RHD) was initiated in 1984 by WHO in close collaboration with the International Society and Federation of Cardiology (ISFC). 16 countries in 5 WHO regions participated: Mali, Zambia, and Zimbabwe (in Africa); Bolivia, El Salvador, and Jamaica (in the Americas); Egypt, Iraq, Pakistan, and Sudan (in the Eastern Mediterranean); India, Sri Lanka, and Thailand (in Southeast Asia); and China, the Philippines, and Tonga (in the Western Pacific). The program was planned for implementation in 3 phases: pilot study and control program in a selected area, control programs in all the selected communities, and their extension throughout the entire country. In Phase 1, a total of 1,433,710 schoolchildren were screened and 3135 cases of RF/RHD were found, giving a prevalence of 2.2/1000 (higher in the African and Eastern Mediterranean regions); 33,651 recently identified or already known cases were registered; completion of secondary prophylaxis was irregular but averaged 63.2% coverage; percentage of adverse reactions (0.3%) and recurrence of acute RF (0.4%) were very small; 24,398 health personnel and teachers were trained. Health education activities were organized for patients, their relatives, and the general public in hundreds of health education sessions. Thousands of pamphlets, brochures, and posters were distributed, and health education programs were broadcast on radio and television. The quality of care for RF/RHD patients improved under the program, which has been expanded to other areas. (author's modified) (summaries in ENG, FRE)
Vitamin A deficiency and attributable mortality among under-5-year-olds.
Reported are estimates of the prevalence in developing countries of physiologically significant vitamin A deficiency and the number of attributable deaths. The WHO classification of countries by the severity and extent of xerophthalmia was used to categorize developing countries by likely risk of subclinical vitamin A deficiency. Using vital statistics compiled by UNICEF, the authors derived population figures and mortality rates for under-5 year olds. The findings of vitamin A supplementation trials were applied to populations at risk of endemic vitamin A deficiency to estimate the potential impact of improved vitamin A nutriture in reducing mortality during the preschool years. Worldwide, over 125 million children are estimated to be vitamin A deficient. Improved vitamin A nutriture would be expected to prevent approximately 1-2 million deaths annually among children ages 1-4. an additional 0.25-0.5 million deaths may be averted if improved vitamin A nutriture can be achieved during the latter 1/2 of infancy. Improved vitamin A nutriture alone could prevent 1.3-2.5 million of the nearly 8 million late infancy and preschool age child deaths that occur each year in the highest risk developing countries. (author's) (summaries in ENG, FRE)
The immunogenicity of 4 different dosages of yeast-derived hepatitis B vaccine (Merck, Sharp and Dohme: 0.6 mcg, 1.25 mcg, and 5.0 mcg), administered at 0, 1, and 6 months (0-1-6 schedule) intramuscularly, was evaluated in 122 seronegative healthy children ages 1-12. 3 months after the 1st dose, 83.9-100% of the vaccinees seroconverted. Peak geometric mean titers (GMT) of between 1088 mIU/ml and 1699 mIU/ml were attained 3 months after completion of the vaccination schedule. After 24 months, anti-HBs (antibody to hepatitis B surface antigen) was detected in 93.1-100% of the vaccines, but the GMT dropped to between 214.3 mIU/ml and 303.5 mIU/ml. After 48 months, 88.8-100% of the vaccinees continued to possess anti-HBs and 70.3-87% had titers above 10 mIU/ml. As expected, the GMT declined further to between 72.6 mIU/ml and 118.8 mIU/ml. There were no significant differences in seroconversion rates and GMT among the different dosage groups. All the vaccinees remained asymptomatic and free from hepatitis B virus infection. The study demonstrated that reduced dosages of the vaccine (0.6 mcg, 1.25 mcg, and 2.5 mcg) were as immunogenic as the standard dose (5 mcg); the 2.5 mcg dose was recommended for the national childhood immunization program in Singapore. No booster is needed for at least 4 years postvaccination. (author's) (summaries in ENG, FRE)
Transfer of DDT used in malaria control to infants via breast milk.
The transfer of p.p'-DDT (1.1,1-trichloro-2,2-bis(4-chlorophenyl)ethane) and its metabolites to infants via breast feeding was studied in an area of KwaZulu, South Africa, where DDT is used to interrupt malaria transmission. Samples of whole blood were collected from 23 infants, together with samples of breast milk from their respective mothers. The mean sum DDT (total DDT) in the whole blood was 127.03 mcg.1<-1> and that in the breast milk, 15.06 mg.kg<-1> (milk fat). The % DDT (%DDT of sum DDT) was significantly higher in the infant blood than in the breast milk (p.<0.05). A multiplicative regression analysis indicated that sum DDT increased significantly (p<0.01) in infant whole blood with infant age. Multiple regression showed that 70% of the variation in sum DDT was due to the variation in parity of the mother, age of the infant, and the sum DDT in the breast milk. These variables accounted as well for the 76.3% of the variation in p,p'-DDE but only for 38.2% of that in p,p'-DDT. Organochlorines were therefore largely transferred to the infant from the mother, with DDT in the environment playing a secondary role. (author's)
[Oral contraceptives and breast cancer: analysis of the statistical power of the association]
The power of the association between oral contraceptives (OCs) and breast cancer was analyzed in all the papers published up to date. 77 publications (from 44 studies) were collected and graded as to quality using meta-analytical methods. Power achieved a figure of >or= 0.8 in a 10.8% of the associations studied. It showed a significant relationship with the existence of a significant relative risk of OCs for breast cancer. The relationship with the sample size of a study was not linear. Power did not demonstrate any significant relationship to other variables related to the design of a study (apart from matching, being the power higher in unmatched studies), or to the biases detected, although studies considered as unbiased yielded a higher power. Logistic regression analysis included as predictors of a power >94= 0.80 the existence of a significant relative risk and the lack of biases in research. (author's) (summaries in SPA, ENG)
Breast-feeding and infant growth in the first six months.
Health professionals followed 67 healthy, full-term, and breast-fed infants every 2 weeks from birth to 6 months old to observe their growth patterns. The group I urban infants lived near Songklanagarind Hospital in the Hat Yai area of Songkhla, Thailand. Group II infants lived in a coastal village 75 km from the hospital. Mothers exclusively breast fed only 5 infants from each group (total of 10 infants) for 4 months. By 6 months, however, only 5 infants overall received only breast milk. The weight curves matched the US National Center for Health Statistics (NCHS) and Bangkok curves for the 1st 3 months then deviated from those standards for the 2nd 3 months. The difference was not statistically significant, however. The lengths of urban boys were not much different from those of the reference population and their trends matched those of the weight curves. On the other hand, the median lengths of the rural boys were much shorter than the NCHS and Bangkok 50th percentiles (p<.01 and p<.05, respectively). Urban boys were always much longer than rural boys (p<.01). For the 1st 3 months of life, the girls' length curves for both groups emulated those of the NCHS and Bangkok. Yet the median length of urban girls was considerable shorter than that of NCHS and Bangkok at 6 months (p<.01) while that of rural girls deviated from the NCHS 50th percentile at 4 months (p<.01) and from Bangkok's 50th percentile at 5-6 months (p>.05). Still all the infants remained physically and developmentally health. Since the weight for age remained good throughout the study, the slow linear growth could not have been due to malnutrition. They concluded that the linear growth differences were due to genetic influences.
Researchers analyzed data on 80 pregnant women seeking a 2nd trimester abortion due to fetal abnormalities at the Federico II Medical School at the University of Naples in Italy to determine the effectiveness and side effects of 2 different prostaglandin analogues and their ability to bring about cervical ripening and uterine contractions. 40 women received 1 mg Gemeprost every 3 hours up to 5 mg in vaginal suppository form while the other 40 women who tended to be primigravidae received an intramuscular injection of 500 mcg Sulprostone every 4 hours up to 2000 mcg. Sulprostone achieved an 85% success rate and Gemeprost achieved an 82.5% success rate. Complete abortion occurred more quickly for multigravidae patients than it did for primigravidae patients (in hours, 10.6 vs. 16.5 for Gemeprost, p<.1; 9.83 vs. 15.65 for Sulprostone, p<.01). There was no statistically significant difference between the 2 treatment groups, however. Side effects were more common among Sulprostone patients than among Gemeprost patients (40% vs. 22.5%). The most common side effects among Sulprostone patients were, in descending order, abdominal pain (75%), diarrhea (50%), and nausea (50%). For Gemeprost patients, they were abdominal pain (55.5%) and headache (44.4%). In terms of uterine contractility, Sulprostone brought about hypertone more quickly than did Gemeprost (in minutes, 18.32 vs. 36.75; range 10-30 vs. 25-50). Gemeprost treatment was more like physiological labor than was Sulprostone treatment. Both prostaglandin analogues produced similar histological and ultrastructural findings of cervical ripening. These results indicated that the women were better able to tolerate Gemeprost.
Cultural study of diarrhoeal illnesses in central Thailand and its practical implications.
Between October 1987 and March 1988, research assistants used the explanatory model interview for classification to interview households in 2 villages in Banna subdistrict and 3 villages in Sam-Tai subdistrict in Ayutthaya province, Thailand. Researchers analyzed the data to examine the respondents' diarrhea-related perceptions, beliefs, and practices. The people used 12 terms for diarrhea. The mean number of terms/person was 6. Everyone used the term tong-sia (generic diarrhea). The Ministry of Public Health used the term ahiwa (severe diarrhea such as cholera) in its health education campaigns but only 39.3% of the people knew this term. 99.1% attributed a transitional phase in normal growth and development to be the cause of taae-tua. Bad child's and mother's food was frequently perceived as the cause of ahiwa, tong-sia, and bid (colicky abdominal pain). Everyone, 93.1%, and 67.5% mentioned flies and germs (sanitation and hygienic practices) as the cause of ahiwa, tong-sia, and bid, respectively. The responses were different between theory and actual practice, however. For example, >91% believed bad food and poor sanitation and hygiene were responsible for tong-sia, but only 34.4% gave this response when referring to index cases. Few people attributed supernatural causes or sorcery to bring about diarrhea illness. Most villagers were impressed with modern drugs and injections but they did not understand their nature. They sought treatment from professional sources that should know appropriate diarrhea treatment but did not. Only 51% used oral rehydration solution (ORS) to treat diarrhea and just 3.5% of them believed ORS to be the most useful treatment. Health education efforts should include descriptions of cholera rather than using the work ahiwa, emphasis on the need to treat diarrhea regardless of its perceived cause, promotion of improved sanitation and hygiene, and communication of appropriate expectations of ORS and its ability to prevent and ameliorate dehydration and reduce mortality.
The New Right and family politics.
Political concern for the family has historically been intermittent; the present context is that there are considerable consequences for individuals, families, and personal life. Socioeconomic and cultural changes brought the rise of the New Right; The Thatcher (UK) and Reagan (US) administrations were committed to strengthening the traditional family. The emergence of the family as a social problem and the political agenda are discussed. The costs of liberalism were felt in a recessionary economy. The US political agenda of Carter to hold a White House Conference on the American Family never materialized. Reagan used the restoration of the traditional American family as a way to get the economy back on its feet. Moral crusaders and the new evangelical Christian movement merged with the political right; the "Gang of Four" (Republican Party right) politicians involved morally conservative communities normally outside the political area into the New Right. Grass roots organizations were mobilized on the Right. The British situation is explained; differences existed in that there were no antiabortion and moral lobby groups tied to the Right although their influence was felt. Pressure group politics is relatively novel to Britain. The Moral Majority in the US and right wing pressure groups on the Tory government are but 1 part of the New Right; it is characterized as populist, proclaiming the Radical Conservatism of Adam Smith and Edmund Burke. The approach in this article is to show the complex interactions of theory, biography, and public opinion in the practical politics of the New Right. Policy outcomes are not predictable because of ideological differences in New Right attitudes toward the family. The attitudes of the moral order and the family is exemplified in the work of Roger Scruton's neoconservative stand on social order, Robert Nozick's Kantian proposition that human beings are ends with natural inviolable rights of individual freedom, Hayak and Friedman's efficacy of the market in guarantees of freedom, and Ferdinand Mount's concern for family based in humanist, secular, and anticollectivist thought. Thatcher and Reagan both incorporated the ideological contradictions of the aforementioned positions. The failure of the New Right in implementing policy is explained. The greatest obstacle was the major demographic, economic, social, and cultural shifts which impacted on the role of women. The camp was divided. Economic policies did not strengthen the traditional family. It is likely that the family will remain as a political pressure point.
Urinary calculi and pattern of fertility among women. A retrospective study.
Researchers compared retrospective data on 250 women who had urinary stones at University Hospital in Alexandria, Egypt with data on 250 matched women who did not have urinary stones to examine the relationship between urolithiasis and fertility patterns among women. They defined fertility patterns by age at 1st pregnancy, number of pregnancies, and oral contraceptive (OC) use. Cases had experienced significantly more pregnancies than the controls (4.6 vs. 3.7; t=3.5797). The cases were significantly more likely to have suffered from a urinary tract infection than were controls (92.8% vs. 21.6%; x squared=258.8392). 95.6% of cases had stones in areas other than the urinary bladder. 56.47% of women who had ever been pregnant had a stone on their right side compared with only 42.86% of those who were never pregnant (Z=2.232). This was probably due to more dilation of the right ureter than the left and subsequent blockage from the pressure of the expanding uterus. Age at 1st pregnancy, pregnancy history, and duration of OC use were not associated with urolithiasis. These results did not consistently match those of other studies looking at the relationship between urolithiasis and fertility.
[International research in family dynamics]
The purpose of this study is to describe the family dynamics of families expecting their 1st or 2nd child. The aim is to describe how mothers and fathers differ in their views on family dynamics and what differences there are between families expecting their 1st or 2nd child. The study forms part of an international comparison study which is currently under way in the US, Estonia and in the Nordic Countries. In the theoretical part of the study family dynamics is examined using the framework developed by Barnhill (1979). The study was carried out in the Turku and Rauma regions of Finland where a total of 136 families were involved. The families were clients of maternity clinics and were expecting their 1st or 2nd child. Family dynamics was studied during the 3rd trimester of pregnancy. A family dynamics questionnaire and measure developed by the Family Research Group in the US were used in the study. Both instruments were based on Barnhill's (1979) conceptual framework of the functioning of healthy families. As statistical methods frequencies, correlations and the T-test were used. Both mothers and fathers reported moderate individuation and flexibility, clear communication, mutuality and role reciprocity. Mothers reported more role conflict than fathers who reported more isolation, rigidity and distorted communication than mothers. There was no significant differences between families expecting their 1st or 2nd child in terms of individuation, flexibility, stability and communication. After childbirth the latter reported more isolation and role conflict. (full text) (summary in ENG)
ICMR's multicentre study on comprehensive MCH care.
The Indian Council of Medical Research (ICMR) is conducting an 8-center study which applies known risk factors to design a system and feasible methodology which uses the high risk approach to maternal and child health (MCH) care within the existing health care system in India. The primary health centers or subcenters include Delhi, Ahmedabad, Chandigarh, Gwalior, Jaipur, Lucknow, Pune, and Varanasi. 3 stages make up the study: situation analysis of each health center (6 months), developmental phase (1 year), and intervention period (3.5 years). The situation analysis has revealed that even though the health centers and subcenters had medical officers, they lacked adequate numbers of paramedicals. Paramedicals lacked practical knowledge and experience. The community did not use MCH services. All the centers needed resuscitation equipment and anesthesia and lacked other equipment. As part of the developmental phase, ICMR has obtained necessary equipment. It also has done some baseline surveys at the centers. ICMR has assigned 1 intervention to each health center which serves 80,000-1,690,000 people. Broad intervention strategies are reorientation training of paramedicals and medical officers, community education, decentralization of MCH/family planning, goals, and development of a referral system. 2.5 years into the intervention stage indicates improvement in prenatal registration (50-80%), detection of high risk mothers and infants (0 to 6-50%), basic services to registered pregnant women, and referral of risk cases. This MCH care program is attempting to provide sterile and safer care for pregnant mothers via traditional birth attendants and delivery kits.
Improvement in neonatal care in India is needed in order to fulfill the National Health Policy to reduce infant and perinatal mortality and low birth weight babies. 50-60% of perinatal and infant mortality is due to neonatal mortality, specifically low birth weight. There have been no declines in any of the states even though there are literacy, fertility, poverty and health personnel differences between states. The health delivery system is described. Basic facilities are lacking in subcenters and primary health centers: weighing scales, blood pressure recorder, urine analysis, and blood transfusion capability; pregnancy registration is <40%. <40% of women believe that the female multipurpose worker (ANM) is a maternal and child health worker; Dais made postnatal visits to 25% of the women and infants, while physicians and ANM's visited <10%. The most frequent method of delivery is home delivery with a Dai or relative in attendance. Information on temperature control at birth, hand washing, feeding, and identification of high risk infants by health personnel is inadequate. There are no neonatal units in the entire country even though there are 8 million low birth weight babies/year and >1 million neonatal deaths/year. Neonatal causes are primarily birth injuries, aspiration syndrome, and neonatal infections (tetanus, pneumonia, and diarrhea). Studies have identified health service improvements to reduce neonatal mortality. In India, the priority should be to 1) establish delivery of neonatal and perinatal care at all 3 levels of care, 2) train and educate all health personnel in perinatal and neonatal care, and 3) improve community participation by involving the community in decision making on kind of care, perinatal care, and health education and by monitoring such services. Infant care must extend from prenatal through postnatal care, which is currently fragmented, through a 3-tiered system. 80-85% of all infants need care at Level I; 15-20% require Level II care; and 1-5% need Level III care. Health services and supplies may need to be provided at the village rather than the subcenter level and in postpartum services. Other possibilities are to include neonatal care within the Integrated Child Development Program or the Universal Immunization Program. Community leaders could monitor neonatal services. Regional institutes could provide training for all health personnel.
Secular trends in infant and perinatal mortality in India -- implications for child survival.
In India, perinatal mortality, neonatal mortality, and stillbirths have stagnated at unacceptably high rates. Yet the infant mortality rate (IMR) has fallen slowly but steadily. Vital statistics differ from state to state making comparisons difficult. Nevertheless IMR, neonatal mortality rate (NMR), and perinatal mortality rate (PMR) are lower in urban areas than in rural areas, but the stillbirth rate (SBR) is essentially the same. Uttar Pradesh has the highest IMR, NMR, and PMR while Kerala has the lowest rates. In Kerala, the slope of decline of IMR is sharper than that of Uttar Pradesh. There were no apparent declines of NMR and PMR in Uttar Pradesh while in Kerala the decline was obvious. Thus health workers must dedicate much energy and time to reduce deaths during the perinatal and neonatal periods. Neonatal deaths make up almost 50% of infant deaths. The proportion of neonatal deaths has risen steadily. Therefore the child survival program has mainly been effective during the postneonatal period regardless of locale. Almost 40% of all deaths (PMR/IMR + SBR ratio) occur in the perinatal period. In urban hospital studies, the major causes of perinatal mortality include birth asphyxia and trauma, low birth weight (prematurity and intrauterine growth retardation), bacterial infections, and jaundice. In Uttar Pradesh, neonatal tetanus causes 25-30% of all infant deaths while in Kerala it only causes <2%. In rural communities, the leading causes of perinatal deaths are birth asphyxia and trauma, infections, and low birth weight. Poverty and inadequate medical care at delivery are the leading independent determinants of neonatal mortality accounting for 62% of the regional variation. Trained health workers must improve perinatal care within the existing health system to improve child survival.
Compliance of Austrian tourists with prophylactic measures.
Researchers analyzed data on 2627 Australian tourists returning from Kenya, Sri Lanka, Thailand, and the Maldives (November 1988-March 1989 and October 1989-January 1990) to examine tourist behavior regarding prophylaxis measures. 94.1% sought health information. 1st time tourists were more likely to get this information than those who had already made at least 1 visit (98.1% vs. 92%; p<.05). Many tourists relied on travel agencies (37.5%) and friends (20.2%) for this information. Experienced tourists were not as likely to depend on travel agencies and friends as were 1st time tourists (p<.05), however. 92% of those who sought information took at least 1 precautionary measure. 96.3% of tourists to Kenya carried out a prophylactic measure compared with 79.6% of those to the Maldives (p<.05). Tourists tended to obtain immunoglobulin prophylaxis against hepatitis A (75.1-84.8%), yet not obtain vaccinations for typhoid fever (55.7-68.1%), tetanus (43.3-56.7%), and polio (25.9-38.7%). They appeared to be aware of dietary risks (86.1%), but not about sexually transmitted disease risk such as AIDS (41.7%) or taking a medical travel kit (50.5%). After a mass media campaign, these figures increased to 93.1% (not significant), 64.7% (p<.01), and 68.2% (p<.05). The Maldives was free of malaria, but 31.9% still took malaria prophylaxis. Most travelers to Thailand (88.35) also took malaria prophylaxis, yet 81.8% of them went to malaria-free areas. Tourists to Kenya had better compliance than those to Sri Lanka (94.2% vs. 82.7%, p<.05). Moreover only 74.7% of travelers to Kenya took mefloquine, the recommended choice for short-term travelers. Compliance was greater among those who took mefloquine than it was for those taking chloroquine (74.1% vs. 90.3%, p< .01). The most important finding was the considerable misinformation about and noncompliance with malaria prophylaxis. For example, the more complex the intake instructions the more likely noncompliance occurs.
Effect of family size and income on the biochemical indices of urban school children of Bangladesh.
The relationship between family size and income and the biochemical indices of 242 children ages 5-12 years from 5 schools in Dhaka City, Bangladesh was investigated. Socioeconomic data were collected by questionnaire and blood samples were drawn by visiting each school on a predetermined date. Mean levels of all measures, except for serum zinc, fell within the normal range. Older boys, but not girls ages 10-12 years had statistically significantly higher hemoglobin, serum protein, and serum vitamin A levels compared with those of the younger boys ages 5-9 years. The children were divided into 3 family size groups (small, up to 4 members; medium, 5-7 members; and large, 8 or more) to investigate the effect of family size on the biochemical data. The children from smaller families showed significantly higher levels of hemoglobin an serum vitamin A compared with the children from large families. For serum protein, copper, and zinc, there was no statistically significant difference between the children of different family size groups. To analyze the effect of family income, children were divided into 3 income groups (low, up to taka 2000; medium, taka 2001-4500; and high, 4501 or more). The children from the low family income group had significantly lower serum protein (7.5 g/100 ml) and hemoglobin (13.4 g/100 ml) levels compared with those of the children from the high family income group (for protein, 7.7 g/100 ml and hemoglobin, 14.1 g/100 ml). The children from the higher family income group showed statistically significantly higher serum vitamin A (46.2 mcg/100 ml) levels and lower serum copper (108.0 mcg/1000 ml) levels compared with those of the children from medium (for vitamin A 38.1 mcg/100 ml and for copper, 140.2 mcg/100 ml) and low family income groups (for vitamin A, 34.9 mcg/100 and for copper, 145.0 mcg/ml). These differences in biochemical indices persisted after statistical adjustment for the effects of age, sex, father's occupation, and family size. These findings suggest that family size and family income play important roles in determining the biochemical indices of urban schoolchildren in Bangladesh. (author's)
Immunochemical tests of potential fertility.
There are many methods of determining the physiological basis of cyclical periods of potential fertility: calculations, sensations, or physical or chemical biosensors. This article reviews the development of self-tests of potential fertility using immunoassay of hormone metabolites in urine. Indices of potential fertility in urine are the concentration of principal metabolites of steroid hormones and luteinizing hormone (LF). The ovaries produce an estimated 50-800 mcg of estradiol/day, the most active estrogen which is concentrated in the peripheral circulation during the preovulatory period of rapid follicular growth. Measurements may be taken from the blood, saliva, or cervico-vaginal fluid, and urine as estrogen-3 or 17 beta-glucuronide. The metabolism of progesterone shows changes at carbon atoms 3, 11, 17, and 20. Urine contains lower concentrations of 5 beta-pregnanediol-3 alpha-glucuronide (P3G), followed by 5 beta-pregnanediol glucuronide and 5 alpha-pregnanediol glucuronide. Methods of measurement are presented, including the mean changes in the urinary concentrations of estrogen 3-glucuronide (E3G) and P3G and their concentration ratio in relation to day 1 of menses, the day of luteinizing hormone LH peak, and the time limits for ovulation during menstrual cycle. A laboratory test of E3G in early morning urine (EMU) from 38 subjects showed that delineating a defined fertile period (day of maximum follicular diameter minus 3 to day plus 2) was possible in 89% of cases. New methods with immunotubes or immunostrips, novel antibodies, and idiometric assay attempt to improve the signal/background ratio; each method is described. Immunotubes for measuring steroid glucuronide may be light absorbing, light emitting (fluorescence polarization), and light emitting with time resolved fluorescence. Each procedure is described. The present technology demonstrates that immunoassays can be performed as self-tests, and what remains to be done is ascertaining the most appropriate one for determining potential fertility.
Prolonged lactation contributes to depletion of maternal energy reserves in Filipino women.
Researchers analyzed data on a large group of postpartum women in urban and rural areas of Cebu, the Philippines and gave birth during 1983-84 to examine short-term effects of lactation. They controlled for caloric intake, energy expenditure, reproductive history, and seasonality. About 14% had a body mass index of <18.5 indicating chronic energy deficiency. 55% of the women lactating at 24 months experienced net weight losses (=or> 1 kg). Women in this group averaged a weight loss of 3.8 kg. They lost weight consistently during the 24 months. Lactation had a significant negative effect on the weight of urban women (p<.01). These effects intensified as duration and intensity of breast feeding increased, e.g., for each 100 days postpartum, lactation caused 0.117 kg of weight loss. Among urban women,the main effect of full breast feeding for the 1st 6 months was significantly greater than that of partial breast feeding (p<.01). By 6 months, urban mothers who exclusively breast fed had lost 3.6 kg. Rural mother did not begin to experience the negative effects of breast feeding until after 13.5 months. At the end of 24 months, they most likely los 1 kg. The key determinants of weight loss included breast feeding for >12 months, greater maternal age, low caloric intake, high energy expenditure, and low initial weight. These results suggested that caloric intake and lactation strongly affect maternal weight and weight loss. To improve the nutritional status of lactating mother, maternal and child health programs should place more emphasis on promoting adequate food intake among lactating mothers of low body mass. They should also continue to promote breast feeding to improve infant health.
Examination is made of the "avoidable factors" in maternal mortality based on the standards realistic under prevailing country conditions: patient factors or inaccessible health services and failures in the health services delivery system. Patient factors are defined as those actions by the patient that are faulty: delayed arrival or nonarrival at a health facility, failure to seek legal abortion or interference with pregnancy, nonuse of prenatal care, and transportation problems. Problems that jeopardize survival chances are also quality of care issues of "doing too little, too late." Conditions in the health services delivery system which exacerbate a woman's condition are shortage of trained personnel, lack of equipment and supplies, and poor patient management. Prevention and control of maternal mortality is dependent on structural factors and women's resources such as their time, money, information they have, and their authority over decision making. Action must be taken by health activists to make fundamental changes in both the structure and delivery of health services. There must be a call for reallocation of national resources to the health sector of which a significant proportion should be directed to the health care of women and, specifically, maternal mortality. 5% of gross national product is the usual expenditure for health by most developing countries, and <50% is devoted to primary health care and a very small amount to maternal and child health. Women's health regardless of maternal status needs attention, but not at the expense of maternal health care. Community level resources need enhancement, so that women have access close to their homes. Proper resource allocation also means equipping the 1st referral levels with necessary supplies, equipment, and personnel. 5% of maternal mortality would be reduced with the availability of 8 surgical functions identified by WHO for health facilities serving populations of 100,000. Training nurse practitioners and midwives is a viable option for complicated deliveries. Innovations such as "waiting shelter" for high risk women in need of transport are creative and use scarce resources to best advantage. Health services must be socially accountable with careful record keeping and public accessibility of records. The deprived section of society should be empowered and participate in the changes.
Measures to reduce the infant mortality rate in Tanzania.
In 1967, the Tanganyika African National Union, now Tanzania, adopted socialism and self-reliance as its national policy. It emphasized rural health development. It decentralized health care planning which encouraged local people to participate. In 1971, the government resettled rural peoples into villages. This made it easier to provide services such as health dispensaries and a clean water supply. Mass mobilization activities ranged from building latrines to improving sanitation. They served to raise health awareness and to promote community participation. The government has consistently expanded rural health facilities and trained more local health workers. By 1984, 72% of the population lived within an hour's walking distance from an essential health care facility. The Ministry of Health (MOH) in Tanzania has various disease prevention programs designed to reduce infant mortality. The maternal and child health program provides services before, during, and after childbirth. Between 1978-84, the percentage of mothers who deliver at a health facility increased from 53% to 60%. The government encourages small-scale farmers to be self-sufficient which prevents child malnutrition. The MOH's nutrition program promotes breast-feeding mothers about an adequate and balanced diet. The control of communicable diseases program has an important role since the leading causes of infant death are communicable diseases. Other programs geared toward reducing infant mortality are the essential drug program and the health education program. MOH efforts have resulted in a reduction in infant mortality from 135 - 105. Nurses in Tanzania have the most potential to affect further reduction in infant mortality. They can do so by becoming more efficient in delivering primary health care. Tanzania could make greater strides in reducing infant mortality by improving economic growth.
Reproductive Health International Program Assistance: semi-annual report, October 1991 - March 1992.
The program objectives, summary of activities, challenges ahead, and accomplishments in logistics assistance, survey assistance, and other activities are given in the semiannual report on the Reproductive Health Program Assistance (RHIPA) program. RHIPA is the product of a 5-year Participating Agency Service Agreement between the US Agency for International Development and the Division of Reproductive Health of the Centers for Disease Control. RHIPA provides longterm technical assistance in logistics management, population-based surveys, epidemiologic training and research, and clinic management improvement. In 1992, 12 person trips (203 consultant days) were made to 9 countries for contraceptive logistics support. 17 person trips (160 consultant days) to 11 countries were made for survey assistance. 3 person trips (16 consultant days) were made for providing epidemiologic assistance. 109 days were spent in Africa, 106 days in the Near East, and 103 days in Latin America and the Caribbean, 34 in Eastern Europe, and 27 in Asia. Survey assistance was provided primarily in the Latin American region. Africa and the Near East received the most support for logistics management. Important contributions made during the 6 months were the collaboration with the UN Population Fund in examining the logistics in Zimbabwe and the meeting with expert personnel to exchange information on recent developments in logistics, specifically contraceptive forecasting. A determination of the acceptable level of error was not reached, but there was consensus that oversupply was less costly than underestimates. Assistance with compilation of Contraceptive Procurement Tables and analysis of contraceptive distribution data was conducted in Turkey, Mozambique, Jamaica, El Salvador, and Uganda. RHIPA with Indian family planning (FP) services in Uttar Pradesh worked to strengthen FP and to act as a catalyst for overall Indian FP activities. The survey assistance provided to 11 countries is described, of which the 1st time only FP survey conducted in Belize is highlighted. Young Adult Reproductive Health Surveys were also completed in Brazil. Epidemiologic research and training assistance was provided to Hungary and Czechoslovakia. Features of the newest challenge in Eastern Europe are given: low fertility, high rates of unintended pregnancy, and data insufficiency.
Theoretical components of STD counselors' messages to promote clients' use of condoms.
Based on constructs of the theory of reasoned action, 2 nursing professors developed and used the Beaman-Strader condom attitude instrument to identify distinct beliefs and attitudes of 310 clients at 2 sexually transmitted disease (STD) clinics in a Midwestern state in the US about condom use. The results formed the basis for 4 vignettes the professors developed which they administered to 40 counselors at sizable STD clinics in the same state. They wanted to determine whether their responses to promote condom use would be based on the clients' attitudes and normative beliefs on condoms. Overall the counselors rarely responded to the theoretical constructs important in promoting behavioral change. They tended to use moralistic messages (19%), informational messages about condoms (17%) and disease prevention (15%), and fear messages (13%). In many cases, counselors used informational messages which were irrelevant for the risk behaviors in a vignette or did not use them when they were relevant. For instance, some counselors provided information about intravenous (IV) drug use but the client in the vignette was not an IV drug user. Since informational messages alone are not effective, moralistic messages work against disease prevention efforts, and fear messages do not change risky sexual behaviors, the results indicated that the messages the counselors conveyed will not result in sex behavior change. They must listen to each client, identify their attitudes and normative beliefs, and then use messages that reflect the behavior and those attitudes and normative beliefs.
Questionnaires were completed by a sample of youth ages 15-24 who attended day hospitals in the Cape Peninsula. Of the total sample of 225, 73.3% indicated they had experienced sexual intercourse; of these, 27.3% had had 2 or more partners in the previous year and on their last coital episode, 91.0% had known their partner for more than 7 days. 52.8% had used some form of contraception. The criteria of a strict definition of missed opportunity for contraception intervention were fulfilled by 7.6% of the total sample, while 43.6% of those who had experienced sexual intercourse and 43.9% of those who had not did not receive contraception intervention but would have liked to. Those who had had more than 1 partner in the previous year were more likely to have satisfied the strict definition of missed opportunity, while of those who had not experienced sexual intercourse, younger respondents and students were more likely not to have received contraception intervention despite desiring such intervention. It is concluded that all youth attending day hospitals should routinely be offered contraception counselling and that the issue of sexually transmitted diseases should be addressed simultaneously. (author's modified)
Staff in the pediatric department at Edendale Hospital in southern Natal, South Africa organized a community pediatric information system to process measles-related data to identify means to prevent measles outbreaks such as occurred in 1987. The 1987-90 data covered the fragment Edendale health ward (EHW) made up of at least 10 geographically distinct areas and administered by KwaZulu health services. Measles incidence fell consistently during the 4-year period despite chronic political unrest which prevented interventions in the peripheral vaccination service. More than 80% of all hospital cases were from EHW which highlighted the need to evaluate KwaZulu vaccination services. More than 60% of these cases were restricted to 1 magisterial district, the Edendale/Vulindlela district. In fact, the highest incidence rates within this district were in the crowded periurban area of Edendale. This high incidence occurred here despite its proximity to Edendale Hospital. So researchers conducted a vaccination coverage survey to learn why coverage was low. During the 1987 epidemic, almost 75% of all measles cases were from the Edendale/Vulindlela (especially Edendale 27/1000) and the Richmond subdistrict (40/1000). The Richmond subdistrict also had very high incidence rates in 1988 and 1990. Since the information system was not yet available during the epidemic, health workers conducted a mass measles immunization campaign throughout EHW. The information system later showed that the campaign could have been limited to Edendale/Vulindlela and Richmond districts to achieve the same results. This would have saved much time and effort. This system helps health workers to conduct measles surveillance, quickly note any increases in measles cases, locate exactly where they are, and to respond to outbreaks in an effective way.
Ethical aspects of termination of pregnancy following prenatal diagnosis [editorial]
Prenatal diagnosis allows women to know fetal status such as pathological and normal conditions and sex. Women then must choose between abortion and continuation of a pregnancy. Many parents want no one to suffer. When prenatal diagnosis reveals a grave abnormality that will cause lifelong suffering many choose to abort. On the other hand, some parents would not abort a fetus unless the mother's life were at stake. Medical counselors also exhibit this spectrum of attitudes. Prenatal screening places women under much stress. Counselors must appreciate the pressures, dilemmas, and anxieties these women experience. As prenatal screening increases its abilities to uncover more and more abnormalities, the pressures, dilemmas, and anxieties will become more profound. Women need adequate information to make an informed decision to either undergo or not undergo prenatal screening. Medical counselors should monitor how screening affects women and families. New knowledge such as body build and conditions which will affect a fetus late in adult life which comes from expanded prenatal diagnosis abilities poses an ethical dilemma about what constitutes quality of life. Any decision made is not made by the person affected by such a condition or particular aesthetic concern. For example, Huntington's chorea characterized by chronic progression of rapid, jerky involuntary movements and mental deterioration may not show up until 30-50 years later and the 1st 30-50 years may be acceptable. Short stature, infertility, and abnormal appearance (Turner's syndrome) may cause difficulties for someone to have a normal life, but such a person has normal life expectancy, and hormones and in vitro fertilization allow some women with Turner's syndrome to bear children. Counselors should ask women before screening and after much counseling which information to withhold from them. If the disorder is cosmetic, minor, treatable, or probably not going to hinder future quality of life, the counselor should not advocate abortion.
Contraception for the disabled.
The obstetrician-gynecologist clinic should provide easy access for the disabled patient such as a hydraulic pelvic examination table. In most cases, disability does not affect sexuality, menstruation, or fertility but may change the level of interest and activity. Thus the physician should include sexual counseling even for abled patients with disabled partners. He/she should document the informed consent process to make sure it is legal and ethical. He/she must do a thorough evaluation of each disabled patient and her needs and develop a special protocol for each patient. The physician must know those disabled conditions that limit pelvic examination ability an contraindicate some contraceptives. Oral contraceptives (OCs) and progestin implants are contraindicated in women with spinal cord injury (SCI), disabled by a stroke, and with neurologic disorders that inhibit mobility in the lower extremities and cause circulatory disorders. Depending on individual circumstances, physicians should not advise OC use for women who are mentally retarded, mentally ill, or are drug abusers since they either do not understand, cannot remember, or are not motivated to take OCs regularly. Progestin implants may be a viable option for drug abusers, the mentally ill, and mentally retarded women. Once the US Food and Drug Administration approves injectable progestational agents, they could be another option for these women. The IUD is contraindicated in women who have no sensory capabilities and could not notice an ectopic pregnancy and pelvic infection. This may include women with some neurologic disorders, stroke, SCI, and multiple sclerosis. It is also contraindicated in women who have a blood disease, use anticoagulants, or have AIDS. Barrier methods could be used if a disabled patient or a partner is able to put them in place. In some cases, sterilization may be justified on medical grounds.
Casey and the resuscitation of Roe v. Wade.
Casey v. Planned Parenthood Association of Southeastern Pennsylvania, 60 U.S. 4795 (1992) is a great victory for procreative liberty. The US Supreme Court reaffirmed the principe of Roe v. Wade, 410 U.S. 113 (1973): a women has a right to terminate a pregnancy up until viability, and thereafter when necessary to protect her life or health. The decision allows the states to impose regulations insuring that abortion decisions are "thoughtful and informed," provided they do not impose an "undue burden," a change from Roe where early pregnancy regulations were permitted only when the state had a compelling interest. In Casey, the Court's perception of its legitimacy and its reliance on stare decisis left intact the substantive due process line of cases establishing the privacy interest related to marriage, procreation, contraception, family relationships, childbearing, and education, reaffirming its authority to define fundamental unenumerated rights through "reasoned judgment" in interpreting the liberty clause of the 14th Amendment. Casey leaves the US with the most liberal system in the world, but the issue is unnecessarily politicized because constitutionalizing the issue has removed almost all ability for compromise. If the federal Freedom of Choice Act is defeated, Casey may provide the vehicle for a compromise. The affirmation of abortion presents the possibility that the manufacturer of the contragestive drug RU 486 will lift its self-imposed prohibition against marketing RU 486 in US. Casey sympathetically describes the choice facing a pregnant woman and explicitly sees abortion as a quintessential issue of women's rights. "Her suffering is too intimate and personal for the State to insist, without more, upon its own vision of the woman's role, however dominant that vision has been in the course of our history and our culture."
Changing abortion laws highlights society's difficulty with finding the perfect solution to the legal and social problems of abortion. The Casey decision underscores that discontent; some urged a return to Roe, while others urged overturning Roe. The US Supreme Court decided in Casey not what was wise, but what was constitutional. It upheld the informed consent provision and the 24-hour waiting period, parental consent for a minor (allowing the possibility of a judicial bypass procedure), medical emergency exceptions to the above, and facilities' reporting requirements of the Pennsylvania law; leaving it to the citizens to determine the law's wisdom. Polls indicate that the majority of Americans wish to "permit but discourage" abortion, suggesting the receptivity to some controls on abortion. England and the US regard the law as commands requiring conformity, with measures to coerce; while continental Europe regard the law as a teaching tool to communicate messages, convey values, summarize stories, and foster attitudes, for laws function to generate, educate, and perpetuate a people's sense of itself. The Pennsylvania law expresses a message of caution, affirming the seriousness of the situation, and communicating values: 1) that time is necessary when making a moral judgment necessitated by conflict and crisis; 2) that consultation adds sources of information and insight; 3) that information about the procedure is necessary for an informed, deliberative choice; 4) that a counseling opportunity allows for clarifying and personalizing the decision, and 5) that alternatives be offered (disallowed under Casey). The author supports these values on behalf of maternal and fetal life, as well as the granting of the final judgment to the woman. Moral living requires that social conditions enable personal judgment and decision, as well as allowing the larger community to communicate a cultural bias. Our discontent can motivate us to alter the conditions making abortion desirable.
Fertility-aware couples can use natural family planning (NFP) to prevent pregnancy or to time intercourse so conception occurs. Fertility awareness also helps in diagnosing and treating premenstrual syndrome, infertility, and abnormal patterns. NFP can be 89% effective (comparable to that of barrier methods) when couples are properly trained and strictly follow NFP techniques. The rhythm or calendar method consists of numerical calculations based on previous menstrual cycles. Menstrual cycle charting involves keeping records of the last 6-12 cycles to predict future cycles. It is undependable during postpartum, lactation, and at the end of the childbearing years, however. The basal body temperature (BBT) method includes women measuring their temperature every morning before rising. A fall in BBT usually comes 12-24 hours before ovulation. Examination of the cervical mucus also helps to identify fertile days. Mucus during fertile days is clear, plentiful, elastic, thin, and slippery and forms a thin strand at least 6 cm long when placed between 2 fingers. These qualities facilitate sperm mobility through the cervix. The sympto-thermal method is a combination of the previous methods. It also takes into consideration other signs and symptoms of fertility such as intermenstrual pain. Breast feeding also provides some protection against pregnancy but can be unreliable. A major disadvantage of NFP is other methods are more effective. Some advantages include it being immediately reversible, safe, and increases fertility and infertility awareness. If a couple is interested in using NFP to prevent pregnancy, health providers or counselors must make the time to conduct the extensive training. NFP success hinges on user's motivation and their ability to interpret signs and symptoms of fertility.
Innovations in contraception: the Norplant system.
The Norplant implant is described: the release rates and serum levels of levonorgestrel, the mode of action, the indications and contraindications, the effectiveness, incidence of ectopic pregnancy related to Norplant use, metabolic effects, advantages and disadvantages, insertion, the role of counseling, and management of side effects (menstrual bleeding changes, headache, weight changes, mastalgia, and acne), continuation rates and reasons for termination, and removal. Norplant is currently the most effective method of contraception. Counseling is important in order to provide women with as much information for informed consent and to increase awareness and interest in Norplant. In a clinical trial in California, 95% expressed a high level of satisfaction upon implant removal and 71% desired Norplant again; 91% recommended Norplant to friends. 82% reported the side effect of menstrual change; 66% reported 2 or more side effects. Clinical development is ongoing for other sustained release contraceptives. Norplant was developed by the International Committee for Contraceptive Research of the Population Council, and manufactured by Huhtamaki Oy/Leiras Pharmaceuticals in Turku, Finland. Clinical trials have been conducted since 1975. 20 nations have approved its use, and more than 1.5 million women use it. Silastic rubber tubing encapsulates 6 capsules of 36 mg/capsule crystalline levonorgestrel, a strong progestin. Implantation is done just under the skin in a fan shape; levonorgestrel is released at 80 mcg/day for 6 months, and 30-35 mcg/day for the remainder of use. The mode of action is not completely understood, but the assumption is that it is similar to the progestin-only pills. The mechanisms that alter fertility are 1) the change in hypothalamic-pituitary level to inhibit midcycle luteinizing hormone surge, while follicle stimulating hormone and estradiol levels remain within the normal range, 2) the thickening of the cervical mucus which prevents the entry of sperm into the upper genital tract, and 3) the suppression of the estrogen-induced cyclical maturation of the endometrium. It is not an abortifacient. Contraindications are few, but include active thrombophlebitis, undiagnosed abnormal genital bleeding, known or suspected pregnancy, benign or malignant liver tumors, and known or suspected breast cancer of progestin-dependent neoplasms.
Over the centuries cervical caps have been made of gold, silver, opium, beeswax, and rubber. US women have been able to use the Prentif cavity rim (PCR) cervical cap since 1988. Women in England have been using it since the early 1900s. It comes in 4 sizes (22, 25, 28, and 31 mm). Before insertion, women must add spermicides inside the cap. The US food and Drug Administration (FDA) does not recommend it be worn for >48 hours, however. During this time period, they can have intercourse more than once without reapplying spermicide. The PCR cervical cap acts as a barrier and the gel or cream destroys any sperms which slip through a gap between the cap and the cervix. Among near perfect users, its effectiveness rate is 94%. Women at highest risk of pregnancy include younger, less educated, and more sexually active women and those who want a family someday. The most frequent complaints are cap dislodgement, cap odor, and partner discomfort but they do not always cause women to stop using it. Some advantages and benefits include high effectiveness, less urinary problems, convenience, inexpensive, and easy to use. Various disadvantages are that there are few trained clinicians, there is limited awareness among women and clinicians, they do not fit 20-40% of women, and fittings are time consuming. An abnormal Pap smear, cervical dysplasia, history of pelvic cancer, history of toxic shock syndrome, and severe cervical laceration constitute absolute contraindications. Temporary contraindications include current history of pelvic, cervical, vaginal, or urinary traction infection; intermenstrual bleeding; medical procedures to the cervix; breast feeding; and oral contraceptive use. As part of the initial cervical cap fitting, clinicians should perform a complete physical examination. They should also take the needed time to counsel and educate the women about the cap and its insertion.
Contraception for midlife women.
For women beyond the desire for childbearing, the contraceptive options are discussed as appropriate for the age and in light of risks and benefits. Reeducation and careful history taking are important. A pregnancy for a woman >40 years places a woman at greater risk for an elective abortion and greater risk of maternal mortality from abortion; low dose contraceptive use can have beneficial effects for menopausal women. Methods are grouped as contraceptive steroids (combination pills, progestin-only pills, oral preparations, implants, and injections), IUDs, barrier methods (diaphragms, cervical caps, vaginal sponges, spermicides, and contraceptive film), condoms, sterilization, and natural family planning. Empowering women means providing current scientific information and urging women to examine their lives, and to review how and why contraceptive choices were made, and the consequences of the choices. Sexually transmitted disease counseling is appropriate for women in new relationships. A positive attitude toward menopause needs to be conveyed. Combination pills at the lowest dose possible are recommended for women >35 years who are healthy, nonsmoking (or smoking <15 cigarettes/day), blood group O, and able to derive benefits from the pill. Benefits include a 30% reduction in uterine fibroids and protection against endometrial cancer, and decreased risk of ectopic pregnancy, pelvic inflammatory disease (PID), and iron deficiency anemia. Multivitamin use with the pill is recommended due to reduced liver stores of vitamin A. Women >40 years with a parent dying of cardiac disease <50 years or with a history of hypertension, diabetes, or hyperlipidemia are not suitable candidates. 35 mcg preparations are recommended for women 35-45 years, and 20 mcg for women over 45 years. Progestin-only pills are recommended for those with contraindication to estrogen, but have a higher pregnancy rate. IUD use among older women may be difficult due to cervical or pelvic surgery; there is a higher incidence of PID and ectopic pregnancy with IUD use. Barrier methods are more successful for older women due to the changing vaginal anatomy. Vasectomy is the safest sterilization procedure.
Hygiene habits and carriers in families with a child who has had typhoid fever.
The relationship between asymptomatic shedding of bacterial enteropathogens and the hygiene habits of families who have had a child with typhoid fever (TF) are investigated. The sample was made up of 80 families: 40 in which 1 child had had TF (group A) and 40 in which no children or either of the parents had had a history of TF (group B). In each group, 20 families belonged to a low socioeconomic status (SES) and 20 to a high SES. A structured interview was used to evaluate the SES and hygiene habits of the child; observations were made to measure the hygiene habits of the family (toilet, kitchen, and food preparation) and bacteriological studies (fecal samples and handmarkers). Results show that carriers were more frequent in group A than in group B. The bacterial species found were significantly more numerous in group A than in group B (fecal samples: E. coli, the classic serotypes, Shigella ssp, and handmarkers: E. coli). Families of group A had higher carriage rates than those of group B. Finally, there exists a significantly higher association between inadequate hygiene habits and carrier families. These results show the need to teach specific habits of proper hygiene to the entire population, because of the fact of belonging to the high SES does not itself preclude inadequate hygiene habits. (author's) (summaries in SPA, POR)
Escherichia coli associated with acute measles and diarrhoea at Kenyatta National Hospital, Kenya.
303 children under age 5 with acute measles and diarrhea (cases) and 300 other age-matched children with diarrhea (controls) were examined for enteroadherent E. coli (EAEC) and other agents including rotavirus and Cryptosporidium. EAEC was determined by tissue culture of HEP-2 cells. Other agents were determined by conventional methods. EAEC was identified from both cases and control accounting for 10.3% (31/303) and 15.2% (46/300), respectively. Other bacterial agents were: 10.3% (31/303) from cases and 12.8% (39/300) from controls. A higher detection rate of enteroparasites was seen among cases 15% (45/300) than controls 8.9% (27/300) whereas rotavirus was the reverse, 3% (9/303) in cases and 30.3% (92/300) in controls. To the knowledge of the authors, characterization of EAEC has not been done before and therefore might be an attributing factor in some of the unexplained diarrheal cases. (author's)
In Brazil, the Prostitution and Civil Rights Program works to fight against stigma and violence against sex workers and to foster self-esteem, self-determination, and greater access to civil rights. It sponsors the Brazilian Prostitutes' Network. In 1988, the Ministry of Health asked the program to join the Ministry to produce sexually transmitted disease/AIDS prevention materials. The materials were ready for distribution in early 1991 when the program began recruiting prostitutes and transvestites for its Health Education Project. The aforementioned groups and the Brazilian chapter of International Planned Parenthood Federation are working together on this project. By mid-1992, the project recruited 17 community-based health agents (15 female and 2 male prostitutes) from different prostitution areas and through a network of contacts from these areas of Rio de Janeiro. After informal training in April or June 1991, they went into their communities to inform people of their health agent role, distributed free condoms and AIDS education material, and promoted the project. Health agents maintain a weekly report of condom and education material distribution. This allows them to monitor their progress. Health agents now meet with their peers to discuss sex and health issues. The communities have opened their doors to the groups. The project is also geographically mapping the sex trade to target health care and other resources in each area. It is pursuing a reference/counterreference relationship within the existing public health system in Rio de Janeiro. Involvement of sex workers in all phases contributes to the success of the project so far. Future research is needed to determine whether the project is reducing risk of HIV transmission, however.
Rapid spread of HIV infections in Abidjan, Ivory Coast, 1987-1990 [letter]
In 1986 relatively high HIV seroprevalence rates were observed among prostitutes, tuberculosis patients and pregnant women living in Abidjan, Ivory Coast (1). Soon thereafter, a high number of AIDS cases were reported (2). In order to evaluate the spread of HIV-1 and HIV-2 infections in Abidjan, we continued the surveillance of these populations from 1987 to 1990. The populations tested were selected each year in the same hospital for the pregnant women and the tuberculosis patients, and in the same areas of Abidjan for the prostitutes. The number tested each year is shown in Table 1. The mean ages in the groups were similar. The serum samples were tested for antibodies to HIV-1 and HIV-2 by an ELISA (ELAVIA-1 and ELAVIA-2; Diagnostics Pasteur, France). All positive sera were retested by a corresponding Western blot (Dupont de Nemours, US, and Diagnostics Pasteur). The criterion for positivity was the presence of antibodies to at least 2 envelope proteins (WHO criteria). Comparison of the groups was done by chi-square analysis. Among prostitutes, overall HIV seroprevalence increased from 39.7% +or- 4.5% to 69.4% +or- 10.9% (chi square=17.5, p<0.001) between 1987 and 1990. This overall increase was due to increases in HIV-1 (22.4% +or- 7.7% to 41.7% +or- 11.6%; chi square=7.76, p<0.01) and dual HIV-1 + HIV-2 infection (6.9% +or- 4.7% to 20.8% +or- 9.5%; chi square=8, p<0.01), whereas HIV-2 infection remained stable (Figure 1). Among pregnant women, no significant increase of HIV infection was observed (5.9% +or- 3.8% to 8.1% +or- 3.8%; chi square=0.55, n.s.). Among tuberculosis patients, overall HIV seroprevalence increased from 27% +or- 3.5% to 38.7% +or- 5.5% (chi square=13.5, p<0.001) and was due to an increase of HIV-1 infection (10% +or- 2.4% to 30.4% +or- 5%; chi square=63.8, p<0.001). These data illustrate the dramatic spread of HIV infection in Abidjan, especially among Abidjan prostitutes. Considering the low frequency of effective preventive measures taken, the women are at very high risk of acquiring and/or transmitting HIV. Targeted interventions aiming at increasing condom use are therefore of highest priority. AIDS is still the leading cause of death in Abidjan (3), and our data show that the impact of AIDS on the public health will be still greater in the coming years. (full text) (5 references cited in original document)
Absence of HIV-2 in Spanish groups at risk for HIV-1 infection [letter]
Since HIV-2 first was isolated in 2 African patients with AIDS in 1986, a number of cases of infection with this virus have been reported, the majority of them from West African countries. HIV-2 infection is rare in the US, where only 1 native-born case has been described, in a woman who had traveled to West Africa. 5 cases have been reported from groups at risk for HIV-1 Brazil. A number of Europe countries have reported cases, most of them among West African immigrants or individuals with a history of sexual relations with persons from HIV-2 endemic areas. Spain has a long tradition of maritime commerce and fishing along the African coast, including those areas of West Africa where HIV-2 is endemic, and West African emigrants frequently pass through Spain on their way to other European countries. This 2-way mobility has raised the possibility that HIV-2 may have penetrated this country, a hypothesis that is being tested as studies begin to look for HIV-2 in the classical risk groups for HIV-1, as well as in resident West Africans. The only confirmed cases of HIV-2 infection in Spain thus far have been in 3 West Africans; some studies have found a positive reaction to HIV-2 among intravenous drug users, and prostitutes; however, the fact that there was concurrent HIV-1 infection in all cases led the authors to suspect that the results were false positives due to cross reactions. We present data from 3 cross-sectional studies carried out in Spain among prostitutes, clients of prostitutes, and seamen (Table 1). The study populations included 1148 prostitutes from 25 provinces throughout Spain, 21% of whom were current or past intravenous drug users (IVDU), 95 clients of prostitutes, 56% IVDU, and 521 seamen, 4% IVDU. Among the seamen, 177 had traveled to areas of Africa where HIV-2 is endemic and almost 30% of these reported having had sexual relations with African prostitutes. The high % of drug use among clients of prostitutes was due to the method of recruitment. Following their informed consent to the study, all participants were interviewed extensively with regard to risk factors and were bled for HIV-2 testing. Sera were analyzed for the presence of antibodies to HIV-2 by enzyme-linked immunosorbent assay (ELISA; Pasteur) with confirmation by New-Lav-blot2 (DuPont), and for antibodies to HIV-1 by ELISA (Pasteur and Abbott) with confirmation by Western blot (DuPont). None of the persons in the samples was HIV-2 positive, although 14.1% of the prostitutes, 1.2% of the seamen, and 38.7% of the clients of prostitutes had antibodies to HIV-1. These results support the findings of other investigators that as yet there is little, if any, penetration of the HIV-2 virus in Spain among those populations that are presumable at highest risk for sexual or parenteral transmission. However, the low rates of condom usage in the groups studied, together with their participation in activities that put them at risk for HIV-1, indicates the need to continue to promote condom use and emphasize other measures to protect against both HIV-1 and HIV-2. (full text)
HIV-1 infection and perinatal mortality in Zimbabwe.
As part of a survey of the causes of perinatal mortality at Mpilo Maternity Hospital, 220 neonatal deaths and the mothers of 221 stillbirths were tested for HIV-1 antibodies. The HIV positive rate in neonatal deaths was 23.6% (95% confidence interval [CI] 18.0-29.2%), significantly higher than 15.4% (95% CI 10.6-20.1%) in stillbirths. Perinatal deaths from congenital malformations, birth asphyxia, pregnancy-induced hypertension, placental abruption, and other noninfectious causes had similar low HIV positive rates averaging 8.1% (95% CI 3.9-12.3%). Deaths from septicemia had a significantly greater rate of 39.3% (95% CI 27.0-51.6%) and the highest rate of 72.2% (95% CI 51.5-92.9%) was found in deaths from congenital infection other than syphilis, indicating that maternal HIV infection predisposes to neonatal septicemia and congenital infection. Unexplained stillbirths also had a significantly greater rate of 22.4% (95% CI 10.7-34.1%), presumably because some died from unrecognized infection. The rate of deaths from congenital syphilis was 17.4% (95% CI 9.6-25.2%), indicating a significant but weak association between these 2 sexually transmitted diseases in Bulawayo. The rate of deaths from hyaline membrane disease was not significantly greater at 15.0% (95% CI 6.0-24.0%). By predisposing to infection, maternal HIV infection was estimated to increase the stillbirth rate by 1.6 times and the neonatal mortality rate by 2.7 times. It predisposed equally to early and late onset neonatal septicemia, but more to infection from streptococci and staphylococci than from Gram-negative enterobacteria. HIV positive deaths from congenital infection had respiratory distress and usually intrauterine growth retardation, hepatosplenomegaly, and congenital pneumonia on lung histology. (author's)
Developing countries account for a disproportionately large share of the world's infant and child mortality. Socioeconomic development has, however, been broadly suggested as conducive to reducing such mortality in these countries. To identify the correlates of infant and child mortality, different theoretical and methodological frameworks have been employed. Demographic theory, modernization theory, and world system/dependency theory are 3 such approaches. These are, however, narrow and highly limited in their ability to allow for the different contexts in which social change and mortality reduction must take place. This paper proposes a theory based upon the political economy of health in which serious analysis may be made of the underlying social, economic, and political determinants of infant mortality. Using this approach, the authors plan to subject secondary date on many countries to analysis. They hypothesize that countries with low infant mortality rates will, regardless of socioeconomic development level, have development strategies and policies oriented toward the equal distribution of development benefits for large segments of the population. Development style, not resource constraints, are therefore responsible for determining the pattern of infant mortality reduction in given countries. The cases of Brazil, South Korea, Bangladesh, and Sri Lanka will also be explored in-depth in 3-segment time series analysis over the period 1975-85, in an attempt to identify and develop a contextual profile of their social, economic, and political/historical characteristics.
Only children in China: social ties and societal change: a reconceptualization of the issue.
Industrialization in western nations has led to a 1-child family norm and low fertility. Population policy, however, aims to achieve these ends in China at a period prior to industrialization in the country. This paper queries the ultimate effect of this policy on future generations and Chinese society at large. Increasingly, 1-child families constitute a large proportion of Chinese society. This trend is expected to continue and grow. Extended family and sibling relations will therefore cease to exist over time in China, with family relations becoming overwhelmingly dominated by natal ties to grandparents and parents. Single-line lineages will become the norm. Only-child youths will develop into adults devoid of inclusion in extensive family networks common to previous generations, and will depend upon acquired ties and institutional relations. The author posits the potential for broad, deep societal change in China as a result of this new type of adult already common in the West. He expects Chinese citizens increasingly to lean toward adopting individualist ideology, free enterprise, and the democratic social system. The author also finds fault with prior socialization research into the only child, and takes issue with such research's inconsistent findings in the text.
Premarital sexual activity is on the rise, fueling an increase in premarital births as a proportion of all births. Using contraception is one way to prevent pregnancy and childbirth from such sexual activity. This paper therefore explores women's motivation to use contraception. Specifically, it considers the 1979-87 National Longitudinal Survey of Labor Force Behavior, Youth survey data on females aged 14-21 in January 1979. The women were sexually active, child-free, never-married, not-in-school white, black, and Hispanic. Interviews took place over the period 1982-85, and examined the role of employment and job characteristics in women's contraceptive practice. Emotional, financial, and educational short- and long-term costs are borne to young mothers in varying degrees depending upon their respective situations and personal characteristics. The perceived costs of premarital sexual activity and pregnancy help shape contraceptive behavior. The amount of risk a women will take may depend in large part upon her worklife quality, labor force experiences, and expectations of the future. With the potential exception of Hispanic women, analysis supports this thesis. Working women, especially those in high-wage, high-status, and full-time jobs, find premarital conception more costly than those who are either unemployed or working in lesser jobs. Women who perceive higher opportunity costs are therefore more likely to use contraception. Constraints and limitations do, however, exist in this model, and are discussed.
Energetic and metabolic cost of growth in Gambian infants.
This study sought to measure the energy used for growth of healthy fullterm and breast fed Gambian infants. The weight gain (WG) of 14 infants (mean +or- SEM 17 +or- 1 d, weight 3.581 +or- 0.105 kg) was measured over a 2-week period; the energy intake (EI) from breast milk was assessed for 24 hours in the middle of the study period by weighing the infant before and after each breast feed. On the same day, sleeping energy expenditure (SEE) and respiratory quotient (RQ) were measured for 30 minutes on 5 occasions through the 24-hour period. EI averaged 502 +or- 25 kJ/kg x d, and SEE 230 +or- 6 kJ/kg x d; thus, an average of 272 kJ/kg x d were available for physical activity and the energy stored for growth. The total energy sent by infants while sleeping and for periods of physical activity was calculated to be 1.7 x SEE. The mean RQ measured on 5 occasions averaged 0.0879 +or- 0.009. SEE was correlated with WG (r=0.747, p<0.005), with a slope of the regression line of 5.5 kJ/g; this value can be considered as an estimate of the energy spent for new tissue synthesis in the resting infant. The efficiency f weight gain was lower in this study (67%) than in studies conducted on fast-growing preterm infants or children recovering from malnutrition. (author's)
Prevention of neonatal hypothermia in Himalayan villages: role of the domiciliary caretaker.
Between June and September 1988, recent physician graduates analyzed data on 202 newborns living in Sirmour, Mandi and Kullu districts (population 16,425) in the Himalayan mountains in Himachal Pradesh state, India to examine how neonatal care and beliefs of mothers or caretakers effect neonatal thermoregulation. 95% of respondents believed infants, especially frail, low birth weight infants to be vulnerable to cold induced diseases during their 1st 4-6 months. Respondents also tended to consider mothers to be vulnerable for up to 1 month after delivery. 98.5% of infants roomed with the mother. Birth attendants bathed 98% of infants immediately after delivery in a warm trough regardless of the season Then they dried and massaged all the infants with warm oil or clarified butter. Next they wrapped 98% of the infants with layers of cotton or woolen cloth. Mothers or caretakers bathed the newborns at least once a day. 22.7% of the infants wore sweaters during winter and 37% also wore a woolen cap during the winter. Even though rooming in and warm oil massage prevented heat loss, early and frequent bathing had an opposite effect. Yet since mothers and birth attendants bathed the infants next to a stove in a closed room and then massaged them with warm oil and swaddled then in layers, the bathing did not significantly reduce body temperature. Besides the houses, especially those at high altitudes, had walls of interlocking stone and wood layers cemented with mud on the inside, wooden floors, ad small windows. Thus they conserved heat. Caretakers were more likely to heat the delivery room during the winter than the summer (p<.01) and at altitudes >150 m than at altitudes <1500 m (p<.05).
Can drug-induced depressions be identified by their clinical features?
Drug-induced depression which is classified as DSM-III-R is difficult for clinicians to diagnose because the cause is not easily distinguishable from adjustment disorders or nonorganic mood disorders. This review summarizes the few articles published within 20 years as searched in the Index Medicus about the clinical manifestations of organic mood syndromes from oral contraceptives (OCs), beta blockers, alcohol and sedative-hypnotic drugs, and other medications. There was a noticeable lack of articles and specific clinical features which would help differentiate causes. Oral contraception may cause depression by inducing hepatic tryptophan oxidase, which may lead to a deficiency of vitamin B6. The most common reason for discontinuing OCs is depression, i.e., there are reports of a rate of 70/1000 woman years during the 1st year of OC use. However, the rate among females examined in a catchment study was similar at 6.6%. There is some indication that depression may be dose related, i.e., low dose is related to the same prevalence as in the control group. A basic requirement of DSM-III-R is severe and persistent depression; OC-related depression does not exhibit sleep or appetite disturbances. The relationship between beta blockers and depression indicates that the prevalence and the nature of the relationship are not consistently confirmed. Depressive episodes (14) reported in 8 studies showed major depression and suicidal thoughts or attempts just after initiation of propranolol and resolution when the drug was discontinued; timing of the symptoms may be the best basis upon which to make a clinical judgement. Alcohol use is usually seen as associated with depression, but the extent to which alcohol induces depression is unknown. Symptoms are transitory and appear during bouts of heavy drinking. Studies on benzodiazepine use and depression are reported to be confounded by other factors. Other depression-causing agents for which information was unavailable are identified as psychostimulants, metoclopramide, H-2 blockers, methyldopa, and steroids.
The role of breast milk in protecting urban Peruvian children against cryptosporidiosis.
Researchers determined the antibody response to Cryptosporidium sporozoites in 6475 breast milk samples from 211 mothers of newborns living in the shantytown of San Juan de Miraflores on the outskirts of Lima, Peru to determine the association of breast milk with cryptosporidial infection rates, mean duration of infection, and age at 1st infection. They determined that 18.5%, 50.5% and 30.8% of the mothers had high, intermediate, and low anti-Cryptosporidium antibody titers respectively (>0.6 optical density [OD], 0.3-0.6 OD, and <0.3 OD respectively). The cryptosporidial infection prevalence rate among the infants was 23.7%. the 50 infected infants experienced 61 episodes of infection. Most of the ill children were confined to the medium and low antibody groups (40% and 38% respectively). Since the study was ongoing, the researchers expected a higher prevalence rate. Infants whose mothers were in the high antibody titer group were significantly younger at 1st infection than those whose mothers were in the low antibody titer group (4.05 months vs. 7.51 months; p<.01). The researchers did not anticipate this result. Infection rates were highest between February and June. They were also greatest among 4-8 month old infants which may be associated with weaning off breast milk. No significant differences in prevalence or duration existed among the infants in the various groups. Considerable antibodies to Cryptosporidium in a mother's breast milk did not necessarily protect the infants from the parasitic protozoan.
Lethal Fournier's gangrene following vasectomy.
A health practitioner performed a standard bilateral vasectomy on a 33-year old male who did not suffer from an immunodepressed state. No complications arose and bleeding was minimal during the vasectomy. 2 days later, he visited a physician with a fever of >39 degrees Celsius and wound reaction. The physician prescribed oral floxacillin, but the following day he suffered acute septic shock and was admitted to a hospital. The incision site was red due to congestion of capillaries, purple, swollen, and painful. Physicians ruled out prostatitis, abscess formation, and a pulmonary source as causes of the fever. The white blood cell count, potassium, creatinine, and glucose levels were very high. Physicians administered parenteral broad spectrum antibiotic treatment (imipenem/cilastatine and metronidazole) even though the blood, urine, and sputum cultures grew no pathogens. They found and evacuated hematoma and necrotic tissue from the vasectomy sites. They placed silicone drains in the sites. Within the next 24 hours, necrosis developed in the scrotum while his clinical condition declined rapidly. He suffered a cardiac arrest. They transported him to the University Hospital in Leiden, the Netherlands where physicians did a necrotomy of the scrotal, penile, and perineal skin and removed both testes. >100 colonies of Streptococcus hemolytic group A, 10-100 colonies of Escherichia coli, and <10 colonies of Staphylococcus epidermidis grew in the cultures of tissue removed at the other hospital. Yet cultures from tissue removed at the University Hospital were negative. No anaerobic bacteria colonies grew. The physicians administered penicillin, ceftazidime, and floxacillin based on antibiotic sensitivity testing results. They also began hemodialysis. 24 hours after necrotomy and bilateral orchiectomy, the necrotizing process had not spread. Yet 13 hours later and 5 days after the vasectomy, the patient succumbed. This case was the 1st known fatal complication of vasectomy. The diagnosis was scrotal gangrene of Fournier.
A community health education system to meet the health needs of Indo-Chinese women.
A proposed community health education system is described for implementation in Kampuchea, Laos, and Vietnam which addresses the problems of maternal care, improved nutrition, prevention of infectious diseases, and screening for breast cancer. Success of this proposal is dependent on cost effectiveness, the economic viability after donor funding ceases, sustainability through community interest, and adequate monitoring and evaluative procedures. Community participation is a major determinant in program success. The lack of participation may be due to a lack of community awareness and resentment of "topdown" messages, authoritarian behavior, and cultural insensitivity. The community health program initially requires national governments to provide salaries alone. Cultural sensitivity is achieved through involvement of primarily national health professionals, a few nonnationals who have been informed of Indochinese traditions, and a core of local people at the village level. The System 1) established and educates key persons (advisory team, community health education unit, community health workers (CHWs), and women's groups) in the system, 2) implements the programs, and 3) monitors and evaluates. The women's group is the most important for program success. 6 education modules make up the program, i.e., a medical module on maternal care (pregnancy and prenatal and postnatal care), proper nutrition, prevention of infectious diseases (germ theory, immunization, personal hygiene, environmental hygiene, and preventing sexually transmitted diseases), and screening for breast and cervical cancer. Other modules are on teaching methods, the use of teaching aids, revision of modules, female community health worker training, video production techniques, a national awareness media component, and evaluation techniques. The CHWs teach the women's groups and villages about health prevention and behavior. Women's groups provide feedback and modify the program and in return develop self-confidence in leadership roles in the family, community, and country.
Linking AIDS and family planning [letter]
I am a committed and enthusiastic family planning nurse and long ago realized that in family planning we have the opportunity to improve women's health by screening and health promotion as well as by helping them make informed choices about when and if they want to have babies. We are also in the position of being able to give advice on safe sex (with sexually transmitted diseases in mind). I hope that we are doing this at every opportunity. I read with rising anger and frustration the news item discussing the various responsibilities given to the new health ministers (April 29, p7). It appears that Tom Sackville will be responsible for acute services, the Patient's Charter and family planning, while Baroness Cumberlege is charged looking after women's health, ethnic issues, AIDS, nutrition and NHS green policy. I am not annoyed about who got what, but didn't anyone see the connection between women's health, family planning and AIDS? What a lost opportunity to have a bit of continuity in our services. If we are promoting safer sex, contraception, screening for precancerous changes of the cervix and good health in general it would have been a good idea to have just 1 minister responsible for these 3 important issues. It might even have saved some money] (full text)
Condoms are not completely protective. Married couples using condoms as a means of birth control experience a 10%-15% failure rate/year. The reasons for those failures seem to be a combination of condom failure, improper use (e.g., failure to use them from beginning to end, failing to withdraw upon orgasm, etc) and not having them available at the time when intercourse is desired. Conception seems to occur more often per act of intercourse than HIV transmission, which may occur as infrequently as once/100 acts of vaginal intercourse. Anal intercourse is more likely to transmit the virus and seems to carry a greater risk of condom failure. Oral intercourse is both less risky and less likely to cause condom damage. Thus, condoms can be considered to be risk reducers not risk eliminators. A special case is the nonlatex condom. Studies have shown that it is porous enough to allow the passage of the virus even if the condom is not damaged. Patients should be warned not to use so-called "natural condoms." (full text)
More on the "gag rule" [letter]
To the Editor: I hesitated to respond to Dr. Laura Hammon's letter in the December 1991 issue because so much has been written about the abortion issue with so little effect. Her letter was so irrational and misguided, however, that I finally had to respond. Her contention is that the "gag rule" prohibiting physicians from discussion of abortion is only a monetary issue. Medi-Cal (California's medicaid program) pays $206 for an abortion. In contrast, prenatal care is reimbursed at $961, and, for a normal delivery, newborn care is $566. If the infant has drug withdrawal, is infected with the human immunodeficiency virus, or is premature, the cost of care is $4509. The welfare payment for 1 person is $326 pr month and for a family of 2 is $535. In addition, the mother will probably get supplemental food vouchers, and the child will receive Medi-Cal coverage for ongoing medical expenses. Every birth costs the taxpayers many times the cost of an abortion, so if the question of morality is not important, Dr. Hammons should be an abortion advocate. She objects to her taxes going to support abortions, referral for abortion, or abortion counseling for poor women who voluntarily request them, but we all have objections to some of the things our taxes pay for, such as military equipment that does not work, tobacco subsidies, and photo-opportunity-rich, policy-poor political junkets. The issue is a matter of free speech. When speech is restricted by application of a penalty based on the content of the speech, it is not free. This particular speech is part and parcel of medical practice. It is not political speech or opposition to or advocacy for some governmental policy. Physicians are not prohibited from the latter, only from discussing medical options, 1 on 1, with their patients. Drs. Sugarman and Powers have provided an excellent analysis of the constitutional issues involved. Obviously, if our only concern were rational, secular, good public policy, we should all be promoting family planning and abortion to control the population that is outstripping our resources. This leads me to believe that the opponents of free speech, good medical practice, and safe abortions have a different rationale, namely, a set of moral values that they want to impose by governmental power on all of us. (full text) (2 references cited in original document)
Traditional healers and the primary health care nurse.
In South Africa, health practitioners should embrace traditional healers since they promote prevention; use a holistic approach; and are inexpensive, accountable to their community, and are available to the community which respects them and considers them to be effective. On the other hand, they use nonstandardized herbal remedies and nonsterile instruments. Other disadvantages include conflict between traditional healers and Western practitioners, and "quacks" easily abuse the profession. They consist of 3 groups. The traditional doctor (inyanga) tend to be male and use herbal medicines. They study for at least 1 year under an experienced and working inyanga. In some instances, the experienced inyanga teaches his son the ways of an inyanga. Women are more likely to be diviners (isangomas). Isangomas must experience ukuthwasa (ancestral spirit possession) at which time an ancestor designates them as isangomas and imparts some medical information to them. They also must undergo training involving seclusion, sexual abstinence, and restraint from eating some foods to receive other medical knowledge under the guidance of a capable isangoma. If an ancestor calls a man to become an isangoma, he becomes a transvestite because in the future he will play the role of a woman. The 3rd type of traditional healer is a faith healer (umthandazi) working either out of churches or missions. Faith healers obtain the power to heal either directly or indirectly from God. Nurses must make a complete assessment of community needs and norms to determine existing resources and health structures. They should ask the community to point out trusted traditional healers. They then should build mutual trust with the healers to determine their treatment methods. Thus nurses could employ useful practices and educate traditional healers to not use harmful practices. They should ask traditional healers to function in other roles such as counselors and mediators.
24 female patients undergoing sterilization through a minor lower laparotomy received, in a double-blind, randomized study, either lidocaine spray 200 mg or placebo in the surgical wound. Postoperative pain intensity was evaluated on a verbal and a visual analogue scale and wound tenderness with an algometer. During mobilization from the supine to the sitting position, VAS-score was lower (p<0.05) in the lidocaine group 2 hours postoperatively, but not 4, 6, and 8 hours postoperatively (p<0.05). no significant differences were found in VAS-scores at rest or during cough, or in verbal scale ratings during rest, cough, or mobilization, and postoperative consumption of morphine was similar in both groups. Pressure pain thresholds were higher (p<0.05) 2 hours postoperatively in the lidocaine group, but not 4, 6, and 8 hours postoperatively. In conclusion, topically applied lidocaine aerosol in the surgical wound leads to a very short and clinically insignificant relief of postoperative pain. (author's)
Evolution of HIV in Africa [letter]
Steve Sternberg's Research News Article of 15 May (p. 966) describes a phylogenetic analysis which concludes that West Central Africa may contain a lineage of HIV-1 (human immunodeficiency virus-1) that is ancestral to the other HIV-1 isolates analyzed to date. This conclusion has been criticized on the basis of the relatively low prevalence of HIV-1 in that region of Africa, but this low prevalence is entirely consistent with the patterns expected from current evolutionary considerations of HIV virulence (1). These evolutionary considerations suggest that the pandemic HIV evolved to a high level of virulence in mid-Central and East Africa in response to an increase in multiple-partner sexual contact brought about by the socioeconomic crisis that occurred there during the 1970s. The lower rates of sexual contact along the west coast of Africa should have favored the evolution of lower virulence. Accordingly, current evidence indicates that the HIV-2 in West Africa has a lower virulence and lower prevalences than the pandemic HIV-1 (1-3). The limited comparisons to date also suggest that these low prevalences of HIV-2 are remaining fairly stable in areas of West Africa where HIV-2 predominates (4). According to this evolutionary argument, the same should be true of HIV-1 strains that have evolved endemically in areas with relatively low rates of multiple-partner sexual contact. That is, we can expect such strains of HIV-1 in western regions to have a lower, more stable prevalence than the HIV-1 strains in mid-Central and East Africa. This evolutionary argument can be tested by assessing the virulence of the root West African HIV-1 lineages in humans by quantifying, for example, the time between the onset of infection and the onset of AIDS. The evolutionary theory predicts that the virulence and replication rates of these lineages should be lower than those of the lineages in mid-Central and East Africa. Seropositivity should also increase more gradually with age, more like the age structure of HIV-2 infections than pandemic HIV-1 infections (2,3). (full text) (4 references cited in original document)
Psychological adjustment of Yoruba adolescents as influenced by family type: a research note.
2 psychologists administered the Psychological Adjustment Scale of the Adolescent Personal Data Inventory to 116 Yoruba adolescents (69 males and 47 females) from middle class families attending a holiday youth camp in Ibadan in Oyo State, Nigeria to test the hypothesis that teenagers from monogamous families are better psychologically adjusted than those from polygynous families. 96 and 26 adolescents lived within a monogamous family and polygynous families, respectively. Males from a monogamous family exhibited better psychological adjustment scores than those form polygynous families (p<.01). On the other hand, there was no difference between the scores of females form monogamous family with those of females from polygynous families. Thus the psychologists' hypothesis was partially confirmed. These results indicated that gender tempers the effect of family type on adolescent adjustment. This may have been a result of role prescription in Yoruba societies. Specifically, male children in polygynous families had to take care of themselves, their many siblings, and sometimes even their mother's sisters which placed them under considerable stress. Various conflicts arose in polygynous families which did not exist in monogamous families, e.g., friction among cowives, sibling rivalry, and minimum contact with parents. According to these results, this stressful role for male children tended to protect female adolescents from the stresses. In monogamous families, however, male children were more likely to receive emotional and moral support. Further research is needed to identify other factors that influence adolescent adjustment and how they interact with or moderate the effect of family type.
An experimental comparison of two AIDS prevention interventions among young Zimbabweans.
In 1990, psychologists compared data on 42 student teachers at the University of Zimbabwe who underwent an information-based health education session designed to increase condom use with data on 42 other student teachers who underwent a skills-based health education session. They wanted to determine whether skills-based, participative interventions are more effective in changing attitudes toward AIDS and practices than are information interventions. Mean age for all student teachers was 23.1 years. All participants completed a questionnaire before the interventions and the same questionnaire 4 months after the interventions. The 1-hour information-based intervention included a talk about HIV transmission and prevention and a question and answer period after the talk. A condom fitting demonstration, individual practice, group formulation of behavioral self-management approaches, sketches of social and assertiveness skills used to negotiate condom use, pair role plays, group psychodrama about effects of AIDS, and a video about a popular African musician with AIDS comprised the 90-minute skills-based, participative intervention. The skills-based group exhibited more knowledge about condoms and their correct use (p<.001), higher self-efficacy (p<.05), fewer obstacles to condom use (p<,05), and fewer acts of intercourse without condom use in the last 30 days (p<.05) than the information-based group. These results were especially encouraging because risk reduction behaviors were maintained over 4 months. Thus more skills-based interventions and skille