A doctoral candidate analyzed 1980-1989 data on mothers and infants living in the grazing areas of Turkana District in Kenya to examine relationships between infant care and feeding practices, infant growth, maternal and infant health and morbidity, and fertility. Between 1985 and 1989, the fertility trend increased, likely due to favorable conditions for livestock on which the nomads depended for survival. Infant age and season significantly caused variation in breast feeding frequency and intensity and in infant supplemental intake. Seasonal patterns in labor demands of the pastoral system and the size of the herding unit mediated inter-mother variation in feeding practices. Even though mothers introduced breast milk supplement early (e.g., as early as the first week of life), they did not completely wean their children until 21 to 24 months postpartum. Conception was the most frequent reason for weaning. A reduced intensity and frequency of suckling during the late dry season for 9 to 13 month old infants appeared to be responsible for the seasonal pattern in conceptions. Breast feeding patterns indicated that the mothers most likely resumed menses during the late dry or early wet season. Children who were often ill suckled less intensely, weighed less, and were shorter than those who were more healthy. During the mid-dry season, maternal fat stores had a significant positive effect on boys' fat stores and body length. During the late dry season, however, maternal fat stores did not have this effect. On the other hand, maternal fat stores had a significant negative effect on girls during the mid-dry season, but not during the late season. The association for girls was stronger than that for boys. Mothers and infants were leaner during the late dry season than during the early dry season. Overall, the infants had considerable fat stores from 0 to 9 months, but they had low weight for age, recumbent length for age, and weight for recumbent length from 0 to 12 months. After 12 months, they experienced falling off of growth in weight.
In 1987 a doctoral student oversaw a study of 235 women living in Ciudad Juarez in Chihuahua State, Mexico, who had undergone sterilization in 1986 at the Mother-Child and Family Planning Clinic, the main clinic of the Juarez affiliate of the Mexican Federation of Private Family Planning Associations, to compare 3 data collection techniques and to assess the comparability of the data. The data collection techniques were in-depth individual interviews (10 women), focus groups (36 women), and a survey (189 women). The women were of lower socioeconomic class and matched in age, parity, timing of sterilization, and education. The study looked at satisfaction with services, informed consent, perceived consequences and benefits, and the decision making process. Facets of the comparability of the techniques included extent to which the techniques produced consistent information and the quantity and quality of additional and spontaneous information produced by each technique. In-depth interviews and focus groups produced 100% consistent results. In-depth interviews and the survey resulted in 93% consistent results. The survey and focus groups had 96% consistent results. The 3 techniques yielded highly consistent information on satisfaction with services and informed consent. They produced still somewhat consistent results for perceived consequences and benefits and decision making process, but more variety (25-40% vs. 0-16%) and inconsistency across data sets (0-25% vs. 0%) existed. The in-depth interviews produced considerable contextual information and detail about the decision making process. These findings suggest that researchers allow the specific topic to determine what data collection techniques to use, combine qualitative and quantitative techniques, use in-depth interviews more often, and standardize procedures used in the analysis of qualitative data.
In 1991, at 25 service delivery points in various regions of Kenya, specialists observed family planning counseling sessions, spoke to family planning providers, took inventories of educational materials, and conducted exit interviews with clients to gather baseline data with which to evaluate the Provider and Client Information, Education, and Communication (IEC) Project. Prior to the first clinic visit, clients received information about family planning via radio (51%) and television (17%) and from family, friends, and community members. 47% of new clients talked about family planning with their partners. Further, partners had the strongest influence in helping 28% of clients decide to make the clinic visit, indicating a need for the IEC project to target spouses. Health workers comprised another important influential source. Almost all service providers and community based distributors (CBDs) exhibited quality counseling skills and took good medical histories. Yet they did not always adapt counseling to a client's individual needs. Few providers and CBDs told their clients about sterilization, implants, or the diaphragm. Moreover, providers did not consistently provide information about the method clients chose. CBDs tended not to use print or audiovisual materials, yet 89% of clients said that a family planning leaflet persuaded them to seek family planning services. Posters were present at 76% of sites, but just 40% of clients remembered seeing them. 40% of sites had leaflets, but just 10% of clients saw them. CBDs did not always schedule return appointments for new clients or encourage them to return if they had problems. These findings indicate that after family planning visits clients were confused about which methods they had discussed and had not received complete information about their chosen method. The situation analysis team made several recommendations to improve the quality of family planning services and to boost public awareness and dialogue about family planning.
65% contraceptive prevalence is needed in order to achieve a stable world population over the next 2-3 decades. Only China and Thailand have thus far reached this level of coverage. Excluding China, it will cost US $6.24 billion to extend the requisite family planning (FP) services to a total 312 million women annually. Current spending, however, ranges between US $2.2 and US $4.5 billion, of which donors contribute US $560 million. Additional funds are clearly needed to sustain current levels of coverage and enhance the degree of services in the future. To that end, developing countries are increasingly using user fee systems to recover public sector health care costs. An estimated 17% of FP costs in developing countries are covered by user fees. Many decision makers and managers are aware of the terms and basic concepts involved in such systems. They do, however, need more information on how to design and implement user fees. The SEATS project therefore developed "Designing a Family Planning User Fee System: A Handbook for Program Managers." In developing FP programs with user fees, planners must understand that the objective is to maximize access to and use of high quality FP services and that designing, implementing, or updating a user fee system need not be complicated. This paper considers issues surrounding FP user fees; fallacies of user fees related to the notion of free services, inhibitors of demand, windfall revenues, and bureaucratic burden; the importance of quality; additional arguments in favor of user fees; experience with FP user fees in developing countries; and determining the context of user fees in FP programs.
Manage the cold chain and other supplies.
While all vaccines remain potent when kept between +2 and +8 degrees Celsius, they grow weak and lose potency when exposed to heat. No vaccine should be exposed to direct sunlight, while polio and measles vaccines should be kept in freezers for longterm storage. Other vaccines should not, however, be frozen. Potency cannot be restored to vaccines once lost and vaccines are rendered useless. The cold chain is a system of transporting and storing vaccines at recommended temperatures from the manufacturer to the point of use. The logistics and maintenance of supplies for mother and child health interventions need to be integrated into the Child Survival and Safe Motherhood program. This text explains how to keep vaccines potent and maintain, monitor, and use cold chain equipment, drugs, and other supplies. Section A discusses storage, distribution, and monitoring of vaccines as well as maintaining cold chain equipment, while section B addresses subcenter drug kits and other supplies. The essential elements in establishing and maintaining the cold chain are people to organize and manage vaccine distribution, storage and transportation equipment, transport facilities, and proper maintenance. The following steps must be taken at all levels: enumerate eligible pregnant women and infants, calculate requirements of vaccines and other supplies, maintain equipment, maintain and distribute vaccines and supplies, monitor the cold chain, plan alternative vaccine storage arrangements, and plan and implement a repair and spare part management system for equipment.
[IUD insertion or a prescription for oral contraceptives immediately after an induced abortion]
A new abortion law took effect in the Czech Republic on January 1, 1987, that resulted in the increase of abortions. In 1989 in the Czech Republic there were 10.6 abortions and 12.4 births/1000 inhabitants and 85.2 induced abortions/100 births. In Slovakia there were 9.1 abortions and 15.2 births/1000 inhabitants and 59.8 abortions/100 births. For the whole country the respective figures were 10.1, 13.3, and 75.4. In 1989 in the Czech Republic there were 351,119 IUD users, 107,792 oral contraceptive (OC) users, and 20.7 IUD and OC users out of 100 women in the reproductive age range of 15-44. In Slovakia the respective figures were 142,733, 33,600, and 15.1; while for the whole country they were 493,852, 141,392, and 18.8. At the obstetrical ward in Dacice with 11,000 women in reproductive age, IUD insertions and OC prescriptions were instituted immediately after miniabortion as of 1988. Most of these women were aged 25-30 with 2-3 children; 41% of them had at least 1 previous abortion. There were 216 induced abortions in 1986, 316 in 1987, 241 in 1988, 345 in 1989, and 244 in 1990. In these last 3 years there were a total of 830 abortions. 761 of them were miniabortions: 344 of these women were inserted with an IUD immediately after the abortion, and 71 received an OC prescription. 54.5% of the abortions were performed on an outpatient basis. The number of induced abortions/100 births decreased from 59.3 in 1989 to 42.4 in 1990. DANA Super Lux, DANA Cuprum, and BIUD Cu 300 type IUDs were inserted. Neogest was the 1st-choice and a limited number of Trisiston pills were also prescribed. IUD complications included a 1.4% failure rate, a 3.6% expulsion rate, a 3.9% removal rate because of bleeding or pain, while the rest continued IUD use. The insertion of IUDs and the prescription of OCs immediately after abortion reduced the high number of repeated abortions and raised the use of contraception.
The world is facing a "biological holocaust" with the HIV/AIDS epidemic running rampant and an estimated 13 million people already infected worldwide. In South Africa, the estimated number of HIV-infected people already has reached the 300,000 mark with up to 300 people being infected with the virus every day. Worldwide, between 4 and 5 million women are infected and more than 2 million cases of clinical or full-blown AIDS have been reported among them. More than a million children are HIV-positive--one-half of them with full-blown AIDS and many have died. "This figure will treble in 1995," said Dr. Ruben Sher, head of the South African Institute for Medical Research, this week. Dr. Sher was speaking at the national launch of an AIDS awareness program for schools. The program will distribute about 700,000 booklets in primary and high schools. Dr. Sher said the world was facing a biological holocaust with the AIDS epidemic relentlessly increasing locally and around the world. In South Africa, there were already 1600 cases of full-blown AIDS with between 40,000-45,000 people having tested HIV-positive. But, it was estimated that the total number of infected people in South Africa was about 300,000. Dr. Sher said that, as there was no preventive vaccine or cure for AIDS, the only feasible and practical solution to prevent the "holocaust" was the prevention of infection through education aiming for a change in sexual behavior. "The fact is that 300 people are becoming infected daily in South Africa. This is surely an indictment. Our education is not working. Perhaps, the number would have been even greater if it were not for our efforts in education. We have tried unsuccessfully for years to get into schools to educate our children on sex and AIDS matters, but we were thwarted by the powers that be. The acceptance of these books into our schools must be seen as a milestone in endeavors to help children defend themselves against the scourge of the 20th century." Dr. Sher said the best way to empower children against AIDS was to make sex and AIDS education compulsory, with an exam in the subject. "Hand in hand with sex and AIDS education must go the restoration of the family unit. Future generations will judge how civilized we were by the way we handled the AIDS epidemic." (full text)
Prevention of maternal mortality program.
The Prevention of Maternal Mortality (PMM) Program at Columbia University in New York City has received various funds to provide technical assistance for solution-oriented research to groups in Africa and in Ecuador. It provides practical research models and programs for the Safe Motherhood Initiative. It stresses 5 points: 1) use of operations research (OR) at all program phases, 2) use field- and literature-based research, 3) even low risk women experience obstetric complications, 4) solutions to infant and maternal mortality are different, and 5) promotion of preventive programs of community and the hospital. The PMM Program's second goal is to reinforce research capabilities in developing countries. It promotes exchange of specialists among developing country institutions and multidisciplinary research. It is working on building networks of developing country scientists investigating maternal mortality. The PMM network now has 12 multidisciplinary teams (7 in Nigeria, 2 in Ghana, 2 in Sierra Leone, and 1 in the US). PMM also continues to provide technical assistance in OR, including workshops. It also guides developing country institutions in securing their own research grants. Activities that work toward achieving PMM's third goal of informing policymakers include involving national and local government health officials in projects, encouraging medical educators to address community problems, collaborating with national and international groups, and distributing information to a wide variety of audiences. PMM Network teams have identified needs for hospitals: improvement of the availability of drugs and supplies in hospitals, hospital management, and the quality of care. Secondary health facility needs are provision of emergency obstetric service and improved staffing and skills. Recommendations for the community include improve emergency transportation, increase blood availability, provide emergency first aid, and treat complications early. PMM has projects in western Africa and Ecuador.
An account is presented of the experiences of a nurse attending a 3-day AIDS conference for nurses and health personnel in Thailand. The conference was sponsored by the National Science and Technical Development Agency. The aim was to exchange information among the 100 participants, of whom only 1 had any real experience with an AIDS patient. Conference presentations were very formal and questions were not solicited from the audience. The tone was patient, quiet, and friendly. The situation in Thailand reflects variability in impact; there were some regions reporting that 50% of their population is HIV positive. The obvious reason is prostitution, which is politically and culturally supported. Economic demands must be considered in dealing with the problems. Of the HIV-positive population, few have begun to show symptoms. Nurses in rural areas are preparing for the challenges, which will include sizable numbers of women and children. Touring the 700-bed hospital on the Srinakarind campus of the university was a contrast from the pristine hospital settings of the US. There were open air courtyards and dogs and cats freely wandered the corridors. There were many large open wards and small rooms. Most of the beds were occupied. There were similarities in the way departments were set up, e.g., surgery, intensive care unit, emergency room, X-ray, and central supply. There was even the internationally recognizable grease board that is usually on almost every nursing unit. Nurses wore the traditional white and worked in the heat and open air. There was the tug of familiarity in routine that made it hard not to want to join in. The experience had a profound effect. The view of another culture broadens one's perspective and shows the universality of health care issues. The experience ties in with nurses contributing to organizations that encourage international exchange. There are many opportunities for working in other countries, taking internationally oriented classes, or attending the upcoming International Council of Nurses convention in Madrid.
Bringing relief to the streets.
The Calcutta Rescue Mission in India has engaged since its inception in 1980 in expanding activities to improve the health of the poor. The first effort was one man, British doctor Jack Preger, who sat on the pavement to deliver medical care to the indigent. Along the river in Calcutta in Nimtolla Ghat a broad awning is set up with a team of doctors and nurses who treat medical problems from the 300-500 people who wait for care. No one is turned away. Another similar clinic has been set up in Middleton Row in the heart of Calcutta, where 12,000 patients are treated every month. Within the past year, Calcutta Rescue Mission has defined future mission, consolidated and strengthened service, increased local staff involvement, and expanded teaching. Each clinic has 7 doctors. Among the new programs is one directed to family planning for men which provides information on methods. The men are encouraged to provide support when wives desire a small family size. Another project is directed to selected women from villages who are trained in health improvement and disease prevention and are expected to share their new knowledge upon return to their villages. A spinning and weaving provides training for 5 students, who will, on completion of the course, be ready to be self-employed making sarees or lunchis or bandages, which will be purchased by the Mission. The school provides a curriculum which includes health and hygiene, music and drama, literacy, elementary math, and life skills for 350 students in 4 shifts. Children are provided transportation both to and from school. There are 11 teachers and 1 local pediatrician who supervises 4 medical staff. Nutritious meals are provided and medical screening and treatment, e.g., 10% were found to have tuberculosis. A special care program was able to treat 275 babies of whom 25 needed hospitalization. 2 teenaged required very expensive hospital care: in one case 2 heart valve replacements and in the other surgery for Fallot's tetralogy. The program continues to need nurses willing to make a commitment for a 6-month stay.
Between November 1988 and June 1989, physicians enrolled 902 women upon delivery at the Hospital Center in Kigali, Rwanda, followed them for 30 months, and compared the outcomes of the 215 HIV-1 positive women with those of 216 age and parity matched HIV-1 negative women. The HIV-1 prevalence rate stood at 30.3%. The seroconversion incidence was 5.1/1000 women years of follow up (18 women, all of whom were excluded from the study upon seroconversion). 9 of their infants seroconverted at the same time. 2 weeks after delivery no woman had clinical AIDS. 5 had chronic generalized lymphadenopathy. HIV-1 positive women were much more likely to have a less than 1 T4/T8 ratio than HIV-1 negative women (72% vs. 10%; p < .001). The difference in syphilis antibodies between the 2 groups was insignificant (16% vs. 10%; p = .16). Tuberculosis was 9.6 times more common among HIV-1 positive women than HIV-1 negative women (8 cases vs. 1 case or TB incidence of 1.44/1000 women years vs. 0.15). 3 HIV-1 positive TB cases had extrapulmonary TB (1 with adenitis and 2 disseminated TB). HIV-1 positive women were considerably more likely to have received more injections (307/100 women years vs. 201; p < .001), have been absent from work more days (893 vs. 641; p < .001), been in the hospital more often (17.4 vs. 11.4; p < .02), and stayed in the hospital longer (11 vs. 5; p = .01) than HIV-1 negative women. The cumulative probability of not developing AIDS at 30 months was 95%. Even though AIDS was rare among the HIV-1 positive group, they had a higher death rate than the HIV-1 negative group (9.3% vs. 1%). Only 8 of the 20 deaths were AIDS related. They had 37 children. The cumulative probability of survival for HIV-1 positive women at 30 months was 93.5% which was similar to that of another cohort study of women in Kigali, Rwanda.
The arguments about the impact of population growth are portrayed in the context of a general discussion of the Pollannas who believe that humanity faces problems but solutions will be possible and the Cassandras who believe that continued population growth will lead to catastrophe. Reference is made to numerous population texts which examine population issues: The Population Bomb by Paul Ehrlich, The Limits to Growth by Dennis Meadows' group at MIT, Malthus' Essays, and Beyond the Limits by Dennis Meadows. A senior fellow at Resources for the Future, Pierre Crosson, is cited as saying that African villagers, when they held land in common, regulated access by unwritten cultural rules; with the introduction of modern crops and technology, yields were high enough to make profits and people broke the rules and left town with the profit. When drought, ethnic conflict, or population growth are added, the result is disaster. Michael Mortimore has collected data for years on farms in Nigeria and Kenya and found that increasing population has actually raised land productivity. Land is more expensive and people take care of what they have. In other parts of Africa, famine persists. Dennis Meadows says that adjusting land-use rules is a short-term solution; overpopulation is the primary cause of nonsustainability, and famine, pestilence, and war the proximate causes. Nathan Keyfitz points out that it is difficult to take action on vital questions when the experts disagree violently. Each sides must recognize the merits of the otherside's arguments. New difficulties are constantly emerging: the ozone layer, exhaustion of fisheries, the greenhouse effect, and overuse of aquifers. Malthus, ever the profound thinker and the dunce, stated that the power of population is much greater than the earth's power to produce subsistence for man. On the other hand, the French thinker Condorcet considers technology capable of solving problems. The example of 2 nations with differing resources is given. Population projections are so different that credibility is lost. Reforestation in the Hudson Valley of New York, is used as an example of how forests can revive themselves to higher levels. The article has interspersed anecdotes about living in New York City and contending with noise pollution and deadlocks in decision making.
In this study of inequalities in economic well-being, date were analyzed from the US census for 165,788 cases in 1960, 183,725 cases in 1970, and 197,605 cases in 1980. Blacks and whites were represented; families were either headed by a married or cohabiting couple, headed by a female without a partner, or headed by a male without a partner. Each family type included variables for number of children in the family. Mean economic well-being is the mean adjusted family income per capita. The age groups were 0-19 years, 20-39 years, 40-59 years, and 60 years and older. The distribution reveals that there were more female-headed households among teenagers, younger adults, and other adults and among whites in those age groups; the increase between 1960 and 1980 was around 5%. In black female-headed households, the increase among teenagers was 17.1%, 11.4% among those 20-39 years, 7.5% among those middle aged, and 10.4% among older adults. Fertility decreased and the decrease in number of children occurred primarily between 1970 and 1980. For whites, the decrease from families with 3 or more children was 18.4% for teenagers, 16.3% among young adults, 5.7% among middle-aged adults, and 1.9% among older adults. The number of families with no children increased also: 16.5% for white young adults, 8.4% among white middle-aged adults, and 7.6% among white older adults. Blacks followed a similar pattern as whites for families with 3 or more children, but there were fewer families with no children. In the regression decomposition analysis of the effect of change in the relative size of population subgroups with mean levels of income held constant shows that for whites decreases in the number of children between 1960 and 1970 led to increased mean economic well-being for only the young adults. Between 1970 and 1980, decreases led to increased mean economic well being in all but the older age group. Increases in female-headed families did not have much effect on well-being for any age group or time period. Female headship and decreased children among blacks led to decreased well being among teenagers between 1960 and 1970 and among teenagers and young adults between 1970 and 1980. Decreases in children lead to increased well being for all age groups except middle-aged ones. Age inequality was affected by female headship and children. more children lowers well-being and heightens age inequality in well being.
This study deals with intervening factors such as family composition, religiosity, and HIV/AIDS knowledge in understanding the association of race and ethnicity with HIV/AIDS-related attitudes and behaviors. Data represent Wave 1 of a 5-month panel design involving 10th grade students in 8 public high schools in Dade County (greater Miami) Florida. Significant differences in attitudes and behaviors were found among racial/ethnic groups. Specifically, Hispanics had more negative attitudes about condom use than blacks or whites. Whites had the most permissive, and blacks the least permissive, sexual attitudes. Hispanics felt least confident and blacks felt most confident about interpersonal sexual skills. Blacks were most likely to have had sexual intercourse, and whites least likely. Religiosity was ground to be a significant intervening variable in the less permissive sexual attitudes of both blacks and Hispanics. The most significant implication of this study is that racial/ethnic differences in sexual behavior can be explained more fully by socioenvironmental factors such as family structure or religiosity than by knowledge or attitudes. Thus, interventions directed toward minority populations should focus on the development of alternative social environments that would support more positive behaviors. More specifically, extended family, religious youth groups, and other community organizations should be brought into the HIV/AIDS risk-reduction arena. (author's)
Children's living arrangements in developing countries.
This paper documents the wide variation in living arrangements experienced by children in developing regions using data from 19 Demographic and Health Surveys. Traditionally, researchers and policymakers concerned with child welfare have assumed that, apart from exceptional cases, children live with their mothers, experience childhood together with their siblings, and have access to resources from both biological parents. Data presented in this paper contradict this assumption. The data demonstrate that, in many countries of sub-Saharan Africa and Latin America as opposed to parts of Asia and North Africa, children spend substantial proportions of their childhood years apart from 1 or both parents and, by extension, apart from at least some of their siblings. The mothers of many of these children do not live with a partner or are in marital circumstances that may attenuate the link between the child and the father. In countries where child fostering is practiced, the likelihood that children will live apart from their mothers is negatively related to their mother's access to the resources of their fathers and other relatives and positively related to the number of younger siblings. The focus of the paper is on 4 essential elements of children's living arrangements that influence their access to resources: 1) mother-child coresidence, 2) father-child coresidence, 3) household structure, and 4) number, presence, and spacing of siblings. The research suggests that significant proportions of young children, particularly in sub-Saharan Africa, benefit from the support provided by family members other than their parents. This support, which involves the coresidence of family members beyond the nuclear unit, can take many forms: the coresidence of 3 generations within the same household, the inclusion of a single mother and her children as a subfamily within a more complex household, the inclusion of a single mother and her children as a subfamily within a more complex household, or the exchange of children between kin. Surprisingly, despite enormous variations between countries in current fertility rates (ranging from roughly 2-7 birth/woman), children in countries as diverse as Thailand and Mali spend their childhood with no more than 2-3 children on average sharing the same household. Thus, childhood as it is experienced in many parts of the developing world has much that is common despite apparent differences and much else that is different despite apparent similarities. (author's)
The politics of prevention. Safe sex.
In the Philippines, preventing AIDS and promoting condom use means taking on the Roman Catholic Church, which asserts condom/AIDS promotion is a subterfuge for promoting the acceptability of condom use for contraception. The Catholic Bishops Conference believes the solution lies in the formation of "authentic sexual values." The Secretary of Health in the Philippines considers that all Filipinos must fight AIDS and dispassionately hands out condoms to everyone everywhere he goes. Secretary Flavier claims he is being "condomized without trial." There are 368 identified carriers of HIV infection of which 68 have AIDS. Other estimates are of 35,000 HIV-infected persons. A study commissioned by Kabalikat recently found that 30,000 men aged 18-45 years in Manila have 2 or more sexual partners and do not use condoms. Some find the controversy is really about Flavier's aggressive style. Senator Francisco Tatad considers Flavier a "moral pollutant," while Senator Ernesto Maceda sees Flavier as acting to drown out the Church's powerful voice. Meanwhile, the health secretary finds that the publicity encourages open discussion. Cardinal Jaime Sin has declared in a large public gathering that the enemies of the Filipino family must not be allowed to win. Birth control, according to Senator Tatad, is "oppressive to the moral and religious beliefs of the Catholic majority." There is a plan to include AIDS education in high schools, which the Senate is currently investigating because of the religious consequences. The health secretary's plan is to promote a higher standard of living though family planning for a small family size. The target is to reduce fertility rates from an average of 3.9/women of reproductive age to 3.2 and to increase contraceptive acceptors from 42.5% to 52%. An independent poll reports 76% practicing birth control. Family planning has been a policy for a while, but it lacked commitment and political will. The family planning campaign will be launched in rural areas where the control of the church is not as strong. The educational emphasis has been supported by local governments and private groups such as DKT which perform street plays, of which an example is given. The Church is being challenged to set up natural family planning clinics in every diocese.
Findings from Latin American operations research projects.
The findings from Latin America (INOPAL) operations research projects between 1984 and 1990 and between 1990 and the present reflect the benefits from postpartum family planning services and from improved training of community-based distribution (CBD) workers. Post partum women find the services to be acceptable. Contraceptive prevalence is increased and services are more cost effective than other comparable services. All national family planning (FP) programs should include postpartum delivery of contraceptives. Surveys conducted in Honduras and Peru revealed that contraceptive services were desired prior to hospital discharge, e.g., 49% of postpartum women discharged from the Honduras Social Security Institute Hospital in Tegucigalpa. Experimental and control groups were compared among women in Peru and Honduras. The findings showed that women offered contraceptives prior to discharge had higher contraceptive prevalence at 6 months postpartum than the control women in the group, i.e., 13% higher in Peru and 7% higher in Honduras. Another project found that, when women did not request contraceptives before discharge, they did so at a 40-day postpartum clinic. Training improvements also reflected successful efforts. Projects conducted in Peru, the Dominican Republic, and Guatemala instituted the development and use of diagnostic and retraining instruments. The purpose was to insure distributor knowledge after initial training and to reduce the cost of retraining. In Peru, the technique was the introduction at 10 weeks of an Individual Diagnostic and Feedback System, which made possible the identification of worker weaknesses in order to apply corrective measures. A comparison with 3-day refresher course held 5 months after initial training showed a 33% increase in knowledge learned from the basic course, while the control group showed a 21% loss. The refresher course for controls lead to a 2% gain in knowledge. CBD knowledge and output of distributors were increased and cost effectiveness improved with the new techniques. Selective supervision and patient-screening instruments were also discussed as successful improvements. The objective of INOPAL projects is to improve the availability, quality, sustainability, and cost effectiveness of services through use of scientific techniques.
Beyond TOT: creating and sustaining organizational change in the Nigerian Family Planning Program.
Training of trainers is important in assuring the effectiveness of managers in meeting program objectives with resources available, but the reality of lessons learned is different from the reality of practice. The example is given of the obstacles encountered when only 1 staff member is trained and the rest of the organization is still functioning with old procedures and attitudes. Organizational systems and patterns of behavior must be attended to by ongoing consultation with participants and their organizations. The training event must not be a final product. The experiences of the Nigerian Family Health Services Project (FHS) in establishing the Network of professionals are offered as an example of how to strengthen family planning (FP) program management at the federal, state, and local level. Training of FP personnel was conducted in planning, leadership, financial management, information systems, and supervision. The Network was used to work with FP staff initiating, supporting, and helping to sustain the changes required for effective management regardless of the time involved. FHS staff were chosen on the basis of their experience, interest in training, openness to participatory training, commitment to FP in Nigeria, support by their organizations, and position as leaders or potential leaders. The core group was expanded to meet geographic requirements. Network activities are carried on during release time provided by their full-time employers. Educational and professional backgrounds vary. Discussion focuses on the Network objectives, phases of competency development, range of activities, determinants of success, problems, future development, and lessons learned. Within 5 years, the following objectives were met: development of a group of experts in human resource and organization development, development of training materials, completion of training courses run by Nigerians and additional conferences and activities, and implementation of a management information system. Competency stages are identified as 1) beginning trainer/consultant, 2) trainer/consultant, 3) training/consultant team leader, 4) master trainer/consultant, and 5) mentor. Participatory learning and a competent team are key factors in the program's success. Other key factors were maintaining political support and assured fundings. One obstacle was pressure to accept or allow to function less suitable members.
Between November 1986 and March 1988, health care providers took cervical cultures from 533 14-39 year old women seeking contraceptive counseling at the family planning clinic of the Center Sainte Marie Hospital in Trois Rivieres, Quebec, Canada, to determine the prevalence of cervical Chlamydia trachomatis infection and its determinants. The researchers also wanted to test an enzyme immunoassay (Chlamydiazyme; Laboratories Abbott Limitee, Montreal) to detect chlamydial infection of the cervix. The clinical specimens for 38 women were inadequately conserved so the researchers could only analyze the samples of 495 clients. The cervical C. trachomatis infection rate was 9%. All 45 cases were younger than 27 years of age (mean age, 19.8 years). All but 1 case was no older than 25 years old. Women who were at the most 25 years old faced a 2.8 increased risk of C. trachomatis infection than those older than 25 years old (confidence interval, 0.4-19.6). Patients who had multiple partners during the year before the study were 2.9 time more likely to become infected with C. trachomatis than those who were monogamous. The enzyme immunoassay detected 82% of the case and adequately ruled out infection in 99% of negative cases. These findings indicated that young age was the most significant risk factor of C. trachomatis infection of the cervix. They justify screening for C. trachomatis infection in all women 25 years old or younger who seek contraceptive counseling. Infected patients should then receive treatment, especially since young asymptomatic females infected with C. trachomatis are at higher risk of complications and sequelae of such an infection.
The South to South Cooperation in Reproductive Health.
The South to South Cooperation in Reproductive Health program is a means for university based scientists and clinicians from developing countries to initiate and collaborate on research. It has been funded primarily by the Rockefeller Foundation since 1987; local governments contribute support. The Cooperative is incorporated as a tax-exempt international organization in Salvador, Brazil, where a computer center with biostatistical capability is maintained. Semiannual meetings are held to plan, critique, modify and approve protocols for research projects. Multicenter studies, managed by the project director who initiated the study, are monitored on a rotating basis in participating countries. This organization provides opportunities for investigators from developing countries to take the lead in projects in their own countries.
Efficacy and acceptability of 2 combined oral contraceptive pills administered vaginally are summarized. This is the 1st collaborative trial published by the South to South Cooperation in Reproductive Health. 1055 women participated in 12,630 cycles, in 9 countries, from June 1988 to May 1991. The pills were commercially available tablets containing 50 mcg ethinyl estradiol and 250 mg levonorgestrel (Schering AG, Sao Paulo, Brazil), or 30 mcg ethinyl estradiol and 15 mcg desogestrel (Organon, Sao Paulo, Brazil). Subjects were aged 17-39 younger and of lower parity from Mexico and Dominican Republic and older from Egypt and China. All had at least 1 pregnancy. 675 participated for 6 months, 470 for 1 year, 364 for 18 months, and 210 for 2 years. The 1-year discontinuation rate averaged 47.01% for the levonorgestrel group and 56.33% for the desogestrel group (p = 0.0061); 2-year discontinuation rates were 48.01% and 69.36, respectively, explained in part by higher involuntary pregnancy rates and prolonged bleeding rates in the desogestrel group. The most common medical reasons for stopping contraception were unplanned pregnancy, vaginal or vulval irritation, nausea, vaginal discharge and headache. Vaginal irritation was reported by 1%, 9 in each group. There were 32 pregnancies, 14 in the levonorgestrel and 18 in the desogestrel group. 17 were in missed pill cycles and the rest were method failures, 6 in the levonorgestrel group and 9 in the desogestrel group. The Pearl index varied from 0 in Nigeria to 12.24 in Mexico, and was 2.45 for levonorgestrel vs. 3.74 for desogestrel. There was a wide variation in discontinuation rates by center: Brazil and China had few, while many women from Dominican Republic, Mexico and Zambia left the study. Bleeding problems were common complaints, more so in the desogestrel group. There were 363 women with intermenstrual bleeding (only once in 80%), 148 with spotting (only twice in 65%). Bleeding duration was significantly less in pill cycles than baseline, pressure. Women gained an average of 1 kg over 2 years, more in the desogestrel group. The pregnancy rate of 2.78 is within the range reported for levonorgestrel rings.
Each week physicians visited the households of 41 mother-infant pairs living in Kalama, Egypt, to examine infant behavior and caregiver-infant interactions from 3 to 6 months of age, as they relate to various factors, e.g., maternal nutrition and health and socioeconomic status. All the mothers breast fed their infants. Liquids which are inferior sources of energy and nutrients were the most customary food supplements during the first 6 months. Even though the median birth weight tended to equal that of the WHO international reference, most infants experienced faltering growth by 3 months. At 6 months, 75% were below the 25th percentile and 20% were in the 5th percentile. Growth faltering was linked with increased diarrhea (p < .05). Even though the mothers' diets contained sufficient niacin, thiamin, folate, and vitamin C, the diets did not supply mothers enough riboflavin, vitamin B-6, vitamin A, calcium, and zinc. Breast milk did not have adequate amounts of vitamin B-6 and, perhaps, not even enough riboflavin and vitamin A. It did contain adequate amounts of calcium, however. Drowsiness was significantly related to maternal diet during lactation but not during pregnancy (especially energy intake from animal sources, p = .0001; energy intake from plant sources, p = .03); number of siblings (p = .009); crowding (p = .06); vocalization from mothers (p = .08); and low socioeconomic status (p = .07). Maternal diet was the best predictor of drowsiness followed by number of siblings. Without remediation in maternal nutrition, infants of undernourished mothers appeared not to receive appropriate care and stimulation, therefore placing them at risk of subsequent development disabilities. Intervention studies should be done to examine this main effect of maternal undernutrition and the importance of covarying environmental risk factors, e.g., crowding.
Trends in population and contraception.
The trends are identified for population growth, the momentum of growth, contraceptive use, choice of method, and future contraceptive needs. The forecast for the 1990s, based on UN estimates, is for growth of 90 million each year. 94% of growth will occur in developing countries. Sub-Saharan Africa will experience the fastest rate of growth, but the largest numbers will be in Asia. Population is expected to increase by 112% between 190 and 2015 (550 million) in sub-Saharan Africa, by 60% (750 million) in South Asia, and by 76% in the Middle East and North Africa. Even if developing countries have replacement level fertility, the numbers of women of reproductive age are high enough in most developing countries to continue to increase population for 6 decades. Fertility rates in developing countries are halfway to replacement level with fertility rates of around 4. Worldwide there has been a ten-fold increase in contraceptive use over the past 30 years. By 1990 over 50% of married couples of reproductive age used contraception. There is evidence that family planning methods have been found to be acceptable by people of many different cultures and socioeconomic conditions. Sterilization is the most commonly used method worldwide. Most of the sterilized population lives in China (70 million) and in India (36 million), which constitutes 59% of persons of reproductive age. Populations with more than 40% of the reproductive age population sterilized include Puerto Rico, Canada, and South Korea. More than 25% of sterilized couples are found in Brazil, the Dominican Republic, El Salvador, Panama, the US, Sri Lanka, Thailand, Taiwan, and the UK. The second most popular method is the IUD. The country with the highest proportion of people using the IUD is China. 67 million in China use the IUD compared to 26 million in other developing countries and 10 million in developed countries. New methods, which lower logistical and cost factors, need to be developed; greater access to the very poor or those in remote areas is targeted. Potential users might be attracted to methods with improved safety, reduced side effects, and greater convenience. Access to a wide variety of methods is a means of reaching a larger audience of users. New contraceptive technology will be available during the 1990s, i.e., implants, a vaccine to prevent pregnancy, and a pill or injection for men.
Study and introduction of family planning methods in developing countries.
A key element of international support for family planning programs in developing countries is research in the development, evaluation, and introduction of family planning methods and services. These countries have the capacity to do high quality contraceptive research (from early preclinical research to phase III clinical trials). 3 international organizations are leaders in collaborating with researchers in developing countries to develop and support a network of clinical research centers in family planning. USAID assists 2 of these organizations because of its interest in family planning research: The Population Council and Family Health International. The Population Council's chief goal is the development and introduction of new contraceptive modalities. The Council developed Norplant, the sole new contraceptive approved by the US Food and Drug Administration in recent years. The International Committee for Contraceptive Research (ICCR) implements most of the Council's development program. ICCR consists of a group of research clinics and laboratories in Chile, the Dominican Republic, Finland, France, India, and the US. It is responsible for the development of 3 Copper-T IUDs and a levonorgestrel-releasing IUD. Family Health International conducts evaluation of family planning programs, epidemiological research in reproductive health, and clinical trials. WHO's Special Programme of Research, Development and Research Training in Human Reproduction is the other major player in family planning research in developing countries, specifically, assessment of contraceptive safety and efficacy, development of new contraceptives, and infertility. WHO and the Rockefeller Foundation have established a South to South collaboration in research to promote cooperation between developing countries. National and international agencies need to further develop and maintain these various international efforts.
Fundal height measurement. Part 1 -- Techniques for measuring fundal height.
Historical and current methods of measuring fundal height in pregnant women and the few studies on their reliability are reviewed, described and illustrated. Historically fundal height was an important technique in the differential diagnosis of pregnancy. Until this century maternal anatomical landmarks were used as reference points to measure fundal height. Currently, while the lower dimension is usually the symphysis pubis, the upper dimension and the method of measuring it varies, whether with tape or calipers. The most common method used today employs a tape measure to gauge the upper border of the symphysis pubis as the inferior border, the uterine fundus as the superior border, and the tape is held fully in contact with the maternal skin rather than parallel to the exam table. The only available comparative study found that the caliper method is more reliable between examiners than the tape measure method. To predict eventual birth weight the tape measure method including the upper curve of the uterine fundus gives a higher correlation than the caliper method. It is important that published reports describe the method and landmarks used to record fundal height, including instrument used, inferior and superior landmarks, how much of the tape contacts skin, whether the fetal or maternal midline is followed, and other details such as maternal position and whether the bladder is empty.
Data on ovarian cancer from 12 U.S. case-controlled studies were combined to highlight the risk of epithelial ovarian cancer in black women relative to white women to see if reproductive factors such as pregnancy and oral contraception can account for the lower incidence of ovarian cancer in Blacks. The incidence of ovarian cancer was 10.3/100,000 black women and 15.4/100,000 white women in 1988. 110 black women with diagnosis of epithelial ovarian cancer between 1971 and 1986 were compared to 251 black population controls and 114 black hospital controls. Reproductive factors were compared in 246 black and 438 white population controls as well. Results were derived by conditional logistic regression, adjusted for birth year. There was a lower risk of ovarian cancer in blacks with parity of 4 or higher (odds ratio 0.53), with breast feeding 6 months or longer (O.R. 0.62). More blacks (48%) than whites (27%) had 4 or more term pregnancies. Blacks were slightly more likely to breast feed for 6 months, and whites were slightly more likely to have used oral contraceptives. Black women had lower risks of ovarian cancer if they had hysterectomy or used postmenopausal replacement estrogens, but higher risks if they had natural menopause. As expected, longer duration of ovulation increased risk of ovarian cancer (O.R. 1.6). This study found that the risk estimates for reproductive factors were similar for blacks and whites, and that the prevalence of these factors cannot explain the lower incidence of ovarian cancer in U.S. black women.
The world's women: fighting a battle, losing the war.
This anthropological perspective on the determinants of fertility decline suggests that family size remains large or increases when people believe that the economic or environmental limits have been reduced. The myth is that modernization, development, lower mortality, and increasing prosperity cause lower fertility. Operationally, the belief in "easily accessed wealth" or "rising prosperity," which is a by-product of development policies and programs, eliminates the motivation to exercise caution and restraint. Modern culture generates the message that new ways make life easier and better and offer a path or prosperity. "Customs that depress fertility are lost faster than modern contraception becomes available or is accepted." In India the transition to modern society and couples having small families is expected to take 20 years, based on the estimates of anthropologist Mahinder Chaudry. It is also suggested by Kingsley Davis that traditional ways accounted for fertility before modernization, which spurred population growth initially. Traditional ways have beliefs, rules, and behavior that depress fertility. The frequent human condition is not one of population out of control. There is evidence that providing easy access to contraception or free condoms does not always lead to increased contraceptive use. Motivation, culture, the nature of decision making within the household, and the woman's desire for children are important factors affecting fertility. Advocacy for women is not a substitute for population control efforts. Improving women's status or health does not directly result in fertility change. Concern is raised that directing limited resources to improve women's health and status is unwise because of the competition with family planning and population control programs.
The collected responses to Simon and other population revisionists.
Brief excerpts of rebuttals to Julian Simon's The Ultimate Resource aim to dispel the arguments of revisionists that population growth is not a problem. A brief introduction to Simon's ideas is followed by quotations from Simon on seven broad, non-mutually exclusive topics and quotations from specialists in demography, economics, and other science fields. The responses focus on the technical problems in Simon's presentations. The problems can be methodological or inconsistencies with observations. The topics are 1) resources; 2) technology, ingenuity, opportunity, and efficiencies of scale; 3) the population-development relationship; 4) pollution and the environment; 5) food; 6) family planning demand; and 7) methodology. Simon's assertion that resources are not finite in the economic sense is refuted by Grant, who states that the concept of infinite substitutability is not based on any systematic rationale and is an assumption appropriate to theoretical model construction. Daly and Cobb argue that abstractions don't always capture the truth about substances. Nathan Keyfitz argues that renewable resources are the ones suffering shortages, and the dynamics of scale can change the model. The strain on the environment is nonlinear. Timmer posits that technological progress as a function of population is evidenced in the variation in public policy and the failure to solve the problems of poverty and misery. Crane states that when infrastructure is weak, greater population density may not promote efficiencies or creativity. Merrick says that technological progress has been developed by developed countries, and developing countries may either not be able to afford the technologies or the technologies may exacerbate conditions. Merrick also says that world food production constraints are political, managerial, and financial, and not technological. Keyfitz points out the that there is no evidence of squatter colonies in Mexico showing creativity. Bartlett responds that physical and emotional environments are important to the occurrence of Mozarts and Einsteins and not statistical enumeration.
Somalia and the overpopulation connection.
Somalia's Operation Restore Hope has been reported in the media as successful in alleviating starvation and human suffering. The perspective missing from these media presentations of conditions in Somalia is the impact of population growth on famine or war conditions. In mid-1992 Somalia had an annual population growth rate of 2.9%, which means a doubling in 24 years. The birth rate is 6.6 children per woman, which is twice the world average of 3.3. The current fertility level contributes a net increase of 657 people per day or an additional 240,000 mouths to feed per year. The question is raised as to whether foreign agencies will be ready to provide humanitarian aid in 24 years or earlier, when food shortages appear again. The evidence points to the notion that Somalia has surpassed its carrying capacity, or the ability to support its population without degrading the physical, ecological, cultural, and social environment. Civil war and drought have exacerbated an already starving country. The question is also raised about when foreign aid will recognize problems of sustainability or carrying capacity. Good intentions may underlie the short-term policy of advocating foreign food aid, but in the long run the result may be unsuccessful. The situation in Somalia represents a failure to recognize that there are limits to resources and population is rapidly increasing. Current policy prevents the integration of food aid with birth control programs and prevents incentives to encourage participation. Ignoring the population growth component means contributing to even greater human suffering.
Rapid coma resolution with artemether in Malawian children with cerebral malaria.
The antimalarials artemether and quinine were compared in 65 unconscious children with cerebral malaria treated from January to June 1992 at Queen Elizabeth Central Hospital, Blantyre, Malawi. Artemether is a derivative of the Chinese traditional remedy ginghaosu, and is chemically unrelated to quinine or other existing antimalarials. These patients had a coma score of 2 or less, peripheral Plasmodium falciparum parasitemia, and no other cause of fever or altered consciousness. They were randomized to be treated with either intravenous quinine dihydrochloride 20 mg/kg over 4 hours (37 children), then 10 mg/kg over 2 hours every 8 hours until the patient was able to drink, or artemether in in oil suspension (Rhone-Poulenc-Rorer, France) 3.2 mg/kg (28 children), then 1.6 mg/kg daily. Both groups received at least 3 doses of the drug until parasite clearance (2 consecutive 4-hourly negative screens) or recovery of consciousness. Then each received a dose of fansidar (pyrimethamine/sulphadoxine). Both parasite clearance time and time to regain consciousness (coma score of 5) were more rapid in the artemether group. Coma resolved in 8 hours in the artemether group and 14 hours in the quinine group. Outcome in terms of fever resolution time, neurological sequelae, and mortality did not differ between groups. The study was too small to compare survival: this is part of a multicenter trial to study the effect of artemether vs. quinine on mortality.
Obstacle course: funding and policy stifle contraceptive research.
Contraceptive research policy in the U.S. during the last 30 years may be changing with liberalizing inroads made by the Clinton administration, but outcomes are still limited by lack of industrial and government funding. The U.S. has fewer contraceptive choices than most developed countries: Depo-Provera was only approved last year and the only new contraceptive about to be marketed is a female condom. It is likely that the very high rate of unintended pregnancy in the U.S. is a consequence of this attitude. The Clinton administration has officially reversed the "Mexico City Policy" which forbade financial support of any institution, even those overseas, that may provide abortions or abortion counseling. In the U.S. funding for contraception research at the National Institutes of Health (NIH) has been cut from $16 million to $9 million. NIH is working on contraceptive vaccines. Vaccines for contraception have made more progress in New Delhi's National Institute of Immunology, however. U.S. pharmaceutical companies have long stopped doing basic research on contraception, but 7 new applications of old products are being developed, such as injectables, morning-after pills, and IUDs. Conservative attitudes still block innovation, reflected in the Helms Amendment of 1973 forbidding research on compounds that may act after fertilization, and the USAID's definition of pregnancy as beginning at fertilization. While conservatives associate contraception with abortion, the public is tiring of this attitude.
Health: the soap opera version.
Watching soap opera is a favorite pastime of millions of Egyptians. Since the spring of 1992, the soap opera "The Family House" has reached audiences with messages on AIDS, drugs, child spacing, home accidents, and hygiene. The shows are the brainchild of the Director of the Center for Development Communication (CDC) in Egypt, Dr. El Kamel; the shows capture the novel and unique concept of both the communication of information and entertainment. Between 1983 and 1990, the CDC has been creating 130 short soap opera episodes on subjects such as the prevention of dehydration from diarrhea and the use of oral rehydration salt (ORS) packets to save children's lives. The ORS episodes were 15 minutes in length and showed the dramatic tension between a baby suffering from diarrhea and the mother's helping to overcome the difficulty. Surveys conducted in 1983 and 1986 on knowledge, attitudes, and practices found that in 1986 98% knew about ORS and 70% had used it compared with 3% knowledge and 50% practice in 1983. "The Family House" will be similar but expand on the number of issues considered and will pretest audience knowledge, attitudes, and practice before and after airing on specific issues. This soap opera also will be the first to be a daily series with an unending story. "The main character is Amina, who is an artisan in her late 40s who raised 4 children by herself." The series of 45-minute long shows will depict urban and rural settings and everyday Egyptian culture: language, clothing, life styles, and moral standards. Distribution is anticipated for other Arabic countries in Africa and the Middle East, which already air many Egyptian television series.
A new family planning tool to slow population growth.
The National Institute of Immunology in New Delhi, India, is conducting clinical trials of a prototype birth control vaccine. 88 20-36 year old women receive a series of 3 injections of 300 mcg human chorionic gonadotropin (hCG) vaccine to theoretically protect them from pregnancy for 1 year. After 1 year, they receive a booster shot to protect them for another year or not receive the booster, thereby resulting in a return to fertility. So far, only 1 pregnancy in 821 menstrual cycles has occurred. In women who do not use contraception, 821 cycles would normally result in 250-300 pregnancies. The developer of the vaccine thinks that these results confirm its effectiveness. The vaccine stimulates antibodies against hCG, thus keeping hCG from preparing the uterus for implantation. Some advantages include the following: it is reversible and effective for 1 year, does not alter women's physiology, and is less intrusive than other contraceptives. The International Development Research Centre of the Government of Canada has supported this vaccine's research since 1974. The Institute is now conducting research on a new contraceptive method using the purified extract of the neem tree called praneem. Researchers have injected it into the uterus of rats and monkeys. They hope it can be a safe and effective method for women to use during the 3 months when they receive their vaccine shots. The Institute is also working on perfecting the delivery system of the vaccine, e.g., a biodegradable implant releasing the required dosage over 1 year. It is also developing a finger-prick test to determine whether women who have accepted the vaccine are producing enough antibodies. Despite the progress, more research is needed.
A recent research effort by the Nepalese Topological Survey Branch and the Department of Soil Science and the University of British Columbia, Canada, found with the use of the geographic information system (GIS) that forest cover has expanded, but soil fertility is decreasing at a rapid rate in Nepal. These findings conflict with media allegations which allege forest destruction from farmers' wood-cutting practices and responsibility for flooding in Bangladesh. The research was conducted in the Jhikhu Khola watershed in the Middle Mountains, which is Nepal's most populous region that is intensively used in subsistence farming and grazing. Migration adds to the existing problems of soil erosion, sedimentation, deforestation, and loss in soil fertility. The soil is prone to erosion. Data were collected through the GIS system by aerial photos, field surveys, and soil analysis. Hydrometric stations to measure the sedimentation process were established in 7 places and farmers monitored the climate, water loss and gain, and sediment movement. Interviews were also conducted among the farm population on demographics, livestock, fodder and fuel consumption, crop yields and practices, and fertilizer use. Researchers aimed both to identify the causes of soil degradation and to estimate the productivity, profitability, and sustainability of different land uses and farming systems. Another finding was that, in Jhikhu Khola, the deforestation of the 1960s has been abated by reforestation efforts in the 1980s. This has contributed to a 10% expansion of forest cover, and increase of sloping terrace by 9%, and a decline in grazing land by 9% and shrub land by 6%. Calculations for the year 2000 showed that the fuelwood surplus would drop to 6% from 73% and food surplus of 25% would become a 27% deficit. The 40% deficiency in animal feed would increase to 54%. Although reforestation has added to forest cover, pine tree cultivation occurred on moderate elevations where grazing and food production are possible, while higher altitudes on steep slopes were untouched. Workshops are conducted in the villages and efforts are being made to promote the exchange of information between departments. The ultimate solution is to increase agricultural production for profit.
Irish doctors row over limited abortion rights.
In 1978 the Irish Medical Council was established under the General Practitioners' Act as a statutory body to regulate the medical profession. Currently the medical council acts as an autonomous body of diverse professions. Critical comment is provided on the recent decision by the Ireland Medical Council that "abortion is not always unethical." 14 of the 20 present Council members supported the new position and 7 opposed the new guideline. Abortion should be allowed where the mother or the fetus have a clear risk to life and health. A qualification was that "it is always unethical to withhold treatment beneficial to a pregnant woman by reason of her pregnancy." Senior doctors have disagreed, but the Pro-Life Campaign supported the position. A member of a liberal medical campaign group pointed out that the Council still had not dealt with situations where women are threatened with preeclampsia or hemorrhage and the fetus is not viable. A psychiatrist from St. Patrick's Hospital in Dublin disagreed with the argument for abortion that pregnant women were 20 times less likely to commit suicide than nonpregnant women. The disagreement was over whether the statistics should pertain to pregnant women who were threatening suicide. Currently the Irish government is preparing legislation to allow limited abortion, based on the Irish Supreme Court's recent decision in the case of "X," which pertained to a suicidal 14 year old with an unwanted pregnancy. The life risk was considered real and substantial; abortion was allowed. Suicide risk is considered to be very important.
AIDS will not be notifiable disease in India, in the interests of maintaining confidentiality for people with HIV/AIDS. This decision was made at the 1st meeting, last month, of the National AIDS Committee, constituted under the chairmanship of the Minister of Health and Family Welfare last October, to provide policy direction and oversee the work of the National AIDS Control Organization (NACO). The committee also decided that providing needles or syringes to injecting drug users would give wrong signals about government policy on drug abuse. Here, drug abuse is a criminal offense punishable by imprisonment. Intravenous drug use (and needle sharing) is widespread in some northeastern states of India, particularly Manipur, where 54% of injecting drug users have been found to be HIV positive. Most of them are now in jail. In the many other parts of the country where drugs are rarely injected, the 1st priority is to prevent a shift towards drug injection. Media campaigns against injection might arouse curiosity rather than deter from injection--as happened in 1991 in Nepal, where after such a campaign, there was a rapid switch from oral to injecting drug use. Only low-key peer programs are likely to be effective in such situations. The committee also raised concern about how hospitals have refused to treat AIDS patients, and called on physicians to educate themselves first. Such a refusal had in early February led the Government to instruct the All India Institute of Medical Sciences not to refuse any AIDS/HIV patient even if surgery were needed--this instruction followed an inquiry into how, in 1991, the institute had to call in a private practitioner to deliver an HIV-positive woman of her baby because its own doctors has refused to do so. (full text)
The UN Population Fund has promoted a study of Islamic views on family planning. The relevance of Prof Abdel Rahim Omran's scholarly account is heightened by the comparisons he makes: maternal mortality is 20 times that in Europe and, at its present rate of growth, the population will double in 23 years against 230 for Europe. He describes the nature and origins of various Islamic traditions without distilling a consensus, yet gives respectful weight to the 1991 judgments of the Grand Iman of Al-Azhar. These are that contraception (by whatever means) is not prohibited; sterilization is permitted only to safeguard a woman's health; abortion after 120 days' gestation is forbidden except to save a mother's life; and artificial insemination with the husband's sperm is allowed (donor insemination is not). Upon one matter only does there seem to be universal agreement in the Islamic world--no law should coerce people to use contraception or fix the number of children in a family. (full text)
Back to the future: ethnodevelopment among the Jalq'a of Bolivia.
The story is told of how several Chilean anthropologists and Bolivian colleagues helped the Jalq'a people to revive their traditional handicrafts as a model for microregional development. The quest was initially undertaken to find out about "potolo" weavings. The Jalq'a people were found in numbers totaling 25,000 impoverished and with very high infant mortality rates, low incomes, and social disorganization. although the traditional woven dresses were still worn, the color combinations and motifs had lost their originality and precision. The story was told about how during the 1960s and 1970s the poor cash economy had forced people to sell their textiles to tourists and traders for lower than market value. Eventually it became apparent that there were no longer models of the traditional garments to inspire new generations. Upon the anthropologists arrival and inquiries, it was related that local interest to revive production of these native textiles was still there. The craft revival took root because of the interest in the people not just as artisans but as people, and rapport was established. The background of the anthropologists is related. A grassroots support organization (GSO) was formed to assist in economic development that was rooted in the life of the community. The pace was set by participants and a few women at first were trained in commercial production. A shaman was asked to conduct a ritual ceremony which involved calling upon the mountain deities, the Mallkus, to give them a sign. The Mallkus agreed the project was good and the Jalq'a must conserve their language and culture and textiles. New workshops were blessed in a similar way. In the first workshop the challenge was for the women to determine how to make the many strange animals that appeared in Jalq'a designs; a photographic archive was put together and the hand-dyed colors restored with some difficulty. The exhibit of the textiles after several years led to new respect for the Jalq'a and indigenous peoples and a means of recognition for further sales. Women's status and Irupampa socioeconomic status has improved; migration to urban areas has been slowed. The experiences of the Navajo in the US has been helpful in the Jalq'a efforts in international marketing. GSO has been able to provide guidance to others in learning about their spinning machines, quality control system, and marketing strategy.
The view from the shore: Central America's Indians encounter the quincentenary.
Indigenous peoples of the Caribbean, except in small areas of the Dominican Republic and Cuba, have vanished through the years since Columbus landed. In the South, indigenous populations were "largely broken and demoralized, and political institutions shattered." In the 500-year celebration of Christopher Columbus's voyage to the Americas, many materials have been produced. In this article, the focus is on the unknown Indian of Latin America, who is invisible and usually isolated. The 40 million surviving Indians make up various percentages of a country's population, from among 50% in Peru to as little as under 1% in Brazil. The political upheavals of the 1980s have propelled Central America into the public eye. Central America's indigenous population is 4-5.5 million people in 43 different ethnic/linguistic groups (16-22% of Central America's total population of 25 million). Population growth of indigenous people has increased in the last 20 years. Most live in the difficult to reach regions of the jagged volcanic highlands of Guatemala and the densely forested Caribbean coastal plains from Belize to the Colombian border. These isolated locations were selected as protection from the colonists; these regions now are threatened by loggers, cattle ranchers, and landless peasants. In Guatemala, the 4.5 million Indians belong to 22 different Mayan language groups, who have been studied extensively by scientists. In Costa Rica, Indians receive limited protection in 21 reservations, and in El Salvador there is a denial of the "naturales" existence and what was owned before the Conquest is long gone. Most of the Indians are poverty stricken and lack basic social services. Indian organizations have appeared; their involvement in Indian welfare is recounted, e.g., the Kuna of Panama organized the first Indigenous Congress on Natural Resources and the Environment in 1989. An obstacle to the Indians survival is the legacy of Conquest: subjugation, humiliation, and discrimination; Indians are perceived to be obstacles to economic and social progress. Concern about deforestation should provide the basis for collaboration with the Indians. Conservation schemes must recognize Indian's beliefs about the sacredness of the earth and community spirit. The Columbus celebration should mark the beginning of the discovery of who Indians are.
[The perinatal aspects of neonates surviving low birth weight]
Records of 277 low birth weight infants discharged alive were analyzed at a tertiary level neonatal care facility in Mexico City. The objective was to identify prenatal factors associated with the more favorable prognosis in the perinatal period of infants small for gestational age compared to those considered adequate for gestational age. 505 newborns of the 3040 born during the study period weighed under 2500 g at birth. 228 of the 505 were excluded, 62 because of neonatal death and 166 for lack of complete information. 3 of the newborns weighed less than 1000 g, 37 weighed 1000-1499 g and 237 weighed 1500-2499 g. The newborns in the 3 weight groups were subdivided into the 2 groups "adequate for gestational age" and "small for gestational age". Maternal variables studied included age, number of prenatal visits, pathologies experienced during pregnancy, and type of delivery. Neonatal variables analyzed were birth weight, sex, gestational age by Capurro's method, growth according to the intrauterine growth curves of Lubchenco et al., Apgar score at 1 minute, and intrahospital morbidity. In the 2 larger weight groups the different variables were compared for small-for-gestational-age and adequate-for-gestational-age infants. The 3 infants weighing under 1000 g were all small for gestational age. 20 of the 37 children weighing 1000-1499 g were considered adequate and 17 small for gestational age. The small-for-gestational-age infants had more prenatal visits and were more likely to be products of multiple pregnancies. Toxemia was more prevalent in mothers with small-for-gestational-age than adequate-for-gestational-age infants, while premature rupture of membranes was more common with infants adequate for gestational age. Average birth weights and gestational ages, respectively, were 1238.7 +or- 159.9 g and 31.4 weeks for infants adequate for gestational age and 1236.7 +or- 143.5 g and 34 weeks for infants small for gestational age. The difference in gestational age was statistically significant. The group of newborns weighing 1500-2499 g included 127 adequate for gestational age and 110 small for gestational age. The adequate-for-gestational-age group was significantly more likely to have experienced premature rupture of membranes. The average birth weight and gestational age, respectively, were 2105 +or- 234.8 g and 35 weeks for adequate-for-gestational-age infants compared to 2260 +or- 195.5 g and 38.4 weeks for the small-for-gestational-age infants, with both differences statistically significant. Although no statistically significant differences were found in intrahospital morbidity in the infants weighing 1000-1499 g, in those weighing 1500-2499 g the group adequate for gestational age was likely to suffer from more serious and life-threatening conditions.
[Morbidity-mortality due to exchange transfusion in a general hospital. A prospective study]
A prospective study was conducted at a general hospital in Mexico City to determine the type and frequency of complications following exchange transfusions in newborns. Exchange transfusions performed by experienced personnel are believed to be safe procedures for treatment of hyperbilirubinemia when other measures fail to correct the problem, but they are not without risk. 50 exchange transfusions were performed in a Mexico City social security hospital in 1 year. The infants were classified according to their clinical status before the procedure into 4 categories: stable, critical stable, critical unstable, or moribund. Blood samples were taken before and after the transfusion to assess hemoglobin, bilirubin, electrolyte, glucose, and calcium levels. 38 of the 48 infants were born at term and 10 were premature. 36 were considered to have adequate nutritional status, 7 were small, and 5 were large. The average weight was 2939 +or- 778 g. 37 were considered in stable condition, with no associated pathology, 8 were considered in critical stable and 5 in critical unstable condition. 84% of the transfusions were performed through the umbilical vessels. In 22 cases both vessels were used and in 10 each the umbilical vein and artery were used. The internal or external jugular was used in 8 cases, in 3 of which attempts to use the umbilical vessels had failed. The indication for the transfusion was ABO incompatibility in 25 cases, multifactorial in 20 cases, isoimmunization to Rh in 3 cases, and secondary to post-transfusion recurrence in 2 cases. The duration of the procedure ranged from 33 to 180 minutes and averaged 64.3 +or- 23.5 minutes. 2 procedures were suspended, 1 for irreversible cardiorespiratory arrest and the other for uncorrectable arrhythmia. 33% of the infants experienced some type of complication. There were 23 cases of alterations in cardiac rhythm, with tachycardia in 14 and bradycardia in 6. The problems with cardiac rhythm were transitory in all cases except the 2 in which the procedure was terminated. There were 20 cases of metabolic alterations, including 11 of hyperglycemia. 10 cases of infection, 8 of necrotizing enterocolitis, and 3 of bleeding on removal of the catheters were also observed. 2 of the infants died, one during the procedure and one 4 hours later. Both were preterm infants in critical condition at the time of transfusion. The results suggest that morbidity associated with exchange transfusion is more frequent than previously reported. Mortality may be due more to the critical condition of the infant than to the procedure itself, however.
The authors reviewed the clinical and pathological features of 24 cases of well-differentiated villoglandular adenocarcinoma of the uterine cervix. The patients' ages ranged from 27 to 54 years, with an average age of 37. At least 15 patients were taking oral contraceptives prior to diagnosis, compared to 5 of 18 in a control group of patients with various other histologic types of cervical adenocarcinoma. All of the neoplasms were exophytic polypoid lesions with thick or thin papillae lines by endocervical, endometrial, or intestinal-type epithelium showing mild cytologic atypia. 10 were associated with adenocarcinoma in situ, 8 with cervical intraepithelial neoplasia, and 1 with microglandular hyperplasia. All tumors were confined to the cervix. 5 patients were treated by excisional biopsy or cone biopsy, 4 by simple hysterectomy with prior or subsequent radiation therapy, and 15 by radical hysterectomy. All patients are alive and well, with no evidence of recurrent disease. The followup ranged from 7 to 77 months, with a mean of 36 months. (author's)
Determinants of sexual habits in Italian females.
This study sought to identify characteristics of women who reported multiple sexual partners and early age at 1st intercourse in Italy. Information on 1139 control women (median age 54 years) interviewed as part of a case-control study of cervical neoplasia conducted in the greater Milan area, Northern Italy, were analyzed using stratified analysis and multiple logistic regression. Overall, 81% of the study sample reported no more than 1 sexual partner, 10% reported 2, and 9% reported 3 or more. The proportion reporting multiple sexual partners tended to be higher among younger and more educated women (4% vs 19% of women with, respectively, less than 7 and 12 or more years of education reported 3 or more partners). Ever smokers reported a higher number of sexual partners than never smokers. The proportion of nulliparae reporting 3 or more sexual partners was higher than that of parous women. These findings were confirmed after taking into account in a multivariate analysis the role of potential confounding factors. Furthermore, similar findings emerged from an analysis restricted to women aged 40 years or less. always considering number of sexual partners, no relationship emerged with marital status, spontaneous or induced abortions, lifetime number of reported Pap smears, and contraceptive habits. With reference to age at 1st intercourse, 25% of the study population reported their 1st intercourse at age 18 or earlier, 34% between 19-22 years, and 41% at age 23 or older. Younger women (i.e., more recent cohorts) more frequently reported earlier age at 1st intercourse and the proportion of never married women reporting early intercourse was higher (51% vs 22% of never married vs married women). No relationship emerged between education, smoking habits, parity, history of spontaneous or induced abortions, number of Pap smears, contraceptive habits, and age at 1st intercourse. This study documents conservative sexual habits in Northern Italian females (at least on the basis of self-reporting) but indicates that any educational campaigns towards safe sex should be focused towards younger women, particularly smokers unmarried, and nulliparae. (author's)
In a recent letter published in this column (Blue B. Vasectomy procedure [letter]. J Fam Pract 1992; 35:254), Dr. Blue told of his practice of saying a portion of the vas after performing a vasectomy so that if the sperm count failed to drop as expected, the vas specimen could be sent to the laboratory to prove that the proper tissue was excised and ligated. I submit that a malpractice attorney would almost certainly try to establish to a jury that such a move was self-serving for the physician and that he would have ample opportunity to substitute someone else's specimen for the one in question. In the current medicolegal climate, I think the physician would have difficulty proving beyond doubt that a specimen saved for several months was, in fact, the one submitted to the laboratory after the fact. This is a pity. I do not doubt that Dr. Blue is scrupulously honest, but I have seen the credibility of physicians I knew to be perfectly honest cut to pieces by unscrupulous plaintiffs' attorneys operating within the rules of a court. (full text)
Urban community health volunteers.
In Nepal, the village health worker program in urban areas has not been effective; the volunteer program has never been tried. In order to increase use of basic health services, a program was initiated in 1987 in Pokhara to survey hospital and health utilization rates and baseline demographic conditions. Urban community health volunteers (32) were trained to conduct a demographic and health survey, to educate and motivate people to use healthy and hygienic practices, and to use appropriate health services. Outreach clinics were established in each ware; home visits were made by the community health volunteers. Clinics attended to prenatal care, immunization, growth monitoring, family planning, and health education. Of the 32 volunteers, 14 males and 8 females dropped out due to the scarcity of incentives, lack of time, and no recognition. An evaluation of the program over the prior two years of operation was conducted in January, 1991, in order to assess the impact on knowledge, skills, behavior, and use of facilities. A random sample of 394 mothers with children aged <5 years, who were registered in the health ward and population registers, was selected for in-depth interviews. The results showed that only 70 of the mothers knew of community health volunteers in the wards; 56 had been in direct contact. 49 of those who knew about the volunteers considered the program helpful. 149 mothers knew about the mobile clinic in their wards; 100 of these mothers had used services in a hospital clinic. There was a lack of coordination among potential oversight agencies, such as: the Pokhara Municipal Office, the Shining Community Health Project, and the Kaski District Public Health Office. Replacement volunteers were not found and trained. Differences were found between service statistics and post-intervention survey results and were accounted for. Community health volunteers did not accurately record statistics on births, deaths, marriages, and migration. Females were more effective than males. Improvements were found in increases in prenatal care, immunization coverage, and use of oral rehydration. The deficiencies in the program were due to inadequate supervision, training, motivation, and follow-up.
The very young as agents of change.
Empirical research in many countries has found that girl's primary school education has contributed to lower infant mortality, better nutrition, and birth spacing. Primary school education for girls is a better predictor of health than the level of health services or other factors. The aim of primary education should be to prepare students by giving them the skills and attitudes necessary to function in society. Encouragement should be given to develop confidence in one's self and continue with education past the primary level. Schools should also prepare students to deal with health problems. The Child-to-Child Trust publications provide information on health issues. There are activity sheets which help to examine common problems. An example is given of how information on diarrhea treatment can be turned into a useful exercise in mathematics by surveying the community on incidence of diarrhea among bottle fed versus breast fed babies. Children can estimate the costs of bottle feeding, which is related to a higher incidence of diarrhea, and set up an action plan to promote better health practices. The Trust also has begun to rewrite texts in such a manner as to incorporate learning about primary health care. For instance, the integration of health issues into mathematics might include statistical information on immunization and oral rehydration therapy. The nature of the communication is important; messages should be practically displayed. Rapid breathing in babies, which is a sign of pneumonia, might be demonstrated with a pendulum (a stone attached to a piece of string and swung back and forth). A 2-meter-long pendulum swings at the breathing rate of adults and older children; a 1-meter-long pendulum swings at the rate of 30 times a minute, or the rate at which a healthy baby breathes. A baby with pneumonia breathes at the same rate at which a 35-centimeter-long pendulum swings. The Trust is a resource center for those interested in creating children's programs.
Environmental NGOs in Ecuador: an economic analysis of institutional change.
Nongovernmental organizations (NGOs) in Latin America have grown more rapidly than has our understanding of the economic and political implications of this major institutional change. In Ecuador, between 1984 and late 1992, at least 24 new environmental NGOs emerged. An economist does a case study of them, especially Fundacion Natura (FN) in Ecuador, to understand their role and behavior which are a large part of environmental politics in Latin America. NGOs are successful because the public sector cannot meet the countries' needs and donors want to help NGOs, thereby providing the demand. For example, FN has received funding from USAID, World Wildlife Fund, the International Union for the Conservation of Nature, and other groups. FN charges donors 15% to cover administrative costs while many other NGOs do not receive international funding for administrative costs. FN is well connected with the public sector which is supportive and beneficial. FN activities complement the public sector's efforts in the environment. Further, it is well connected with private industry from whom it receives financial support. It has been criticized for supporting industry on some environmental issues, however. In fact, its Cuenca chapter split from FN in 1984 to form Tierra Viva, because FN sided with industry when industry wanted to build on agricultural land in Cuenca. FN's relationship with USAID is strained. FN is successful because it employs quality personnel who are committed to FN objectives. Yet FN and other NGOs do not have the monetary incentives for efficient production. Most other NGOs are financially strapped and depend on volunteers. The more radical environmental NGOs do not accept donations from the private sector and do not want to work with government. Despite the influence donors have on NGOs, the NGOs' powerful presence and their environmental education programs have consequences beyond donor control (e.g., FN and USAID).
Reassessing priorities: identifying the determinants of HIV transmission [editorial]
Despite remarkable advances in knowledge of HIV and AIDS, the social context of HIV transmission has been neglected. A few writers have addressed some key issues in the social, historical and cultural content of HIV transmission, such as economic need of women and their use of transactional sex as a survival mechanism, and similar use of transactional sex in some Asian countries by young women, with full family support. Population displacement, troop movements, migrant labor, urban squatter settlements in the developing world, and drug and alcohol use in the developed world, have received minimal attention in research on HIV. It is important to identify and target high-risk situations such as homeless youth for HIV prevention strategies. Women's groups and community-based organizations, trade unions and even the organized gay community are examples of effective empowerment and influence for change in behavior. These institutions are all the more effective because of people's district of official channels such as the government. The focus is the U.S. needs to be changed to minimization of harm, and the language altered to reflect high-risk situations. Well-designed experiments should be mounted to see if an approach like that used by the gay community can be applied to other groups. If such context-specific approaches, focused on high-risk situations, are effective, they should be applied to HIV transmission and to other environmental-social situations such as alcohol and tobacco related disease and accidents.
The impact of induced abortions on fertility in Israel.
The aim of this study was to determine whether the incidence of legal, induced abortion had any effect on the already high fertility rate (TFR) in Israel in 1988 and 1989. Abortion is permitted for 1) women under the legal marriage age of 17 years or over 40 years, 2) as a result of rape or incest or out of wedlock, 3) suspected physical or psychical malformation of the fetus, and 4) possible danger to a woman's health. 28 public or private hospitals are granted permission to perform abortions. The general abortion rate has shown a steady decline from 18-20/1000 in 1979-83 to around 15/1000 in 1987-89. Abortions for ground 3 have risen over 10 years, and declined for ground 4. Data pertain to applications for legal abortion (AFLA). 16,200 out of 18,000 abortion requested were approved in 1989 and 15,200 were actually performed. Refused abortions might constitute black market abortions. From AFLA rates, the total abortion rate (TAR) is approximated. In 1988, the TAR was 543/1000 women aged 15-44 years or a little more than 1:2 women in a reproductive lifespan. The adjusted TAR is .600-.620 abortions/woman in a lifespan. TAR was 15% of known pregnancies in 1988 with higher percentages in the teens and over 40 years; i.e., 33% among teenagers, >40% among those over 40 years, and 10% among those 20-34 years. The ratios of age specific AFLAs and TFRs, and TAR and TFR shows for those over 40 years to be 3 abortions to 4 births. For teenagers the ratios are 5 abortions to every 10 births. For those 20-34 years the ratio was 1-1.5 abortions for every 10 births, and for those 35-39 years 3 for every 10 births. The analysis of AFLAs for grounds 1 and 2 shows nontherapeutic TAR to be in a ratio of 1 to every 3 women in a lifespan or .31 or .36. If all nontherapeutic abortions were avoided, then the total fertility rate would be increased 10-12% . Since women use abortion for birth spacing, the continued pregnancy would probably replace a future pregnancy. Biologically, 1 abortion does equal 1 birth because one could have 3 abortions in the time span of 1 pregnancy. Also, an intentional abortion if continued could result in miscarriage or stillbirth. The TFR of 3.06/woman in 1988 would have reached 3.3 if pregnancies were aborted only for therapeutic reasons, which is very low. Efforts to prevent abortions should be directed to young women and new couples.
State of the world 1993: a Worldwatch Institute report on progress toward a sustainable society.
The Worldwatch Institute has release its 10th State of the World Report which is now translated into 27 languages. It stresses that we have entered a new ear in which reversing environmental degradation is the key to future economic progress. California now produces sufficient electricity from wind power and solar thermal plants for almost 2 million people. Between the late 1970s and the early 1990s, the number of newly constructed, nuclear power plants fell from 20-30 plants/year to almost 1 plant/year. Between 1988 and 1991, world production of chlorofluorocarbons declined by 46%. Between 1985 and 1990, conversion of erodible cropland in the US to grassland or forests reduced soil losses by at least 33%. Environmental awareness has increased greatly in the last 10 years, even among industry and political leaders. Despite these gains, environmental degradation continues. A new study shows that sulfur deposition is adversely affecting forests in every country in Europe and that productivity of Europe's forests has fallen 16%. Grain production per capita has decreased 6% since 1984, thereby threatening food security. Deforestation continues to cause soil erosion, reduction of the ozone layer, and increased flooding. 92 million people are added to this planet each year. Human activities have reduced groundwater tables and brought about other forms of water scarcity. Environmentally related illnesses are increasing worldwide. The report warns that policy decisions made in the 1990s determine the condition of the world left for our children. It notes that we must make revolutionary changes to achieve sustainable development and provides recommendations to do so, e.g., replace fossil fuels with efficient, solar-based energy systems, and the greening of business.
Directory of surveys in developing countries. Data on families and households, 1975-92.
Many sample surveys have been conducted in developing countries over the past 20 years. This directory provides a listing by developing country of the survey and data and key data available on fertility, child welfare, economic factors, and households. Information included war obtained from a search of individuals and institutions and other survey inventories. The criteria for inclusion had to do with whether the survey data was obtained in the context of families or households , thus eliminating labor force surveys or reproductive behavior surveys which did not provide information on children or households. All data in the included surveys is gender-based and pertains to all ages. Male-based and female-based surveys are included even though the data may not be representative of their partners. Sample size was not a criteria for inclusion. The time period was 1975-92, even where the survey began prior to 1975, as in the case of multi-round surveys. Data also had to be available to users in computer readable form. User documentation and file format information is not included in this directory. 306 surveys from 184 developing countries are included of which 153 were national in coverage and 111 (about 40%) were part of large international survey programs. Large surveys include the World Fertility Surveys, the Demographic and Health Surveys, the National Household Survey Capability Program, and the Living Standards Measurement Study. Large regional surveys conducted by regional centers include the Asian Marriage Surveys and the Pan Arab Project for Child Development. Of the 278 surveys with full-page entries, 215 are single-round surveys. Countries without known surveys are listed in an appendix. The directory may be useful in reviewing the availability of existing survey data, in assessing future needs for new data collection, and in building upon existing data bases to expand the focus. Omissions and errors may be reflected in the entries, which is understandable in light of the data collection process. Countries are arranged alphabetically, and surveys, chronologically.
Family Planning and Child Survival Survey, Ecuador 1989. Final English language report.
In Ecuador in mid-1989, the Center for the Study of Population and Responsible Fatherhood and the Ministry of Health (MOH) interviewed 7961 15-49 year old women as part of the USAID-supported Demographic and Health Surveys. The total fertility rate fell 13% between 1987 and 1989 (from 4.3 to 3.8). The coastal region accounted for almost all of the decline. Fertility control within marriage accounted for this decrease in both urban and rural coastal areas, except in Guayaquil, where increased marriage age was responsible. Improved educational levels increased demand for contraception among younger women and decreased fertility. 89% of the women knew at least 1 contraceptive method. Contraceptive prevalence increased steadily between 1982 to 1989 (40-53%) with 66% of the increase occurring between 1987 and 1989. Female sterilization accounted for 35% of all contraceptive use among married women. The MOH supplied 27% of all modern contraceptives followed by private clinics (26%), pharmacies (17%), and the Ecuadorean affiliate of International Planned Parenthood Federation (APROFE) (12%). MOH mainly provided sterilization while APROFE mainly provided IUDs. Almost 25% of married women were at risk of an unplanned pregnancy (30% in the rural Sierra). The infant mortality rate was 53/1000 live births and the mortality rate for children under 5 years old was 70 (in 1982, 58, and 82, respectively). Leading causes of postneonatal and child mortality were diarrhea (33.3% and 29.8%, respectively) and acute respiratory infections (31.9% and 28/2%, respectively). Just 39% used well baby services, prenatal services, and postpartum services. Immunization coverage varied from 73% to 75% for DPT and polio, 76% for measles, and 91% for BCG. The primary treatment for diarrhea was oral rehydration therapy. 23% of 15-24 year olds had has premarital sexual intercourse. 21.6% of these women who had ever been in as union experienced premarital pregnancy.
Policy choices depend in part of political values and assumptions about adolescents' decision making abilities. The focus of this article is on judging the probability of adverse outcomes and the tendency to be overconfident. Discussion is directed to adolescent and adult invulnerability and evidence of other decision making skills. The conclusion from the review of evidence is that invulnerability is not particularly larger during adolescence. The hypothesis of this study directly tests adolescent invulnerability. A sample of 86 pairs of low-risk teens and parents and 95 high-risk teens were obtained from recruitment efforts at public high schools. The mean age of students was 15 years; the mean age of adults was 43 years. Low-risk persons were primarily girls and adults, more primarily mothers of teens. 23% of high risk teens were girls. Eight events were chosen to reflect high and low controlability (auto accident injury, alcohol dependency, unplanned pregnancy, mugging, sickness from air pollution or pesticides or radiation poisoning, and injury in a fire explosion). Evaluation for each event was made for controlability, probability of occurrence, preventive effort, and experience with the event. Subjects also evaluated 2-3 target individuals. The results pertain to the probability response mode as an ordinal scale; to control, prevention, and experience judgments; and to an examination of the absolute invulnerability hypothesis for group, target, and event factors. 43% of the time adolescents did not perceive any differences between their own level of risk and the target's. Otherwise, respondents were twice as likely to assign a higher risk probability to targets. 10% of the time, subjects assigned a risk of 0 or no chance. 33% of the time, the risk was less than 1 in 10,000. Risk was not any greater for teens than adults. Teens tended to overdifferentiate their situation, as indicated in the Elkind fable. Risk was gauged higher for the more active events. Teens were sensitive to how the question was posed; i.e. one time vs repeated actions. Low-risk teens and adults were moderately overconfident; high risk teens showed greater overconfidence. The theoretical and policy implications are dependent on the event; further research might focus on why adults view teens so harshly and deny them the right to govern their own actions.
[Quality of care in family health]
Tunisia's National Office of Family and Population (ONFP), created in 1973, has 5 distinct components at the central level: the Departments of Medical Services, Communications, Studies and Planning, Training, and Family Health. The ONFP has facilities in all regions of Tunisia. In 1991, Tunisia's population was 8,220,000, the crude birth rate was 24.7/1000, and the crude death rate was 6.5/1000. The resulting rate of natural increase was 1.82% and the total fertility rate was 3.45. In 1989, there were 1834 inhabitants per physician, 6548 per midwife, and 354 per paramedic. The contraceptive prevalence rate in 1988 was 50%. These data demonstrate that Tunisia is in a relatively advanced state of its demographic transition, and that its coverage of health services is among the most advanced in the Third World. The methodology of the ONFP requires diagnosis of the preexisting situation including identification of needs, translation of needs into a program, and evaluation of the impact of the action. All "products" of the Office, whether medical procedures, contraceptive methods, or media support, are pretested. Tunisia's criteria for assessing its family planning program demand that the contraceptive choice be free, multiple, and informed, and that services be offered in conditions of confidentiality, scientific rigor, and with human dignity. The ONFP currently offers copper T or Multiload IUDs, 4 different oral contraceptive formulations, Norplant, Neosampoon vaginal spermicide, condoms, and male and female sterilization. Injectables are under study. ONFP clinic personnel are trained in counselling techniques in order to improve interpersonal relations with clients. The definition of quality of care in family planning is different for service providers and clients. Providers stress method efficacy and coverage rates without special emphasis on side effects or discomfort, which are not defined as illness. For users, high quality family planning allows control to be exercised over the body, health to be preserved, and sexual satisfaction to be increased, without concern about implications for public health. A 1988 survey indicated that among clients of public and private sector family planning facilities, respectively, 82.3 and 94.4% found no problems to report, 3.1 and 2.1% complained of long waits, 11.8 and 2.1% of poor treatment, .3 and 7% of cost or accessibility, .6 and 0 that the desired method was not received, and .9 and .7 % of deficient hygiene. The same study showed that very low proportions of women had discontinued use of any method because of poor follow-up.
Exploring cultural diversity of the people of India.
An examination of cultural diversity in India was conducted on the basis of data collected in the People of India (POI) project. Data on 776 individual items about identity, ecology, food habits, occupation, kinship networks, marriage rules, art and music, educational status, and impact of development programs were obtained from 2753 communities. States are identified by the number of communities, population size, mean number of traits, mean dissimilarity, and total number of traits. Homogeneity is reflected in union territory geographic units; heterogeneity is reflected at the state level. Communities may be predicted based on population size only at the state level. It is common for villages with 500-1000 inhabitants to support 8-16 communities. The minimum number of traits a community will support is 32 and the maximum is 406. The northeastern states of Nagaland and Mizoram reported a higher number of traits, while the northwestern states of Gujarat and Rajasthan reported a lower number of traits. The northwestern states tended to have physical features that were more similar and supported tribal groups with more food taboos, more rigid cultural practices, and caste-dominated occupations. Very few traits were reflected in little-known tribal groups such as the Sentinelese or Jarwas in the Andaman and Nicobar Islands. Differences between communities showed that trait dissimilarities were lowest within the geographic tract comprising Rajasthan, Gujarat, Maharashtra, and Madhya Pradesh and followers of the Jain religion. Trait dissimilarity was highest among Christians who were scattered across all states, followed by Buddhists, Muslims, Hindus, and Sikhs. Nomadic pastoralists had the highest levels of trait dissimilarity; agriculturalists had the lowest. Of the populous states with over 250 communities, Bihar (261 communities) had the lowest dissimilarity and Maharashtra (305 communities) had the highest. Low trait richness was correlated with high levels of trait dissimilarities. The distribution of trait richness and dissimilarity is described. Clustering of traits shows the geographic proximity is not a simple predictor of differences, but a multivariate one. There is a clustering around 6 different food plants; clustering also occurs around resource use, or occupation with specific foods habits, or nomadic life and ecological setting. Changes in occupational patterns were also described.
[Determination of progesterone in saliva]
The progesterone derivative, 11-alpha-glucuronide-iodine, tyramine (125I), was used for a radioimmunoassay analysis to study the possible correlation of progesterone concentration in saliva with progesterone level in serum. Female subjects had 2 ml of blood taken during the menstrual cycle in the morning after saliva samples were collected. Group A consisted of 1 women who used 2-3 citric acid crystals for inducing saliva production, while in Group B, consisting of 10 women, there was not such stimulation. Basal temperature was also measured. In Group A 1 of the women was taking a hormonal contraceptive, 8 women had regular cycles (24 an 20 days), and 2 had irregular cycles. In Group B 1 woman was also using contraceptives. 2 male subjects also participated in the saliva tests daily for 4 weeks. In precision measurements the intra-assay variation coefficient range within a series was 8.4% (lower concentration area) and 3.9% (higher concentration area). The sensitivity of the assay was 3.12 pg/ml in a volume of .4 ml (p 0.05). The 11 menstrual cycles of Group A consisted of 5 normal cycles, 5 with luteal insufficiency, and 1 under hormonal therapy. The 5 normal cycles showed a biphasic course of progesterone value in the saliva, whereby in the 2nd half of the cycle the values averaged about 100 pg/ml over the values of the follicular phase, which were 100 pg/ml compared to 200 pg/ml in the luteal phase. The progesterone values in the saliva of patients with corpus luteum insufficiency and the 1 under hormonal treatment did not show periodicity: the values ranged between 75 and 150 pg/ml. In Group B only 4 cycles had a biphasic course of progesterone in the saliva, in another 2 it was doubtful, and in the remaining 4 it did not show any periodicity. The progesterone values of the 2 males averaged from 80 to 120 pg/ml. The daily changes of saliva progesterone levels in 5 subjects indicated individual scatterings of 25 to 100 pg/ml from the average values. The progesterone profile of 3 subjects showed similar abrupt changes in 3 measurements but only a 20 pg/ml deviation from the average.
[Infant girls in danger of dying]
A new method of predicting the gender of the unborn child has made it a practice in Bombay to abort about 40,000 female fetuses per year. In only one hospital 8000 such induced abortions have been recorded. Sex discrimination in developed countries manifests itself in the work place, wages, and access to work, but in India and other countries such discrimination is often deadly. In some Asian countries there are fewer women than men; at least 60 million women are missing from statistics. The Southeast Asian Association for Regional Cooperation (SAARC) declared the 1990s the decade of the infant girls, with educational efforts geared to their survival, protection, and development. 70 state and government leaders took part in the world meeting on children in 1990. UNICEF supports the endeavor to draw attention to the plight of women. The reason for many millions of women missing in Asia is that 5-6% more boys than girls are born. Under normal circumstances mortality is higher among boys than girls in all age groups. In Denmark there are 105 women for every 100 men, but according to the 1991 Indian census there were 92.9 women for every 100 men, a decrease from 93.4 in 1981. In Afghanistan, Bangladesh, Bhutan, China, Nepal, and Pakistan the gender ratio is similar. Both mothers and fathers are responsible, because of tradition, when it comes to choosing a girl or a boy. A large number of girls die of undernutrition and untreated diseases. They are forced to work in the household, in agriculture, or in industry twice as many hours than boys. Thus, they do not have time to go to school. The bordellos of Bangkok, Bombay, Calcutta, and Manila have a constant supply of young women for tourists from rich countries. In most cases they are forced into prostitution because of the poverty of parents. In the Indian state of Karnataka 8-10 year old daughters are rendered as temple servants who end up as prostitutes after ritual deflowering at puberty. Social engagement, political will, and education could give Asia's infant girls a chance to be on equal footing with their brothers.
The success and failure of condom use by homosexual men in San Francisco [letter]
In California, the San Francisco Men's Health Study has followed at least 807 homosexual and bisexual men since 1984. (49%) tested HIV seropositive in 1984 and 11% have since seroconverted. After researchers identified anogenital intercourse as the primary risk factor of HIV transmission among homosexual men in San Francisco, health education messages have promoted condom use. The researchers have followed the practice of anogenital insertive and receptive intercourse and condom use for at least 13 examination cycles (each cycle = 6 months). During cycle 1 (1984) 68% either ejaculated or received ejaculate during anogenital intercourse, but by cycle 7 (1987), this figure had fallen to and stabilized at 30% throughout the remaining cycles. At cycle 1, 33% of HIV seropositive men used a condom at least once during anogenital insertive intercourse with ejaculation compared with 18% of HIV seronegatives. By cycle 7, these percentages increased to 90% and 77%, respectively. After cycle 7, the percentages neither decreased nor increased. Regardless of the cycle, a higher percentage of HIV seropositive men used condoms than did HIV seronegative men. 13% of men who used condoms experienced condom breakage during 1 cycle. This percentage increased consistently to 59% among men who used condoms during 8 cycles. 5% of men who used condoms during 1 cycle began anogenital intercourse before putting on a condom. This figure was 44% for 8 cycles. This study indicated that men responded quickly and appropriately to health education messages about the primary risk of HIV transmission in their population group. It also showed that HIV seropositive men were more likely to use condoms than were HIV seronegative men. On the other hand, it also showed a deficient response to properly putting on or use of a condom to reduce condom breakage and to initiating intercourse prior to putting on a condom.
Changes in HIV-2 seroprevalence in Cape Verde, West Africa [letter]
Virologists conducted HIV serodiagnostic tests on serum samples from 339 san Nicolau natives living on the island of San Nicolau, Cape Verde and from 313 San Nicolau immigrants living in New England, US (from 1963) and from 335 San Nicolau, Cape Verde natives (from 1987) to determine whether HIV-2 existed in Cape Verde in 1963 and to compare the 1963 prevalence with that of 1987. Among the 1963 serum samples, 2 (0.6%) samples from immigrants living in New England and 2 (0.6%) samples from San Nicolau natives reacted to the HIV-2 ELISA (just in the p24 band), but the immunoblot analysis did not confirm HIV-2 positivity in any of these samples. On the other hand, 28 samples (8.4%) from San Nicolau natives in 1987 reacted to HIV-2 ELISA, yet, the immunoblot analysis confirmed HIV-2 positivity (gp140/41) in just 4 (1.2%) samples. There was a statistically significant difference in the prevalence between 1963 and 1987 (p = .049). These findings suggested that HIV-2 was relatively new to Cape Verde in 1987 and has recently infected humans. This study should settle the controversy surrounding the concern that Cape Verde may be the origin for HIV-2 transmission in the US sparked by detection of 3 HIV-2 positive cases in the late 1980s among immigrants with Cape Verdean origins living in New England. Nevertheless, the distribution of HIV-2 could be similar to that of HIV-1 in that they both dispersed more widely as people became more migratory.
The real prevalence of pelvic inflammatory disease (PID) is unknown since many women are either asymptomatic or have atypical symptoms. It is often difficult to detect, manage, and prevent PID. Since PID has obstetric, gynecologic, and contraceptive-related causes, its prevalence is quite high. About 70% of PID hospital admissions in sub-Saharan Africa are a result of reproductive tract infections (RTIs) while this figure is 34% in Asia and 31% in developed countries. Only 10-20% of lower RTIs ascend into the upper genital tract and an even smaller percentage of women with PID develop chronic sequelae. Still, just 1 episode carries an increased risk of a tubal infertility, ectopic pregnancy, chronic pelvic pain, considerable pain during coitus, a new episode, and menstrual irregularities. Neisseria gonorrhoea and Chlamydia trachomatis are the most common causative organisms of PID. In Africa, the risk factors for PID are the same as they are for sexually transmitted diseases (STDs): multiple sex partners, young age at first intercourse, high frequency of coitus, and a high rate of acquiring new partners. The largest percentage of women with RTIs are monogamous women who are infected and constantly reinfected by their promiscuous husbands. The primary means to prevent PID are promotion of safer sexual behavior and condom usage. Secondary measures include accessible, acceptable, and effective STD services and education and counseling during case management. WHO suggests that STD treatment become part of the primary health care system. It has developed flow charts on syndromic diagnosis for urethral discharge in men and genital ulcer disease in women. Health workers should assume increased PID risk if the partner has had a history of urethral discharge and/or treatment for gonorrhea or nongonococcal urethritis. Partner notification is also needed for case management, but stigmatization in some countries poses a problem. WHO also recommends use of drugs which have a 95% STD cure rate.
A community-based longitudinal study was conducted in Matlab, a rural area of Bangladesh, from May 1988 to April 1989, to examine the associations among malnutrition, cell-mediated immune deficiency, and the incidence of diarrhea in children under age 5 years. A cohort of 705 children was followed for a year; illnesses were ascertained every 4th day by home visits, anthropometric status was evaluated monthly, and cell-mediated immune status was assessed by a multiple antigen skin test at baseline and every 3 months. The diarrhea incidence rate was 4.6 episodes/year. Approximately three fourths of the children were below -2z score weight for age and height for age, and about one third were below -2z score weight for height. There was a modest association between undernutrition and the incidence of diarrhea. About 10-20% of the study children were anergic, and these children experienced a 50% increased incidence of diarrhea compared with their immunocompetent counterparts. This association persisted after controlling for the effects of age, nutritional status, socioeconomic status, and history of diarrhea in the previous 3 months. Malnutrition and cell-mediated immune deficiency were important independent risk factors for the occurrence of diarrhea and must both be considered in the design of interventions for the control of this condition. (author's)
Exposure to children and risk of active trachoma in Tanzanian women.
The authors surveyed the trachoma status of 515 women aged 18-60 years and 527 children aged 107 years in the trachoma hyperendemic region of Kongwa, Tanzania, in 1989 to further describe the importance of exposure to young children as a risk factor for active trachoma in women. The women were identified as caretakers, who currently cared for children aged 1-7 years; noncaretakers, who live with, but did not care for, children aged 1-7; or those without children aged 1-7 in the household. The age-adjusted odds ratios for active trachoma seemed to rise with greater exposure to young children, from 1.00 for women without such children, to 1.63 for noncaretakers and 2.43 for caretakers (trend test, p = 0.08). Among those who lived in households with young children, the prevalence of active trachoma in women increased with the total number of young children cared for and with the number of infected children cared for. The prevalence of active trachoma was 40% (6 of 15) for caretakers of 3 or more infected children, compared with 0 (0 of 88) for caretakers with no infected children (p < 0.0001). Caring for infected children also appeared to be associated with signs of chronic trachoma in caretakers. Noncaretakers who lived with infected children were not at a significantly increased risk for trachoma compared with noncaretakers who were not exposed to such children (5.4% [3 of 56] vs 5.6% [1 of 18]; p > 0.4). None of the facial signs observed in the children (flies on the face, nasal discharge, etc.) appeared to increase the odds ratio of active trachoma in caretakers beyond the increase associated with trachoma alone in the child. These data support the hypothesis that active disease in women is associated with direct caretaking of young children with active disease. Strategies that interrupt household transmission may affect the blinding sequelae of trachoma in women. (author's)
China's rural reform: the state and peasantry in constructing a macro-rationality.
As a critique of the popular perspective on China's rural reform centered on microinstitutional problems of collective farming such as work