Safety of birth control pills.
The literature shows that established adverse effects of oral contraceptives (OCs) include stroke, venous thromboembolism, myocardial infarction, and liver neoplasms. The relative risk of liver cancer is high in long term OC users (4.4-20) but this risk may be due to hepatitis B virus (HBV) infection in countries with a high HBV prevalence. Possible adverse effects of OCs are breast cancer and cervical neoplasia, but the risk has not been proven. Many physicians believe that OCs' adverse effects occur most often in women with certain risk factors, thus, medical screening and monitoring of OC users is justified. Screening and/or monitoring serve to identify absolute contraindications to OC use, factors that might increase the likelihood of suffering an adverse effect of OC use, and disease at an early stage. Absolute contraindications include thromboembolism or thrombophlebitis, a history of deep vein thrombophlebitis or thromboembolism, cerebrovascular disease, coronary artery disease, endometrial cancer, known or suspected estrogen-dependent neoplasia, known or suspected breast cancer, benign or malignant liver tumor, undiagnosed abnormal genital bleeding, and known or suspected pregnancy. In theory, women with contraindications to OC use can identify their own risk status, but no empirical data exist to show that they can accurately identify their risk status. Research is needed to examine the ability of women, particularly those with limited education, to understand risk and contraindication. It should also determine whether OC use in women with human papilloma virus (HPV) infection are at higher risk of cervical neoplasia, or whether OC increases susceptibility to HPV infection.
Efficacy implications of making the pill available over the counter.
Even though a current prescription is needed to obtain oral contraceptives (OCs), considerable improper use of OCs occurs. Nevertheless, contraceptive efficacy remains high even when OC compliance is poor. The prescription requirement does not increase efficacy enough to warrant the costs of current obstacles to access. These costs are money, time, psychological costs of visiting a physician for a prescription, the financial and human costs of unplanned pregnancies that occur due to the barriers to OC access, and administrative costs linked with prescriptions. If OCs do not become available over the counter (OTC), improved packaging and simplified instructions could improve user understanding, and various changes in the current prescription system could improve availability, understanding, and efficacy. If they do become available OTC, they would be much more available for postcoital contraception use. Yet, considerable ignorance would limit this use because no one can promote OCs for an unlabeled purpose.
The Deputy Commissioner for External Affairs of the US Food and Drug Administration (FDA) assures family planning specialists that FDA will follow its scientific criteria to evaluate the possibility of switching oral contraceptives (OCs) from a prescription status to over-the-counter (OTC) status. OTC OCs are a logical step in a consumer movement toward health promotion, self-medication, and self-care. Before switching OCs to OTC, FDA needs to determine whether: the drug is toxic, particularly if the user overdoses; it is addictive; potential for abuse exists; the condition to be treated is self-diagnosable and self-treatable; adequate directions for use and adequate warnings against unsafe use can be written; the ordinary person can understand the labeling; and the benefits of OTC use outweigh the risk. FDA OTC specialists consider the drug's safety, simplicity, regularity, and individualism. Some public health and social issues raised by OTC status for OCs include payment for OTC OCs, access to women's health care, and use of barrier methods with OTC OCs. FDA reviews new medications and devices for safety and effectiveness and monitors the safety of drugs and devices once they are approved. FDA is sometimes involved in the early research and development stages of new products that could benefit public health (e.g., medications for AIDS). In May, 1993, it approved a recommendation by the Planned Parenthood of America to defer the routine physical examination before beginning to use OCs if a patient asks for deferment and the provider believes it is appropriate. FDA believes in and aims to improve consumer education and patient information.
Over-the-counter birth control pills: an overview.
The foremost concern among family planning providers regarding the prescription status of oral contraceptives (OCs) is not safety. Except for women with contraindications, OCs are as safe or safer than current over-the-counter (OTC) drugs when used as directed. Leading concerns about easing OC prescription requirements revolve around whether OTC status will improve access to OCs, promote earlier or more frequent sexual activity, increase out-of-pocket costs for poor women, and reduce access to preventive services. We need to look more closely at the link between OC access and expanded primary/preventive health care. Limited data exist on trends in employer and insurer coverage of OCs and the rationale for coverage, the source of payment, and the costs to consumers of OCs. Research on education and public understanding of OC risks and benefits could contribute to a greater understanding of OC use patterns and reasons for improper use. It could examine the ability of women to self-identify risk factors or the effectiveness of medical screening and monitoring for contraindications. Research should also assess the knowledge and behavior of OC use among various populations of women, particularly knowledge about protection against STDs and HIV in association with OC use. Some family planning providers recommend condom samples in OC packages to stress the need for barrier protection against STDs and HIV. The US Food and Drug Administration (FDA) calls on pharmaceutical companies to simplify and standardize language on patient package inserts. It has relaxed requirements that physical examinations be required before women receive OC prescription at federally funding clinics. States could do pilot studies of OTC access to OCs. Nonphysician providers could prescribe OCs. Physicians could lengthen the time for valid prescriptions. Use of current OCs as postcoital contraceptives is another option. Large cooperatives could buy OCs at discounted rates.
The pill without prescription: the international experience.
Experience with oral contraceptives (OCs) in developing countries has 3 overall lessons for the US, as it struggles with the issue of easing or removing the prescription requirement for OCs. A physician's supervision does not guarantee safe distribution of OCs. Dropping the prescription requirement will improve access to OCs if costs are kept low. Promotion of consistent and correct use of OCs is very hard. This difficulty and the inconsistencies of the US health care system cause some family planning specialists to encourage their colleagues to be cautious when applying international experience to the US. Two great differences between the models in developing countries and what is proposed for the US exist. Interpersonal contact between providers and clients is allotted much more emphasis in the programs in developing countries than those in the US. Most developing country governments subsidize the cost of contraceptives. Many people assume that cost, inconvenience, and language barriers keep poor women in the US from going to a provider to secure an OC prescription. Yet, the data show that poor women will visit a provider if they can locate one who will talk with them and respond to questions. Full retail prices for OCs may present an obstacle, since many insurance plans now include cost of OCs and government-funded, family planning clinics distribute low-cost or free OCs. This would especially be true for women who are already facing barriers to health care and contraception. The over-the-counter (OTC) approach may reduce OCs' effectiveness for them. It is not yet clear whether making OCs available OTC would make it easier for more women to use OCs safely and effectively. Providers need to provide constant support and information for proper and long term OC use. Society needs to help women use OCs correctly.
In 1960, US women were first introduced to oral contraceptives (OCs). In 1994, 28% use this physician-prescribed contraceptive. The pill is used safely and effectively by most of these women. Thus, some family planning specialists want OCs to be available without prescription, as are aspirin and cough syrup. Over the counter (OTC) OCs would save women the cost and the trouble of a clinic visit. A possible advantage of OCs being available OTC is fewer unplanned pregnancies. A disadvantage would be if women did not visit a physician at all, since they would not need to have annual exams to renew their pill prescriptions. The Kaiser Family Foundation invited leading specialists on both sides of the issue to a 2-day Kaiser Forum in June, 1993, to further the discussion by addressing the advantages and disadvantages of selling OCs without prescription. Participants presented research on OCs' safety record, access, cost, and role in the broader issue of women's health care. They included physicians, lawyers, activists, and pharmaceutical representatives.
The human sperm protein SP-10 in the acrosome and its fate following the acrosome reaction.
A University of Virginia doctoral student obtained human testes and epididymides from 60-75 year old men undergoing orchiectomy to treat prostate cancer, semen from normal healthy donors, and sperm from primates and rabbits to examine how sperm protein-10 (SP-10) relates to other cellular systems and to evaluate the potential utility of SP-10 as a component of a contraceptive vaccine for humans. He characterized the biochemistry and acrosomal distribution of SP-10 during sperm maturation in the male reproductive tract and following ejaculation. Western blot analysis (monoclonal antibody MHS-10) found an immunoreactive 45 kDa peptide as the full-length SP-10 precursor protein in the testis. Proteolytic processing of the 45 kDa SP-10 precursor protein took place in the testis and the proximal epididymis, but not in the distal epididymis or after ejaculation. Immunogold labeling of SP-10 was prevalent in the principal segment and in the most posterior portion of the equatorial segment, but quite reduced or absent in the anterior equatorial segment. Caput and cauda epididymal sperm, ejaculated sperm, and capacitated sperm displayed this same pattern of acrosomal distribution of SP-10. Thus, before epididymal sperm maturation and during ejaculation and capacitation, SP-10 is found in the principal segment and posterior equatorial segment of the acrosome. Further analyses indicated that SP-10 is a hydrophilic molecule and not an integral membrane protein in the acrosome. Instead it connects with Triton X-114 resistant structures and/or the acrosomal membranes via strong ionic and hydrophobic interactions. SP-10 was found on the hybrid vesicles, equatorial segment, and inner acrosomal membrane, all of which play a significant role in fertilization. Thus, induced immunity to SP-10 could inhibit fertilization.
Abscess in fibromyoma following instrumentation [letter]
In India, a 45-year-old multiparous mother was admitted to the Postgraduate Institute of Medical Education and Research in Chandigarh with fever, pain, and a 3-month old lump in the abdomen. Three months earlier, a midwife had conducted intrauterine instrumentation at 8 weeks amenorrhea to terminate a suspected but unconfirmed pregnancy. The day after instrumentation, the patient had a high grade fever with chill and rigor. At no time did she experience excessive bleeding. Five days before admission to the hospital, she underwent cervical dilatation and check curettage to treat a suspected pus-filled uterus. No pus or conceptus was found. In the hospital, physicians performed abdominal and vaginal examination and found a nontender, almost immobile uterine lump of 20 weeks size. They did not find any evidence of peritonitis or free fluid in the abdomen. Ultrasound detected a 14 x 13 x 11 cm pelvic consisting of a central hypoechoic area and a few hyperechoic shadows. Based on their findings, the physicians made a provisional diagnosis of infected and degenerated fibromyoma. They began antibiotic treatment (cloxacillin, gentamicin, and metronidazole). Her fever continued, and the blood culture did not grow any microorganisms. Four days after admission, they performed laparotomy which confirmed a 20 week size uterus with a large cystic area on the left posterolateral aspect. No pus was observed in the peritoneal cavity. They performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Pathological examination revealed a submucous, benign fibromyoma (16 x 13 x 13 cm) with a collapsed abscess cavity filled with about 500 ml of pus. Escherichia coli was isolated in the pus and cervical swab cultures. Her fever began to wane on the 3rd postoperative day. She was discharged on the 7th postoperative day. This case highlights the importance of avoiding traumatic intrauterine instrumentation in a woman with uterine fibromyoma.
The use of the partograph in monitoring labor in a prior cesarean section [letter]
During 1991-1992 in Ghana, obstetricians analyzed the case notes of 1079 parturients delivering at Korle-Bu Teaching Hospital in Accra, who had previously had at least 1 cesarean section, to examine vaginal delivery after earlier cesarean section. 532 parturients who had had at least 2 cesarean sections, declined to attempt a trial of labor, or had other obstetric and medical contraindications were excluded. 171 of the 547 (31%) remaining women delivered vaginally. Instruments assisted in the delivery in 5.3% of cases. Cephalopelvic disproportion and slow progress of labor made up 72.6% of indications for repeat cesarean section after trial of labor. The obstetricians used the partograph to monitor labor. Women whose cervices dilated more than 1.5 cm/hour in the 1st 4 hours of the active phase were more likely to deliver vaginally than those whose cervices dilated less than 1.5 cm/h (73.2% vs. 29.7%; p< .01). A significant association between the success of trial of labor and the level of the head on the alert line existed (5/5 = 19.7%, 4/5 = 40.6%, 3/5 = 70.9%, and 2/5 = 80%; p < .01). These findings revealed that the partograph allowed physicians to determine the level of the head and the initial rate of dilation of the cervix which, in turn, enabled them to predict the outcome of the trial of labor.
Uterine and intestinal perforation during first-trimester elective abortion [letter]
Between 1986 and 1994, the National Taiwan University Hospital in Taipei experienced 2 cases of uterine and intestinal perforation caused by dilatation and curettage (D&C). The women were primigravidae. The 1st case (21 years old) had severe abdominal pain, mild fever, diffuse abdominal tenderness with rebound pain, and leukocytosis 1 hour after the D&C during the 9th week of pregnancy. A 150 cm-long, 0.5 cm-diameter section of intestinal mucosa protruding through intestinal and uterine perforations was hanging from the cervical os. The ileocecal valve was 60 cm below the intestinal perforation. Surgeons corrected the problem by retracting the intestinal mucosa to the peritoneal cavity, repaired the uterine hole, and performed a segmental resection of the small intestine and an end-to-end anastomosis. Physicians had performed a D&C at the 7th and 12th week of pregnancy in the 2nd case (29 years old). She had peritonitis 2 days after the 2nd D&C. Sonography revealed, and laparotomy confirmed, a gestational sac with 2 dead fetuses in the right cornus of the uterus. The X-ray showed severe ileus and free air in the subphrenic space. Laparotomy found a perforation site at the posterior uterine wall and 3 intestinal perforations leaking fecal material at a site 30-50 cm above the ileocecal vale, adhesions, and many fibrinous substances coating the intestinal surface. A wedge excision of the uterine cornus with removal of the gestational sac and a segmental resection of the terminal ileum with end-to-end anastomosis corrected the condition. Conservative surgery is sufficient to treat perforations. If resistance is noted when performing a D&C, surgeons should not vigorously extract uterine contents. Surgeons should routinely conduct an ultrasound in those cases where the D&C does not remove gestational tissue.
In October, 1993, the Fertility and Maternal Health Drugs Advisory Committee of the US Food and Drug Administration (FDA) convened to examine recent research on oral contraceptive (OC) formulation and ovarian cysts. It needed to determine whether or not various OC formulations increased the risk of follicular enlargement and then to determine whether a change in product labeling was needed. The medical officer of the FDA Center for Drug Evaluation Research provided the introductory overview of the controversy and a review of recent studies. Investigators of 3 recent FDA-requested phase IV clinical trials by manufacturers of multiphasic OCs presented their results. They found no real intrinsic difference between whether an OC formulation is multiphasic or monophasic in terms of follicular development. Yet, a major difference needed to be addressed about the potency/dose effect of the progestogen at the 30-40 mcg range of estrogen. Specifically, the newer, lower-dose OCs did not suppress follicular activity as much as the older, higher-dose OCs, resulting in the rate of ovarian cysts being closer to that of nonusers. For example, the diameter of the maximum follicular structures were around 7.5 mm in the higher-dose, monophasic OC group, compared to less than 15 mm in the lower-dose, monophasic OC group and about 13.5 mm for the nonuser group. For the multiphasic OC group, it was essentially the same as that of the nonuser group. None of the differences were statistically significant. The panel considered the normal ovarian activity level in the low-dose, monophasic OC group and the multiphasic OC group to be good. Based on these results and their discussions, panel members agreed that neither monophasic nor multiphasic OCs increase the risk of ovarian cyst development. Thus, there was no need to change product labeling.
Weaning in southern Brazil: is there a "weanling's dilemma"?
In Pelotas, Brazil, 400 newborns from low income families were followed up until 26 weeks of life to study the relationship between their feeding patterns and growth as modified by access to water and by diarrhea. Effects of access to water were the strongest among non-breastfed infants. In houses without indoor water taps, the weight gain of non-breastfed infants during the first 3 months was approximately half that of partially or predominantly breastfed infants (p < 0.001). In houses with indoor water taps, non-breastfed infants' growth was similar to or exceeded that of predominantly breastfed infants from 2 months. Predominantly breastfed infants' growth was similar in houses with and without water taps. Breastfed infants had less weight loss per day of diarrhea than non-breastfed infants during the first 4 months and less diarrhea through 6 months of life, particularly in houses without taps, in which diarrhea was most prevalent. The existence of a "weanling dilemma" was approached by comparing the duration of the detrimental effects of not breastfeeding (i.e. 0-3 months in this study) with the age at which breast milk alone becomes less than optimal for growth (i.e. at 5 months). Because these two points did not coincide, the authors conclude that there is no "weanling's dilemma" in this population. (author's)
The practice of clinical nutrition in a developing nation.
Recently the academic community has been charged with nutrition malpractice for allegedly spending billions of dollars in international nutrition research and failing to make a difference. Looking at this issue from a field perspective, one would conclude that notable progress has been made and is being made on a daily basis. The analysis presented is based on the author's experience as a clinical nutritionist in Chile, a developing country in transition. It points out the issues and some of the answers by using selected examples of what can be accomplished by integrated health, nutrition, and educational interventions. The results have been a dramatic decline in infant and childhood malnutrition and mortality rates and the emergence of a pattern of mortality that closely resembles that of developed countries. The specific nutritional problems of hospitalized clients are discussed and the benefits of enteral nutritional support are presented. Preventive strategies are emphasized; they require wide coverage of basic human needs and community participation. Nutritional improvement is a prerequisite for economic development and is only possible if individuals and institutions are committed to making this happen. Critical dilemmas facing clinical nutritionists in developing countries are addressed. (author's)
Family context and adolescents' fertility expectations.
Data from the National Longitudinal Surveys of Labor Market Experience of Youth are used to examine and contrast the effects of family context and individual characteristics on adolescents' expectations about adolescent fertility, nonmarital childbearing, family size, and childlessness. The findings indicate that family structure has modest but specific effects on adolescents' fertility expectations. Living with mothers only increases expectations for nonmarital childbearing, and living with fathers (without biological mother) lowers the total number of children expected. Larger subsize raises expectations for nonmarital childbearing and family size. Poverty raises expectations for adolescent childbearing but does not affect other fertility expectations. Adolescent women are less likely than men to expect nonmarital childbearing, and overall, expect fewer children. Blacks are more likely than Whites to expect adolescent and nonmarital fertility and Hispanics are significantly less likely than non-Hispanic Whites to expect childlessness. (author's)
Knowledge of pregnancy symptoms among abortion patients: is race a predictor?
This cross-sectional study characterizes first-trimester abortion patients who perceived inadequate knowledge of pregnancy symptoms and identifies net predictors of inadequate symptom knowledge. Data were collected at an abortion facility in Hampton Roads, Virginia. Study subjects were women surveyed on the day of their abortions, prior to termination procedures. Self-reported knowledge of pregnancy symptoms was the study's dependent variable. Of 342 women, 120 (35%) perceived inadequate symptom knowledge. These women more often were young, Black, single, and poorly educated. Only black race was a net predictor of inadequate symptom knowledge when study variables were entered into a multiple logistic regression. Black race was the only net predictor of inadequate symptom knowledge among first-trimester abortion patients. This racial difference was not explained by socioeconomic or access factors. Future research should consider an alternative hypothesis, the possibility that more effective communications with black abortion patients are needed. Additionally, health-care providers should not presume that first-trimester abortion patients are familiar with pregnancy symptoms and should not stereotype patients who perceive knowledge limitations with regard to socioeconomic status. (author's)
President Hosni Mubarak: main points in the opening speech.
We do not want that this [International Conference on Population and Development] be a mere third conference on population. We want it to be a historical landmark for humanity vision in its population problems, as we are partners in work and destiny on this planet. 822 million persons of world population have a mean annual income that is more than 20 thousand dollars, while the majority have a mean annual income of 350 dollars. That means that 15% of the population in the world acquire 75% of world income. The Population Program in Egypt was successful in achieving its objectives, because it counted on providing the people with facts, and we refused policies that used coercion, and insisted that policies should be in conformity with Sharia. We shall try to search for common aspects of various visions, in order to make the ICPD recommendations a reflection that suits every taste. (full text)
The prevalence of sexual behaviors was estimated from a survey of 3854 Australian secondary school students. Self-reported prevalence of intercourse increased from 9.9% (age 13 years or less) to 23.9% (age 15) and 51.2% at age 17 and over. Among 932 sexually experienced youth in the final 3 years of secondary school, 26% of males and 18% of the females reported having 3 or more partners in the previous year; 89.4% had used a condom at least once, with males (71.8%) reporting more last occasion condom use than females (53.4%). "Last occasion" and "usual," but not lifetime, condom use was significantly lower among older respondents. Although nearly 90% of females in each of 3 age groups reported lifetime condom use, just 27.6% of female students aged 17 or more reported that condoms were always used during intercourse. The decline with age, noted in research with adults and older adolescents, may begin in the middle teens. (author's)
Incidence of sexually transmitted diseases among massage parlour employees in Bangkok, Thailand.
The results of a study of sexually transmitted disease (STD) incidence and related risk factors for STDs among uninfected women at high risk of contracting STD infection in Bangkok are reported. Comprising the control arm of a randomized controlled trial of a vaginal contraceptive sponge and STD incidence, 163 women aged 18 or older were recruited from 4 massage parlors and followed for evidence of new infections over a 6-week period or until cervical infection occurred. Gynecological examinations were performed and endocervical specimens were obtained at weekly intervals, at which time women returned coital logs recording their number of sexual partners. There were 76.5 new STD infections per 100 woman-months, including 31.7 with gonorrhea, 43.1 with chlamydia, 1.8 of trichomoniasis, and 3.5 of candidiasis. None of the risk factors examined were good predictors of STD infection in this population, which may be related to the restricted admission criteria in the study. (author's)
A total population sample of 7286 multigravidae from the Greek National Perinatal Survey (April 1983) was used to determine the association between maternal obstetric history and low birth weight of the subsequent singleton delivery. Significant associations were found with previous early and later fetal losses (miscarriages, induced abortions, stillbirths) and history of hemorrhage during a prior pregnancy. It was found that mothers who had experienced miscarriage(s), induced abortion(s), or stillbirth(s) had relative risks (RRs) of 1.65, 1.81, and 3.59, respectively, compared with mothers without any fetal loss. The risk increased substantially with the increasing number of losses and reached 8.83 for the small group of mothers who had experienced all three kinds of fetal loss. For mothers with a history of bleeding in a previous pregnancy, the risk was double that of mothers without such a history. The results above were changed only slightly when the significant socioeconomic characteristics of the family were taken into account. (author's)
"The operation was very painful. The midwife cut me up without a shred of mercy. I lay down "tied" for two weeks, which was very hurting. At the age of 12, my grandmother examined me and heartlessly declared that I was not "closed" enough, and the procedure was done again." This is the experience of 25-year-old Loise Wakahia. She explained further, "I contracted an infection from the wound inflicted by the traditional midwife circumcision. Doctors have told me I will never conceive because of the damage done. This cruel and inhuman operation has ruined my chances of marriage and motherhood." Doctors say the practice can also be associated with the spread of HIV, the virus that causes AIDS, through contaminated instruments as well as through cuts and abrasions in scar tissue during intercourse and childbirth. The long-term effects of female circumcision are infertility, painful intercourse, obstructed labor, hemorrhage during childbirth, lack of orgasm or sexual gratification, and depression. The majority of women advocate for the total eradication of this practice. Female circumcision is outdated, primitive, and dangerous. It has no beneficial effect and is the mutilation of the physical integrity of a woman. Female circumcision was banned by the government in 1982 but up to now, the practice goes on unabated in many communities. Measures to eliminate a deeply rooted practice must be carried out in a manner respectful of cultural values. The challenge to the government and concerned organizations is to work with communities to design and introduce ceremonies of ushering young girls into womanhood that will retain the positive aspects of female circumcision--the passing down of social values from one generation to the next--while eradicating the physical and psychological trauma associated with the practice. (full text)
Pakistan does not rank first in many things; however, UNFPA figures place Pakistan's rate of maternal mortality higher than any of its South Asian neighbors, with at least 28,000 women dying from pregnancy-related causes each year. In a country where the virtues of motherhood are consistently extolled, it is ironic that motherhood is more dangerous than anywhere else in the world. Each time a woman becomes pregnant in Pakistan, the risk of death is 31 times higher than in the developed world. High rates of maternal mortality and morbidity reflect the low status of women in Pakistan's society. The direct causes of high maternal mortality lie to a large extent in the refusal by the state to recognize the possible dangers of pregnancy. Since "doctors are to treat sick people and pregnancy is not a sickness," access to maternal health services is limited. It is estimated that 85% of all deliveries in Pakistan are carried out at home, usually by female relatives or traditional birth attendants who do not have adequate training to deal with complications or maintain hygiene standards. (full text)
According to a myth, still very much alive in some parts of Indonesia, babies who die go straight to heaven because they are considered clean of sin. They will wait there to open heaven's gate for their mothers. Mothers who die during childbirth are also considered martyrs, and thus a place in heaven is definitely reserved for them as well. We have to admit that myths are alive and well in our country, way beyond our wish to eliminate them. We believe that life is in God's hands. Yet if an unfortunate mother's death was due to inappropriate medical facilities or inaccessible emergency treatment, the problem lies in the hands of man. (full text)
Mexico: mortality for pregnant women.
"All talk and no action" is an expression that perfectly describes the attitude of Mexican society about pregnancy. On the one hand, motherhood and its social role are sublimated in song lyrics, poetry, and literary essays. The Viva la Familia promotional campaign describes the work of housewives and mothers as the most difficult and important. The monument to motherhood in Mexico City praises our mothers who loved us before they knew us. The old Mexican movies, becoming fashionable once again, portray the boundless self-denial, silent sacrifice, tender and selfless love of women who gave us life. On the other hand, when a woman becomes pregnant, there is little or no concern about her health. "It is a natural process," we hear. "She is chickening out on me," says a pregnant woman's husband; "my mother had 12 children and she never saw a doctor," And the woman says, "I think that this will go away by itself." Pregnancy, birth, and postpartum-related conditions are, indeed, natural processes that would normally not pose a threat to a woman's health. However, they can lead to many complications which, if not properly addressed, might result in permanent damage and even death. An historic lack of attention to women's nutritional health and our society's indifference to pregnancy are the reasons why 1 of every 72 Mexican women is likely to die from pregnancy, childbirth, and postpartum-related conditions. That is four pregnant women dying each day, according to official Mexican figures; PAHO estimates this figure to be 17 deaths daily. (full text)
Morocco: the state of maternal mortality.
A 1992 demographic and health survey specified three categories of deaths falling under maternal mortality: deaths resulting directly from pregnancy, deaths caused by childbirth, and deaths occurring in the two months following childbirth. From 1985 to 1991, there were 332 maternal deaths in Morocco for every 100,000 births--a decline from the 1978-1984 rate of 359 deaths per 100,000 births. There are more maternal deaths among rural women. From 1985 to 1991, in 67% of the births, the mothers had had no medical care during their entire pregnancy. In only 32% of the cases, the mothers sought antenatal care, either from a doctor, nurse, or midwife. Over the last five years, more than one out of every two pregnant women received a tetanus shot. For this, we must commend the combined efforts of the Ministries of Health of the UMA in organizing their regular vaccination campaigns targeting mothers and children. Another problem that may be contributing to maternal mortality is the great number of home births. 72% of births in the last five years took place in homes. In 48% of births, the mothers gave birth with the help of a quabla--a traditional birth attendant--20% were assisted by other people (parents, cousins, friends), and only 31% of the births were assisted by a professional health worker. (full text)
99% of maternal deaths occur in developing countries--and if India's numbers were not included in that figure, its absence would be conspicuous. The lifetime risk of a woman in a country like India dying from pregnancy ranges from 1 in 25 to 1 in 40, which contrasts sharply to the fact that only one in several thousand women run a similar risk in England, France, or the US. India stands a level above some of the other developing countries in terms of attention to maternal health needs: safe, licensed abortions; a primary health system to undertake care of rural mothers and children; growing levels of literacy; an awareness of the need for family planning; and the absence of belief in rituals like female circumcision. Each of these gives Indian women some measure of safety during maternity. Yet, there are miles more to go. (full text)
The Hyde Amendment and Roman Catholic attempts to put restrictions on Title X funding have been criticized for being intolerant. However, such criticism fails to appreciate that there are two competing notions of tolerance, one focusing on the limits of state force and accepting pluralism as unavoidable, and the other focusing on the limits of knowledge and advancing pluralism as a good. These two types of tolerance, illustrated in the writings of John Locke and J.S. Mill, each involve an intolerance. In a pluralistic context where the free exercise of religion is respected, John Locke's account of tolerance is preferable. However, it (in a reconstructed form) leads to a minimal state. Positive entitlements to benefits like artificial contraception or nontherapeutic abortions can legitimately be resisted, because an intolerance has already been shown with respect to those that consider the benefit immoral, since their resources have been coopted by taxation to advance an end that is contrary to their own. There is a sliding scale from tolerance (viewed as forbearance) to the affirmation of communal integrity, and this scale maps on to the continuum from negative to positive rights. (author's)
183 women were enrolled in an open, randomized, multicenter study in which the effects on acne of a low-dose biphasic oral contraceptive containing a daily dosage of 25 mcg desogestrel and 40 mcg ethinyl estradiol (7 days) and a daily dosage of 125 mcg desogestrel and 30 mcg ethinyl estradiol (15 days) were compared to Diane-35 containing a daily dosage of 2.0 mg cyproterone acetate and 30 mcg ethinyl estradiol (21 days) during four cycles of treatment. Clinical and photographic evaluation of acne plus laboratory assessments were done before treatment and at the end of cycle 4. A reduction with regard to the number of lesions and the degree of severity was observed in both groups. No differences were found between the two treatments in the clinical and photographic evaluation. In both treatment groups, a decrease in total testosterone and 3alpha-17beta-androstanediol glucuronide was observed and an increase in SHBG. The decrease in 3alpha-17beta-androstanediol was statistically significantly more pronounced in the Diane-35 group. (author's)
Norethisterone enanthate (NET-EN) 50 mg combined with estradiol valerate (EV) 5 mg was studied as a once-a-month injectable contraceptive with regard to effectiveness, cycle control, adverse events and acceptability. In eight Family Planning Centers from five Latin American countries, 931 fertile women were followed-up for a period of 36 months, providing a total of 15,787 woman-months of experience. Only one pregnancy occurred: in the first treated month a few days before the second injection (failure rate 0.08 per 100 woman-years). Under treatment, the first cycle was drastically shortened in most cases, but thereafter cycles tended to recover to pre-treatment patterns. There was a significant decrease of hypermenorrhea and dysmenorrheic cycles. Intracyclic bleeding and spotting appeared in 1.8% and 2.2%, respectively, and amenorrhea in 2.8% of cycles. The incidence of other adverse events was very low with the exception of weight gain of more than 2 kg (36.8%). The continuation rate at 12 months was 64.7% at 24 months 31.0% and at 36 months 20.4%. The cumulative discontinuation rate due to bleeding problems was 6.1% and 7.2% due to adverse events at 36 months. The treatment was shown to be a highly effective contraceptive method that offers fairly good cycle control, good tolerance, and a continuation rate that makes it suitable for use in family planning programs in the Latin American area. (author's)
The efficacy of administering an antibiotic prior to IUD insertion to reduce the risk of introducing an upper genital tract infection during the procedure has not yet been established. Two double-blind randomized studies conducted in Africa comparing a 200 mg prophylactic dose of doxycycline with a placebo did not conclusively identify a reduced risk of post-insertion pelvic inflammatory disease (PID). A clinical trial of comparable design is currently under way in the US. This multi-state trial will evaluate whether use of an antibiotic prior to insertion reduces the risk of IUD removal for all medical reasons, including upper genital tract infection, within the first three months after insertion. This paper reports on the pilot phase of this study, which was designed to test the protocols and data collection instruments in advance of the full-scale clinical trial. A total of 447 prospective IUD (TCu-380A) users were randomly assigned to receive either a 200 mg dose of doxycycline or a placebo one hour before IUD insertion. 3.6% (8/219) of participants who received the antibiotic had the device removed for medical reasons (infection, bleeding, cramping, etc.) within three months post-insertion compared to 4.5% (10/223) of participants who received the placebo. This reduction in the removal rate was not statistically significant given the limited size of the pilot study (RR = 0.81; 95% CI 0.28-2.29). Only two subjects, one from each treatment group, met the diagnostic criteria for acute PID. The overall three-month retention rate was 91.8% for the antibiotic group and 89.7% for the placebo group. These retention rates indicate that US women can exhibit a high degree of user acceptance. (author's)
Family planning campaigns the best opportunity for AIDS advice.
Advice on contraception should be coupled with AIDS and STD prevention, warned Dr. Massimo Musicco, from the Department of Epidemiology of Italy's National Research Council. "Family planning campaigns and the spontaneous request for contraception must become opportunities for the evaluation of risk of acquiring AIDS and for appropriate counselling," he said. His advice for women who were sexually exposed to HIV and seeking contraception was that condoms must be used to prevent infection, while the pill remains the most effective reversible method of birth control. "Since heterosexual transmission from men with high risk behavior is the key event for the spread of AIDS, the role of contraception becomes of crucial interest and has to be regarded mainly in relation to the risk of women acquiring the infection," he explained. Today in Africa, about 90% of all AIDS cases acquired the infection through heterosexual transmission, although in most developed countries the numbers vary between 5 and 20%. In a study of heterosexual couples conducted in Italy, the number of infected men was five times higher than that of women--hence the key issue of contraception. In that same Italian study--which analyzed a cohort of 500 women in steady relationships with HIV-infected men--the overall female risk of acquiring the infection from a single act of intercourse was found to be very low (0.01 to 0.2%). The study showed that condom use provided the best protective effect against infection. However, it was also seen that groups using only oral contraception or coitus interruptus showed lower infection rates than those groups which used no contraception at all. Based on the data, Dr. Musicco said that use of condoms is the most important single preventive practice, while the presence of concomitant STDs is the most important single biological factor. (full text)
The UN sponsored the population conference in Cairo for a reason. The West consumes more than 70% of the world's resources, much of which come from Africa, and is increasingly alarmed that Africa's population, depleted through European predation from the 17th century onwards, is now growing. World Bank officials have deliberately failed to point out that some of the most densely populated areas of the earth are the most productive, as is the case with Hong Kong, Japan and Singapore. They have also not pointed out that Africa is by far the least densely populated of all the world's continents. Of course, what alarms the West is that with a population to fit its size, Africa could seriously challenge the unjustified hegemony exercised over it through enforcing institutions such as the IMF [International Monetary Fund] and World Bank. The West recognizes the old adage that there is strength in numbers. Hence, instead of devoting the Cairo conference to economic development, the Bank narrowly focuses the agenda on methods of population control and so-called "crimes" against African women. But the usual western hypocrisy is again evident here: I doubt very much whether any of the Bank's position papers focuses on the barbaric but routine practice of late term abortions and male genital mutilation legally sanctioned in western hospitals. (full text)
Method switching and not using modern methods lead to abortions in Mauritius.
Contraceptive prevalence in Mauritius (76%) is among the highest in the world. Yet, it is estimated that each year there are some 20,000 cases of induced abortion, which is illegal in the country. A study based on a sample of 475 women admitted to three hospitals with complications due to induced abortion revealed considerable use of unreliable methods (e.g., withdrawal and natural methods), frequent method switching, and inconsistent use of modern methods. The study also found that women seeking abortion were usually under 30 years of age, and 20% of women with abortion complications were not using any method, and some 50% were using an unreliable method at the time they became pregnant. It emerged that with increasing numbers of women employed, their work schedules hindered their going to a family planning clinic and resulted in abortion being used as a back-up to contraception failure. Among the women with abortion complications, 25% had already had a previous abortion. These findings came as a big surprise to the family planning services. To discuss the findings, a national symposium was held in July, 1993. The symposium was attended by government ministers, members of parliament, and international personalities in the field of family planning. A discussion of the results of the study also took place in the National Assembly, where a motion was tabled to decriminalize abortion. The findings also facilitated, albeit indirectly, the approval of Norplant in the country. (full text)
Important conclusions from abortion studies.
In general, it can be concluded that the initiative on the determinants and consequences of induced abortion has shown some important patterns. For example, induced abortion is not restricted to adolescents but occurs also within marriage to limit family size. Induced abortion is prevalent both where family planning services are available and contraceptive prevalence is high as well as where family planning is not common, but for different reasons. In the former, motivation to limit family size is high and women would use any option if contraception fails or an unwanted pregnancy occurs. In the latter case, induced abortion forms part of a mix of incipient fertility regulation alternatives, most of which are traditional and of little effectiveness but including some use or improper use of modern methods. Few abortion seekers, and among them even fewer adolescents, were using a modern contraceptive at the time the pregnancy started. High use of traditional methods in some countries leads to abortion as women/couples fail to follow proper instructions with regards to the safe period. Unsafe clandestine abortions are more likely to be sought by poorer women and by adolescents. The findings of this research are increasingly being used to question the legal status of abortion in countries where the law is restrictive, or to strengthen family planning efforts in order to reduce abortion incidence. (full text)
AIDS education reaches Pacific atolls.
The Republic of Kiribati consists of 33 islands and 69,000 inhabitants dispersed over a large area of the Central Pacific. It includes the former Gilbert Islands, which were linked as British colonies with the Ellice Islands until the latter declared themselves independent as Tuvalu. Kiribati became independent from Britain in 1979 and joined WHO [the World Health Organization] in 1984. Launched in 1988, the national AIDS program is now implementing its second medium-term plan. As part of this plan, the program recently held its first AIDS awareness workshop for hotel workers, health care workers and youth. The workshop was held on Kiritimati, the world's largest atoll. Also known as Christmas Island, the atoll of 2650 inhabitants has excellent bird-watching and fishing opportunities, which have drawn growing numbers of tourists in recent years. Although neither of the two HIV infections identified in Kiribati by March 1994 were on Kiritimati, the prevalence of other sexually transmitted diseases there has been on the rise. Meeting in a traditional thatched building, the workshop participants proved eager to learn about HIV and STDs [sexually transmitted diseases]. They received instruction in prevention skills, including a demonstration of proper condom use led by the national AIDS coordinator. At the close of the workshop, condoms were provided to hotel staff for distribution. (full text)
Many members of the AIDS Challenge Youth Club in Uganda have had direct and distressing experiences of AIDS, having lost parents or close relatives. Members are aged 13 to 25 years old, and the group meets regularly to share experience and ideas, learn about AIDS, and support others. During training courses, counseling sessions and club meetings, members have built up their confidence and self-esteem. They are open and honest about their family situations, and able to support others in affected families. They talk very freely about relationships, friendships, sex and condom use. Free condoms are also available. Club members are encouraging better communication with their parents. During recent discussions, these issues were raised. Young people said they had difficulties in talking about sex with their parents, and recognized their own responsibility to start communication by discussing neutral subjects such as work or school. Above all, young people wanted to live with hope, not anxiety and fear. Parents said that although traditionally they are not open with their children, they wanted to develop more honest relationships. But they felt that young people themselves were not open with them. They did not want to tell children what to do, but to help them make decisions, while respecting their views. Parents felt there is a need to build confidence in teenagers, by involving them in family decisions. They also felt that it is essential to give education about sex and condoms, and that not doing so could result in a young person's death. (full text)
A survey was conducted on 131 mothers in rural Bangladesh to examine knowledge and perceptions of helminth infection in relation to use of health facilities and treatment-seeking behavior. Almost all respondents considered worms to be a cause of bad health, and a high percentage of mothers had obtained deworming treatment for their children. However, marked differences were found in mothers' description of the causes and prevention of helminth infection in two adjacent areas; Pullakandi and Shekpara. The discrepancies in biomedical knowledge corresponded with differences in treatment-seeking behavior in the two areas. All households in the area had access to free deworming treatment provided by a health clinic, but this facility was predominantly used by women living nearby in Pullakandi. Because of the cultural and social constraints on female activities, women living further from the clinic, in Shekpara, preferred to send their husbands to a pharmacy in the nearby town to buy deworming treatment. As a consequence, these households were at a relative disadvantage in respect of the low exposure of women to health education and the greater financial cost of deworming treatment. The study highlights the influences of social and cultural factors on treatment-seeking behavior, which in turn affect women's exposure to health education and biomedical knowledge of helminths. Further questions are raised, however, on the ability of women to implement preventive measures and the impact of health education on rates of parasitic infection. (author's)
Food crisis in Sahel: women's issues.
Agricultural production trends in Burkina Faso, Niger, and Mali were investigated for the period 1960-1980 using data from Food and Agriculture Organization Production and Trade Yearbooks. These countries were severely affected by the drought and famine of 1972/1974. There was a decline in food production and agricultural products for all three countries during the 1960s and 1970-1976, while cereal production for exports increased significantly. Total per capita production declined for all during 1970-1976 except for Burkina Faso. Per capita food production declined by 8% for Mali, increased by 9% in Niger, and increased by 1% for Burkina Faso from 1957-1977 to 1980-1982. Livestock populations increased. In Mali, cattle stocks increased by 23% in two decades; in Niger they decreased by 13%; and in Burkina Faso they increased by 8%. In 1975, livestock populations declined in all countries because of the drought, but by 1980 they had recovered. As a result, daily dietary supplies per capita had been declining since the 1970s in these three countries. In 1987, daily dietary supplies were below minimum requirements, and close to 50% of the population both in Mali and Niger were in the undernourished category. Women were even more affected, although exact data were not available except for Burkina Faso. While food consumption was declining, there were major increases in livestock and cash crop production levels owing to the booming export trade in these countries. This, however, did not translate into increased prosperity for these countries. Programs should target improving food production among women who are responsible for over half of Africa's food supply. To increase the recognition of women as agriculturists and farmers could alleviate famine and the vulnerability of food production to climatic conditions.
Towards an analysis of fertility exposure in the Philippines: new evidence from the 1983 NDS.
The analysis of the levels and patterns of the proximate determinants of fertility (menarche, age at first union, contraception and fetal wastage before first birth, and primary sterility) was conducted in the Philippines using data in the 1983 National Demographic Survey (NDS). For some proximate determinants, data of 10,843 ever-married women were used. In others, the file of 12,771 children was used for those births born from January, 1978, until the 1983 NDS. The average start of childbearing was 22.5 years, with rapid sequence of childbearing after an average of 18.2 months. Urban women had their first child at the age of 23 years compared to 22.1 years for rural women. Contraceptive use before the first birth was only 1.8%. Only 7.9% had not given birth or had not been pregnant at all. Age at menarche was on a decreasing trend, while age at first marriage was increasing. Younger cohorts had shorter birth intervals, and the minimum of 1.5 months postpartum amenorrhea was extended by only 4.5 months because of the short duration of breast feeding. Sexual relations were resumed 2.8 months after birth. The time required to conceive was 16.6 months, twice the biologically expected exposure interval of 8.5 months, which was attributed to contraceptive practice or fetal loss. Fetal wastage was seriously underreported, and only 6.4% of women who reported that they had had their first pregnancy said that it ended in a non-live birth. The majority of Philippine women continued childbearing up to age 37.6 years for last birth. However, childbearing could end at an earlier age because of the high contraceptive prevalence among women aged 25-34.
Asia and Near East Bureau Health Sector financing model for microcomputers.
The Resources for Child Health Project was requested to develop this Health Sector Financing Model in order to provide a tool for the US Agency for International Development's Health, Population and Nutrition officers to demonstrate the effects of government investment and revenue policy choices on the financial sustainability of the health sector. The model shows the effect of alternative investment and recurrent financing plans on resources and health services. In addition, the model graphically displays the excess or shortfall of revenue over expenditure over a 5-year period for any given combination of investment and revenue choices for the government. Since the model is interactive, the user may choose combinations of financing mechanisms to arrive at desired revenue totals from various sources. On the investment side, the user may raise or reduce expenditures in order to live within the dual constraints of operating and investment resources. In addition, recurrent cost parameters, such as the rate of growth of salaries, may be selected and modified by the user. The model may be used by decision makers and analysts in the health sector to carry out more coherent and rational planning. The model works by taking data entered by the user and transforming them into a set of outputs in the form of numerical tables and graphs. These outputs are grouped in four categories: revenues, expenditures, services and health services indicators, plus the key output that combines revenues and expenditures. Pie charts are used to illuminate both the sources of revenue and expenditure cost centers for each of the 5 years, given the options chosen by the user. They are complemented by numerical tables showing the same information. Finally, a table and a bar graph combine the revenue and expenditure information to show how projected revenues match expected expenditures on a yearly basis.
[Clinical experience with the Medusa Cu 240 Ag intrauterine device (IUD)]
In the family planning center of an obstetrical-gynecological university clinic in Graz, Austria, 224 women were fitted with the IUD Medusa MPL Cu250 Ag in order to assess its contraceptive safety and complication rate. 215 women were followed over a 3-year period. The size of the IUD was chosen according to uterine size as measured by ultrasonography of myometrium thickness. The IUD was inserted under sterile conditions by disinfecting the vagina with betadine. Every 6 months, the correct location of the IUD was ascertained by ultrasonography, speculum inspection, and palpitation. 14 (6%) of the women were nulliparous, and 94% of the women had given birth to at least 1 child. There was a statistically significant relationship between the distance of the fundus and the IUD, the uterus sound length, and myometrium thickness (p < 0.001). Insertion was not possible because of scarring of the external os in 4 patients with a history of cervical conization. In 7 cases, a narrow cervical canal had to be dilated with the Hegar instrument. In 3 cases, the inserted object broke. The incidence of complication not requiring removal of the IUD varied from 9% to 29% at follow-up. The IUD had to be removed earlier than planned in 13% of the patients. Two intact pregnancies were terminated at the request of the patient, and 1 missed abortion underwent curettage in the 7th week of pregnancy. The Pearl Index was 0.5. The IUD was removed because of strong bleeding in 2 cases and because of pain in 4 cases. In 11 cases, dislocation of the IUD was demonstrated by ultrasonography, the IUD was removed, and in 9 cases a new IUD was inserted. In 1 case, the patient decided on taking ovulation inhibitors, and in 1 case hysterectomy was performed. Excellent acceptance was reported at follow-up by 79% to 88% of the patients. There were no cases of spontaneous expulsion or uterine perforation.
The experiment was carried out with 277 volunteers, homosexual men residing mainly in Amsterdam. A subgroup of 172 men was recruited from the participants of an AIDS study: 97 were seronegative, 73 were seropositive, and 2 seroconverted during the period of investigation. Another subgroup of 105 men was chosen from the Amsterdam subscribers list of a national gay newspaper. These participants were not investigated concerning their HIV status. The average age of the 277 men was 36.2 years. They were interviewed verbally three times between July, 1985, and December, 1986, concerning anal sex and condom use with steady and casual partners. The latter served as the basis of the study. Those who used condoms consistently from the beginning of the study were designated innovators, while those who used condoms consistently during the 6 months before the 3rd interview were called early users. The early consistent condom use was related to the serostatus of the studied population. Among seronegative and untested men, 37% never, 30% occasionally, and 33% always used condoms with casual partners. Seropositive men used condoms significantly more often: 13% never, 45% sometimes, and 42% always (p < .02). The early users were more often cognizant of the fact that a positive HIV test result was not identical with having AIDS (p < .01). They were also more familiar with the fact that it was not true that worldwide most men with AIDS were homosexuals (p < 04). Both the early users and the nonusers were of the opinion that the use of condoms with anal sex reduces the risk of HIV infection. The personal acquaintance of an AIDS patient was not associated with the use of condoms, as 63% of those who never used condoms at the time of the 3rd interview had known at least one AIDS patient at the beginning of the study. In the case of early users the corresponding percentage was 56%. The consistent condom users had more control over sexual impulses and more social support, which could be used in prevention strategies aimed at these groups.
[Partnership and pregnancy decision-making conflict]
A total of 132 couples were interviewed concerning pregnancy conflicts (disagreement relating to abortion). 74 couples had such a conflict, 27 couples had had an abortion in the previous year, and 31 couples who had no conflict served as controls. The age of the men ranged from 17 to 52, while that of women from 17 to 42 years. 56% of couples had at least one child, but only 75% of those children were of both partners. In the control group, those making higher income (between DM 3000-4000 net per month) were overrepresented, while only the couples in the conflict and abortion groups had a monthly income below DM 1000. About one third of men and women in the abortion group were still in school or unemployed. About 40% lived in Munich, the rest in various Bavarian towns. 60% were Catholic, over 20% were Lutherans, and 17% had no religious affiliation. As expected, there was a close relationship between the financial situation of the couples and the occurrence of pregnancy conflicts. 86% of the women with conflict and 95% of the women who had had abortions were in financial straits. The relationship with their own parents was disturbed in 65% of men and 48% of women who had a conflict as well as in 85% of men and women who had an abortion, and these parents were informed only in exceptional instances. The relationship with the fathers was negatively judged in more than 50% of cases, as they had left their families or did not devote any time to their children. 90% of women with negative relationships with the fathers had a conflict. The quality of the partnership had a decisive influence on the occurrence or resolution of these conflicts. Mutual attachment was manifest only in 1/5 of couples with conflicts and abortion history compared to more than 2/3 in controls.
[What measures should be taken when a "pill" has been forgotten?]
Since the 1970s, oral contraceptives (OCs) have been improved, with the result that over 50 types of OCs are available in Germany in 1994. There are gestagen-only preparations and estrogen-gestagen combinations. The combination preparations consist of 1-phase (high dose with over 50 mcg ethinyl estradiol (EE) and low-dose with less than 50 mcg), 2- or 3-phase OCs, and 2-phase (sequence) preparations. OCs are sold as 21 and 22 pill preparations. According to data of the World Health Organization, the failure to take OCs ranged between 30 to 70%. In the case of high-dose preparations, the diminution of contraceptive safety occurs only after missing more than 5 pills. However, with micropills (with less than 30 mcg EE), missing even 1 tablet compromises the contraceptive safety. Levonorgestrel-containing preparations are more safe than those containing norethisterone acetate. The most risky is belated taking of the OC, since by the 7th day without OC already in some women the endogenous estrogen concentration increases and follicle ripening occurs, which is suppressed if OCs are taken regularly during the first seven days. It is recommended to take the forgotten pills and continue with the regular schedule in order to avoid menstrual cycle irregularities. Additional contraception is also recommended, since the contraceptive effectiveness in this case is questionable. In the event the OC is forgotten between the 7th and the 14th day, it has no effect on contraceptive safety, provided the delay is no more than 12 hours. If the interval is longer, ovulation can occur, and additional contraceptive measures are needed. If an unprotected intercourse occurs on the day when the OC was forgotten, the postcoital, day-after pill is suggested. In case the OC is forgotten in the 2nd half of the cycle, further contraceptive measures are not necessary, only the regular pill taking has to be continued as instructed until the package is finished.
A total of 123 tissue slices from uterine curettage of women using IUDs were examined. The material was obtained either during IUD change or in order to clarify complaints. In addition, an IUD was also studied that was removed in connection with an operative uterus removal. All IUDs were made of copper. The minimum duration of use was 1 year and the maximum 8.5 years. Histological slices were dyed with HE, PAS, Gomori, van Kossa, Ziel-Neelsen, and Gram. In 3 cases an energy-dispersive X-ray microanalysis was carried out. The IUD obtained from the removed uterus was studied by stereo microscopy and light microscopy. In 14 tissues, structures were detected that could easily be mistaken for actinomycotic sulfur granules. These were characterized by radial filamentous eosinophilic structures with peripheral club-like swellings. The dissimilarities to a true sulfur granule were evident with Gram staining, which showed single filaments substantially wider than those of the true actinomycotic granules. In contrast to the actinomycotic granules, the pseudo-actinomycotic granules demonstrated no branching; the individual filaments were wider than 10 micro millimeters, while the actinomyces filaments reached maximum of 1 micro millimeter. In one case there was a larger colony with a central hollow space that obviously corresponded to the negative imprint of the IUD copper filament. The Gram dying was positive, and the PAS reaction showed a weak positive reaction. The other dying tests were negative, and in particular the van Kossa reaction could not detect calcium sedimentation. The microscopic investigations indicated that in the case of pseudo-sulfur granules the process had to do with such chipped off sedimentation on the copper filaments on which cockade-like amorphous hyaline structures with finer radial filamentous pattern were deposited.
A comment is made on R. Esser's letter that she considers the practice of abortion by doctors in general and gynecologists in particular as an expression of public influence on the medical profession. She accuses the doctors of deficient sensitivity towards the moral-ethical and legal problem of preservation and protection of life, saying that by fulfilling state interests they become reduced to the stooges of law-making. These severe charges against the profession are based on a one-sided and dogmatic view of abortion as murderous treatment and severe infringement on the basic and human rights of the unborn. These personal charges should be repudiated, as even philosophers and theologians have not succeeded yet in finding a universally suitable answer to the issue of when human life begins and when the protection of this life takes precedence over other interests. There is a conflict between the protection of the unborn life and the generally recognized basic right of preserving the bodily integrity of the individual. The situation of the woman who is forced to carry to term an unwanted pregnancy conflicts with this basic tenet. Moreover, the weighing of the rights of the unborn, on the one hand, and those of the pregnant woman, on the other hand, is deferred with the progress of the pregnancy. The physician executes a difficult task when performing abortion, as professional duty is part of medical responsibility in accordance with ethics. Limiting doctors' performing of abortions unquestionably would bring back the time of illegal abortions with high morbidity and mortality rates, and thus it must be rejected as irresponsible. The attempt to destabilize the profession and make abortion impossible must be resisted, because many women in need would pay a desperate price.
[Use of condoms prevents sexually transmitted diseases (letter)]
Several research and newspaper articles have shown that the Norwegian public's knowledge about sexually transmitted diseases was found very scanty, although there was debate about the way the questions were posed. They inquired whether the use of condoms would prevent gonorrhea or other sexually transmitted diseases (yes, no, or don't know). The message about condom information relates to safer sex, not safe sex, which requires sex without intercourse, and further precautions about the ejaculate or vaginal secretions not to be transferred to the partner's mucous membrane. The use of condom does not prevent infection by gonorrhea with 100% certainly, as the condom can break, however, both epidemiologically and individually, the condom is highly effective in preventing the risk of infection transmission. The correct use of the condom requires practice and technique in order to avoid the risk of the condom's breaking or sliding off. As long as the condom is in place, it prevents infection to and from the area of the penis covered by the rubber membrane. However, it does not prevent infection of the partner from microorganisms that are found outside the covered area. The failure to use the condom is frequently ascribed to being under the influence of alcohol and to forgetfulness. At a clinic, an effort was made to eroticize condom use as part of foreplay. Condoms of different shapes, colors, and flavors have been put on the market.
[Oral contraceptives as postcoital prevention -- time to withdraw the requirement of prescription?]
Unwanted pregnancy is a serious issue, and despite the development of a number of new prevention methods, the abortion rate continues to be high. In recent years in Norway, the annual number of induced abortions was 15,000-16,000. It is obvious that information alone is not sufficient to reduce the abortion rate, particularly among teenagers, who have a high rate. As an alternative pregnancy prevention method, the postcoital pill has been known for 20 years. It consist of taking a high-dose pill (100 mcg of ethinyl estradiol) within 72 hours after intercourse. 12 hours later two more pills are taken, and this method is effective in 98-99% of cases. However, it may be difficult to have time within 72 hours to go to the doctor, and just the idea of contacting a doctor is an deterrent for many young girls. The sale of pills without prescription would improve their access greatly. A central question in a discussion about prescription-free sale is whether the method is dangerous or if it can be misused. Serious side effects and clotting do not seem to be a factor in postcoital pill use. However, it is important to point out that this method is truly for emergency prevention. About 50-70% of inadvertent pregnancy can be potentially prevented this way. Another possible prevention method is the IUD and the antiprogestogen mifepristone (RU-486), which is not available in Norway. A Norwegian/Swedish conference of experts concluded that this is an alternative that needs to be considered for wider use, although prescription-free access was not yet endorsed. In India and South Africa, oral contraceptives are available without prescription, and in the United States, an experiment concluded that OCs ought to be sold without prescription because of their safety record. In order to reduce the number of unwanted pregnancies and abortions, OCs as secondary prevention could improve the situation.
[Treatment in miscarriage and abortion. Widened use of drugs has many advantages]
In the fall of 1992, an abortifacient, mifepristone (Mifegyne), was introduced in Sweden. Mifepristone is an antiprogesterone that binds with progesterone receptors without releasing the biological effect of progesterone. The result is a local progesterone burst that causes damage in the blood vessels in the capillaries of the decidua, bleeding, necrosis of the decidua, the detachment of the pregnancy, increased sensitivity of the myometrium to prostaglandin, uterine contractions, and expulsion of the conceptus. Treatment with a combination of mifepristone and a prostaglandin analog, usually gemeprost (Cervagem), is a very effective method of abortion and an alternative to vacuum aspiration during the first weeks of pregnancy. At the present, time this is the only well-known indication for antiprogesterone. However, the range of use of antiprogesterone will most likely rise in the coming years. In a 1992 study, 60 patients with pregnancy up to the 13th week were treated with 600 mg of mifepristone and 36-48 hours later with 600 mcg of misoprostol (Cytotec) for missed abortion and anembryonic pregnancy. 57 aborted, and the rest underwent vacuum aspiration. The average time of abortion was 4 hours, and the period of bleeding averaged 10 days. Uterine pain required analgesics in 20 cases. In a 1993 analysis, 44 women were given prostaglandin for abortion: either in the form of an intramuscular injection of 0.5 mg of sulprostone or in two tablets of misoprostol (400 mcg). The treatment failed in two cases, but 50% of women could return to work immediately, while the rest waited an average of 3 days. Often after the 12th and always after 14th week of pregnancy, a 2-step method is used that consists of prostaglandin analogs such as gemeprost given vaginally. However, it takes up to 24-28 hours to abort. Cervical ripening with intracervical PGE2 or laminaria can shorten the time to 10-15 hours equivalent to one day of hospitalization instead of 2-3 days.
[Methodical and practical reliability of natural family planning (letter)]
A great number of natural family planning methods are known that differ from one another with respect to their reliability. The calendar method of Knaus and Ogino was a step forward, because it correctly connected the event of ovulation to the fertile period of the female menstrual cycle. However, this method based on calculation is unable to properly take into account the multiple changes of the cycle. Therefore, its reliability is characterized by a Pearl index of 6-20. The Billings ovulation method, known since the 1970s, infers from changing cervix characteristics the fertile periods, and the Pearl index of its reliability is 5-30. The basal temperature method and the more recent symptothermal method are the first natural methods to reach the reliability of the so-called modern family planning methods. The symptothermal is a method that measures symptomatic temperatures and is based on the examination of cervical mucus and the body temperature at morning waking. The Pearl index of the symptothermal method ranges from 0.5 to 3. In a German analysis of this method, a total of 16,533 menstrual cycles of women aged 19-45 from 9 countries were studied. In 6008 cycles the symptothermal method was used exclusively, while in 8308 cycles another method was employed in addition, such as the condom. The Pearl index of the symptothermal method amounted to 2.7. However, the method failure because of user error amounts to 0.7 per the Pearl index, thus it is comparable to the reliability of the IUD and the oral contraceptive pill. In an Italian study, 8140 cycles were evaluated with a user Pearl index of 3.6 and method Pearl index of 0.4. In comparison, in 1981 the World Health Organization found that in Ireland the combined Pearl index of the Billings method was 16.3 and its method index was 3.4, while in New Zealand the figures were 28.6 and 6.3, respectively.
The federal constitutional court promulgated on May 28, 1993, for the second time the act of the federal parliament to amend section 218f dealing with abortion, and declared important parts of it invalid. The parliamentary positions consisted of total elimination of penalties for abortion proposed by the Greens and the restriction of the abortion law in the old provinces by cancelling the social indication. The court assumed a fundamentalist stance, whereby it attempted to formulate regulations from a right wing dogmatic point of view. Basically, every pregnancy termination was to be declared wrong, but in certain cases this wrong was justifiable by law. The formulation of the hardship situation was in conflict with the ethos of social equity. The term indication stayed in force, albeit with restrictions. Fundamentalist mentality and practices have been at work in the legal theories and their underlying moral precepts, including the tendency to issue absolute pronouncements, terrible simplification, enemy images, rejection of rationality, antimodernisms, lack of readiness to compromise, intensified emotionality, adherence to authority figures, and propensity to violence. Social ethics embraces pluralism and regards the respective roles of all participants in the abortion issue: the unborn, the parents, especially the mother, the health professionals, elected legislators, and the state.
Certain medications can accelerate the inactivization of contraceptive steroids via enzyme induction, thereby causing the fall of serum concentrations, and can lead to irregular bleeding and pregnancy. Barbiturates and rifampicin are the most potent inducers of hepatic enzymes. Various medications can strengthen the serum level of contraceptive steroids and their effect via inhibiting the cytochrome P-450 enzyme responsible for their metabolism. Medicaments that are eliminated mainly through conjugation can reduce competitively the sulfate conjugation of ethinyl estradiol (EE) in the small intestine, whereby the EE level increases. Estrogens, particularly EE, can stimulate the glucoronidization of drugs and strengthen their clearance, whereby the serum concentration of the drugs is reduced. Contraceptive steroids, particularly EE, can increase the serum concentration of the drugs through inhibition of their metabolism by enzymes, and thereby strengthen their effects and side effects. Antibiotics can prevent the hydrolysis of steroid conjugates by harming bacteria in the colon and can interrupt the enterohepatic course of EE. By 1985 worldwide more than 700 reports had been presented about interactions between drugs and the pill. More than 90% of these reported pregnancies had to do with high-dose preparations with 50 mcg of EE or more and primarily rifampicin, antibiotics, antiepileptics, and antidepressives. The effect of these interactions fluctuates greatly and also depends on other factors such as nutrition.
[Neonatal mortality in residents of an urban area in southern Brazil]
1990 neonatal mortality rates in Maringa, Parana State, Brazil, were described in terms of several variables. There were 87 deaths of children under 28 days of age during the period January 1-December 31, 1990. Information was obtained from death certificates, hospital archives, home interviews, health center files and autopsy records. The infant mortality rate was 25.6 per 1000 live births, and neonatal mortality rate was 19.4 per 1000 live births. Most of the deaths occurred in the first week of life (92.0%); in newborns with less than 37 weeks of gestation (79.8%); in low birth weight infants (74.1%); in male newborn infants (56.3%); and in infants delivered by cesarean section (54.2%). In 77.4% of neonatal deaths, the mother's age was under 30, and 22.6% were under 20. 74.1% of deaths of infants less than 28 days old occurred in the low birth weight group (less than 2500 g). 39.5% of deaths occurred in the extremely low birth weight group (less than 1500 g). 96.6% of these deaths occurred in the hospital. The underlying causes of death were codified in accordance with the International Diseases Classification, 9th revision. Perinatal causes together with congenital anomalies accounted for 94.0% of neonatal deaths. Perinatal causes were responsible for 83.2% of neonatal deaths, of which prematurity was considered the main cause accounting for 15.8% of deaths. Prematurity was the cause most frequently associated with the deaths of newborn infants (59.0%). Prematurity was intimately related to most basic causes in all the neonatal deaths caused by maternal maladies, maternal complications of pregnancy and intrauterine hypoxia, and asphyxia at birth. In the majority of deaths by complication of the placenta, of the umbilical cord or membranes, by difficulty of respiration, and by other perinatal causes, prematurity was implicated.
[Probability of dying in the first year of life in an urban area of southern Brazil]
A birth cohort of 4876 children born alive in 7 hospitals in an urban area of southern Brazil was selected and followed through up to the age of one year, with a view to estimating the risk of dying in the first year of life. Information on death was collected from death certificates. A total of 103 deaths were located in Maringa, of which 97 occurred in 1989. All of them were born in 1989, and the only requirement for belonging to the cohort was that of residence in the area. The selected variables were: sex, birth weight (low, adequate, and normal), age at moment of death (neonatal, late neonatal, and post neonatal) underlying cause of death (according to the International Classification of Diseases--9th Revision), and maternal age. The estimated probability of dying in the first year was of 19.9 per 1000 (77.3% of the deaths occurred during the neonatal period) in contrast with the official rate of 22.6/1000. The probability of dying in late infancy was 4.5/1000 compared to 15.4 in neonatal age. Perinatal causes and congenital malformations contributed to 80% of the deaths, and infectious diseases were the underlying cause of death in only 1.1% of the losses. 63.8% of infant deaths were caused by ailments acquired in the perinatal period, yielding a probability of death of 12.3/1000. The risk of a female infant dying was 1.4 higher than that of a male. The risk of dying in the fist year of life owing to ailments arising during the perinatal period was higher among vaginally delivered babies (20.3 per 1000) than it was for those born by caesarian section (9 per 1000). A higher probability of death was present among infants born to adolescent mothers, and those with low birth weight (less than 2500 g). The results signify the need to improve the quality of prenatal and infant care, and suggest the possible association between high infant mortality and lower socioeconomic level.
[Health profile of children cared for in nurseries and the prevention of communication disturbances]
An inquiry was undertaken into the health of children at the 3 day care units assisted by the Nursery Program and financed by the city authorities of Sao Paulo, Brazil. A questionnaire consisting of both open and closed questions concerning personal identification, personal history, development, and health was administered to 133 children during September and November, 1991. Results indicated that, in Creche Maria de Nazare and the Creche Santissima Trindade, the children lived with an average of 4 other children, while the number was 4.8 in Creche Jardim Julieta. 69.2% of children lived in houses made of masonry, while 30.8% lived in tents. 37.6% of living accommodations were humid and 62.4% were dry. In the Creche Jardim Julieta, where there were more inmates and more humidity, half of the children had pneumonia, vs. 36% at Creche Maria de Nazare and 20% at the Creche Santissima Trindade. They also presented other respiratory infections and otitis (affecting hearing and language development) in greater numbers. 115 children were breast-fed initially, but 40.9% were started on artificial milk when 2 months old. 68 of 125 children who were bottle fed were started on it at two months of age. 85.7% of children were introduced to various solid foods at the appropriate ages, and 79.7% to salty foods, which were well received. Normal language development occurred in 76.9% of children in the Creche Maria de Nazare, while in Creche Jardim Julieta it was 56.9%, and in the Creche Santissima Trindade it was 45.0%. Speech development delay was related predominantly to ages 3 to 7 with the Creche Jardim Julieta predominating. The systematic use of the proposed questionnaire will not only help gain better knowledge of the health of the children, benefiting the multidisciplinary attendance of the child, but also the improvement of preventive practices.
[International and intercultural aspects of pediatrics and adolescent health care]
Population statistics of Amsterdam between the 17th and 19th centuries indicate that 20-30% of young married people had been born in foreign lands. At the present time, 6% of the country's population, nearly 1 million people, are direct descendants of foreign parents: 240,000 Surinamese, 210,000 Turks, 170,000 Moroccans, and 80,000 from the Antilles. 40% of foreigners live in the four large cities, and there they make up about 15% of the population; 30-50% of children in these cities have foreign born parents. Among health concerns affecting these people are parasitic diseases, tuberculosis, salmonellosis, and the importation of infections such as viral B hepatitis, which so far has been successfully controlled. About 4% of the foreigners (30,000 people) carry a defective gene, and when two such people marry, in 25% of cases a child can be born with a severe defect as well as thalassemia major (mainly children of Moroccans and Turks) and sickle cell anemia (Surinamese and Antillans). 20-40% of children from tropical or subtropical areas also have lactase enzyme deficiency, which gives them stomach complaints because of incomplete metabolism of milk sugar. In recent years it has been reported that asthma and respiratory infections with longer hospitalizations occur more frequently among foreign children. Infant mortality is also 2-3 times higher among them. Intercultural aspects affecting Turkish and Moroccans immigrants include communication problems, primarily those of the first generation, which should be facilitated by language centers and educational materials. Generation conflicts arise from contrasts between homelife and the outside world as well as from the fact that many of the parents are illiterate. Cultural difference are rooted in Islam, which requires loyalty to the group with traditional role patterns. Other problems pertain to the social isolation of the mother and the lower position of women, and the uncertain legal position of foreigners, which can result in sometimes unwarranted feelings of discrimination.
[The pill and cancer of the female sex organs and breast]
At the present time in the Netherlands, mainly oral contraceptives (OCs) with 3-35 mcg of ethinyl estradiol are used with progestagen components of levonorgestrel, norethindrone, and lynestrol. The modern progestagens gestodene, norgestimate, and desogestrel have fewer androgenic side effects and less effect on the serum lipids and glucose metabolism. Alleged carcinogenic effects of OCs have not been proven, in contrast, their protective effects against certain tumors have been discovered. The progestagen in OCs eliminates endometrial hyperplasia and reduces the chance of endometrial cancer. The high-dose estrogen pills without use of equally high dose progestagens increase the risk of endometrial cancer, and in women under 45 who developed this cancer, the use of such sequential preparations was relatively high. A 1980 study found that the use of combination OCs compared to nonusers reduces the risk of endometrial cancer by 50%. The protective effect lasts 5-15 years even after discontinuation of OC use. The risk factors for ovarian cancer are advanced age, early menarche, late menopause, race, nulliparity, low number of pregnancies, and family history. Even the short-term use of OCs significantly diminishes the risk of ovarian cancer, and the protective effect lasts 5-10 years. A 1983 study indicated that women using OCs had more risk of dysplasia and cancer of the cervix. The relative risk was 1.5 up to 5 years of use and 2.1 =or> 10 years. Nevertheless, the causal link was neither proven nor denied, thus, such women are advised not smoke. Several investigations hinted at an increased risk of breast cancer and long-term OC use (over 8 years) with earlier preparations containing 50 mcg of EE or more. In a large study in 1986 no link was found, however, in a World Health Organization control study, a slightly significant risk was ascertained in women under 25 years who had used OC before the birth of the first child.
[Vietnam back in perspective; reforms also concern health care]
Vietnam has a population of 71 million people with a per capita income of $205 per year. In recent years the economy has become liberalized, and development has accelerated, as foreign investments have poured in. The changes have their drawback, as the gap between the rich and the poor has widened, health care is no longer free in practice, the number of admissions into hospitals has decreased, and hospitals and health posts are ill-maintained. There is an extensive network of basic health care with district hospitals and health posts in the villages. In most district hospitals, there are essential drugs available (penicillin, ampicillin, co-trimoxazole, and chloramphenicol), but no cephalosporin or chinolone, which are too expensive. There are X-ray facilities in 50% of hospitals, but there is no echo apparatus. Six medical schools graduate 2000 doctors per year, but the quality of education was mediocre for many years. Malaria, diarrhea, and respiratory infections are the greatest problems. In 1992, there were 20% more malaria cases than in 1991. There were 29,000 cases of serious malaria in 1992 and 3300 deaths, compared to 4561 serious cases and 1070 deaths in 1987. The increase is attributable to socioeconomic factors: the dwindling of aid from the Soviet Union and less DDT spraying, people who are not immune to malaria settle in new economic zones for rice cultivation, diminished effectiveness of the antimalarial network because of scant resources, the chloroquine- and sulfadoxine-pyrimethamine-resistant parasites since mefloquine and halofantrine are too expensive, and the resistance of certain mosquitos against insecticides. Severe malaria has a mortality rate of 20-30% in spite of treatment. Vietnam produces hundreds of kilos of artemisinine annually, and derivatives are experimented with that could be used parenterally. The country needs help because its resources are limited, and unless the US economic embargo is lifted, it is parcelled out only piecemeal.
[The risk factors for the transmission of HIV infection among intravenous drug users in Russia]
Narcotic users and particularly persons who inject drugs are at the highest risk of being infected with and transmitting the HIV infection. Monthly reports of AIDS prevention centers, reports of HIV infection cases, and communication about epidemiological investigations were utilized in order to measure the correlation between HIV infection and narcotic use. Questionnaires were administered to 86 drug users (56 men and 30 women aged 17 to 33 years) with the objective of learning about the duration, frequency, and nature of drug abuse as well as about sexual habits such as number of partners, foreign partners and prostitutes, taking money or narcotics for sex, use of condoms, and the history of sexually transmitted diseases. As of November 1, 1992, there were a total of 316,281 drug abusers in Russia, of whom none was infected with HIV. However, among 588 registered HIV-infected patients, 8 patients had had sexual partners who were drug addicts. Among the 86 drug addicts, 36 persons (24 men and 12 women) used opiates and 50 (32 men and 18 women) used pervitin (refined by red phosphorus and hydrochloric acid). The duration of addiction ranged from 2 to 8 years, the frequency averaged 3-4 injections a day with 91.4% of opiate users and 92% of pervitin users injecting in groups without sterilizing the syringes. Among pervitin users a high percentage engaged in sex after drug use because of its psychostimulating effect. 20% of drug addicts from both groups reported heterosexual sex, while 8.6% of opiate users and 24% of pervitin users reported several partners. Pervitin users reported having 100 sexual partners compared to 60 partners among opiate users in the previous 5 years. The respective figures for the preceding year were 25 and 15. 28% of pervitin users and 8.3% of opiates users paid with sex for narcotics. The majority of subjects never used condoms. Only 5.5% of opiate and 6% of pervitin users had sex with foreigners. 69.5% of opiate and 88% of pervitin users had gonorrhea, syphilis, trichomoniasis, and hepatitis B (22.2% among opiate and 38% among pervitin users).
A recent review article on HIV-associated tuberculosis (TB) in developing countries discussed strategies for preventive chemotherapy. There are several fundamental problems associated with the use of this approach as a public health measure. There is simply no practical way of identifying those who are coinfected with HIV and TB in a developing country early enough to implement prophylaxis. In HIV-associated TB in Africa, TB is usually the presenting feature of HIV infection. The financial costs of offering voluntary HIV testing and tuberculin testing to any substantial part of the population in the developing world would probably exceed the cost of the entire existing health services in many communities. Even the most successful TB programs are barely able to meet the demands of delivering adequate treatment to patients identified with active TB. Conservative estimates of HIV and TB prevalence reveal that TB prophylaxis delivered on a large scale would multiply many times the burden on a national TB service. Widespread distribution of antituberculosis drugs in communities containing many individuals with unrecognized multibacillary tuberculosis would create the ideal conditions for rapid emergence of resistant organisms. Chemoprophylaxis may be used in patients whose diagnosis of HIV is made on other grounds before TB has developed. Furthermore, the only prospective study quoted by the authors supporting the efficacy of INH prophylaxis in HIV-infected patients has shown, in the most recent follow-up, that the effectiveness of prophylaxis declined as time elapsed after completion. Until some very dramatic breakthrough in chemoprophylaxis has been documented, any diversion of attention or resources towards prophylaxis and away from the critical adequate TB treatment and control, is much more likely to do harm than good.
NICHD funds studies of contraceptive vaccines.
Researchers funded by the National Institute of Child Health and Human Development (NICHD) recently reported progress in the development of contraceptive vaccines for men and women and attempts to develop a contraceptive vaginal ring and vaginal compounds that protect against the AIDS virus. At NICHD's three contraceptive development centers--the University of Virginia, the University of Connecticut, and the Population Council of New York--much of the research involves antigens of sperm and eggs. The researchers hope that once injected into the body, these antigens will spur the development of antibodies, immune system molecules that bind to antigens, targeting them for eventual destruction by the cells of the immune system. Scientists from the centers are studying ovarian antigens to make sure that immunizing animals with them would not result in an immune response against the animals' own tissues. NICHD-funded researchers have genetically spliced sperm and egg antigens onto the surface of nondisease-causing strains of Salmonella bacteria. Currently, the researchers have produced high levels of antibodies in animals for long periods of time and have completed human safety testing. Other researchers have developed a contraceptive vaccine against luteinizing hormone releasing hormone (LHRH) as well as completed animal studies on the vaccine's safety and effectiveness. So far, the researchers have found the vaccine to be effective at lowering LHRH in four men castrated as a treatment for prostate cancer. NICHD investigators are also developing a contraceptive ring that can be inserted in the vagina. Preliminary clinical trials indicate that, although the device delivers 1/3 less hormone than conventional oral contraceptives, it is as effective and is nearly free of side effects. Another project involves the development of a spermicide that will protect men and women from the human immunodeficiency virus.
Abortion and sterilization better covered than contraception by the majority of insurance plans.
Two-thirds of typical fee-for-service insurance plans routinely cover abortion, and 9 in 10 routinely cover sterilization, according to a new study by The Alan Guttmacher Institute (AGI). In contrast, half of typical fee-for-service plans provide no contraceptive coverage at all. Only 15% cover the most effective medical family planning methods: Norplant implants, Depo-Provera, the IUD, oral contraceptives, and the diaphragm. Only 22% of plans cover contraceptive counseling. While coverage of sterilization and abortion services by health maintenance organizations (HMOs) is similar to that of indemnity plans, contraceptive coverage is considerably better. Only 7% of HMOs provide no coverage, four in 10 typically cover the above medical family planning methods, and nearly all cover contraceptive counseling. These are findings from the first large-scale examination of private insurance coverage of reproductive health care services being conducted by AGI. Portions of the study were released on March 9, 1994, in testimony at a Congressional hearing of the Senate Labor and Human Resources Committee. The findings portray private insurance coverage that is biased toward surgical care over nonsurgical procedures, curative care over preventive care and medical procedures over counseling and education. These patterns of coverage leave women with little or no coverage for key services they need during their childbearing years. The emerging national health care reform plan must not model itself on current capricious patterns of coverage that fail to address the needs and circumstances of women and couples today.
Multicentre criterion based audit of the management of induced abortion in Scotland.
The objective was to assess and improve the quality of care provided to women undergoing induced abortion. Two rounds of prospective, criterion-based case note review audit were carried out in 10 National Health Service gynecology units throughout Scotland, and 2004 patient episodes of abortion care were identified. The first round comprised 967 cases and the second round 1037. Significant improvements occurred in quality of care as assessed against 16 previously agreed upon criteria across the 10 study hospitals and within individual hospitals. These included increased availability of early medical abortion, decreased utilization of surgical abortion at very early gestation, increased use of mifepristone priming before 2nd trimester medical abortion and increased provision of follow up. At the individual hospital level, 42 of 150 elements of care studied were close to optimal at the time of the first round of audit, rising to 54 at the second round. A total of 31 significant improvements in individual elements of care occurred, but 11 significant deteriorations also occurred at the p < 0.05 level. At the time of the 2nd round of audit 4 significant overall improvements across the 10 hospitals were detected: the use of medical abortion for women at < 9 weeks' gestation rose from 39 to 516 (7.6%) to 172 of 541 (31.8%) (p<0.0001); the inappropriate use of surgical abortion in women at < 7 weeks' gestation decreased from 68 of 85 (80.0%) to 56 of 98 (57.1%) (p=0.0017); the use of mifepristone cervical priming before midtrimester medical abortion increased from 15 of 64 women (23.4%) to 64 of 102 (62.7%) (p < 0.0001); the recording of a follow up arrangement in the case notes increased from 52% to 69% of cases (p=0.037), and the advising of follow up within the recommended interval of two weeks after abortion also increased (from 5% to 32%; p=0.0645). There were no overall deteriorations in relation to any elements of care. The prospective multicentre audit proved feasible and achieved the aims of any form of audit in terms of identifying deficiencies and variations in care.
Validity of assessing change through audit.
Penney et al have reported an audit of the management of induced abortion in 10 hospitals in Scotland, comparing the results obtained in a first round of 6 months in 1992 with those obtained in a second round of 2 months in 1993. Four statistically significant improvements were detectable when all 10 hospitals were taken together and no overall deteriorations occurred. However, when individual hospitals were evaluated considering 15 of the 16 criteria of care, giving 150 comparisons of the two rounds of audit, major improvements occurred in 31 comparisons and significant deteriorations occurred in 11. The authors believed that audit was instrumental in producing the dramatic improvement in the frequency of mifepristone priming before midtrimester abortion. The problem with drawing any such conclusion from such evidence is whether it is valid. An apparent difference between 2 treatments has 4 possible explanations. First, the difference could be real owing to the difference in treatment. Second, it may have occurred by chance. Third, the patients in the 2 treatment groups might be different, there might be an allocation bias. Fourth, there could be an assessment bias. The role of chance is considered by performing a statistical test to give a P value. If P is less than 0.05, chance may be rejected as a reasonable explanation of the difference. When several P values have been calculated, it is more likely that low values will occur even if the true differences in all the comparisons made are zero. Allocation and assessment bias also need to be considered. Trials using inferior methods of allocation are not acceptable to the British Medical Journal (BMJ). It seems that the BMJ is using a double standard in requiring much more rigorous methodology for treatment comparisons that are explicitly labeled as research but not applying such rigorous criteria for other studies which attempt to draw causal conclusions.
Population ideology: a Canadian perspective.
The language used in Canadian population policies and practices is investigated by examining documents that refer to population controls within Canada (Quebec's pronatalist program) and without (state-sponsored population reduction programs in developing nations). The premise is that internal and external programs share an ideological base regarding development, the environment, reproduction, and population. Original documents and policy statements of Canadian governments provide the evidence. A variety of programs and policies that have existed since the time of European colonization share a particular form of social control in protecting national identities. The improvement of regional economic disparities is attempted by reducing the birth rates of targeted peoples. In contrast, certain populations are actively encouraged to reproduce. The Quebec pronatalist policy, Parental Wage Assistance program, was introduced in the 1988 Quebec Government's budget as a family support package with an explicit mandate to preserve Quebec culture through population growth. Today, cultural assimilation is not enforced by law, however, the 1989 document Adoption and the Indian Child proves that the practice persists. Women's cultural traditions surrounding birth, healing and dying are replaced by second rate western medical care. Implantations of Depo-Provera are now routinely encouraged in young Inuit women throughout most of Northern Canada. The marketing of pharmaceuticals is also an instrument of controlling populations in Canada and abroad. Hoecht's Buserelin (an LHRH analogue) was being marketed in a nasal spray form for use in the third world as a contraceptive. Women are seen as gateways to population control in a global concern that constructs third world nations as separate (economically, culturally and morally) from so-called first world nations. Within first-world nations, racial discrimination encourages desirable populations to procreate and undesirable ones are controlled through continued cultural, economic, and medical sanctions. These national and racial defense strategies reinforce global disparities.
Ageing and the family in the developing Asian and Pacific countries.
In many developing countries older people are cared for within the extended family, and sometimes within the community at large. In those societies, traditional culture emphasizes respect and assistance to the elderly as a value. However, in an increasing number of developing countries the extended family system is gradually changing toward a nuclear family system. Rapid economic development, urbanization and industrialization bring about major changes in the traditional role and status of the elderly within the family. Older family members are being left on their own as the young members move away from the family residence to seek employment and career opportunities. The average household size decreases with population aging. In the less developed countries of the Asian and Pacific region, Afghanistan, Bangladesh, Fiji, Pakistan and the Philippines, the average household size is approximately 6 persons, and the population aged 60 or over represents less than 5% of the total population. In the developed countries of the region (Australia, Hong Kong, Japan and New Zealand) the average household size is between 3 and 4 and the elderly account for 10% or more of the population. The other industrializing, developing countries fall between these 2 groups. In many Asian countries, old-age dependency is rapidly increasing with population aging. This means that the working-age adult population will be called upon to provide support for a larger proportion of the aged in the future. At the same time, along with socioeconomic development, traditional family structure is also changing. Therefore, the welfare of the aged will require the strengthening of family support systems and development of supplementary community-based programs concerning matters such as employment income maintenance; health, nutrition and medical care; housing and living arrangements; and personal social services.
Sex preference and fertility in peninsular Malaysia.
Preliminary discussion addressed the issue of sex preference and fertility in developing countries and in Malaysia among the Chinese, Indians, and Malays. The study aim was to examine sex preference and fertility among the ethnic groups in Malaysia with Cox's proportional hazard models. Data were obtained from the Second Malaysia Family Life Survey, conducted in 1976-77, for all ever-married women with at least one live birth. Data included the first 7 parity transitions for Malays and the first 5 for Chinese and Indians (6129 Malay births, 2548 Chinese births, and 1556 Indian births). The hazard rate was computed for each parity transition from the birth of the surviving index child and a subsequent live birth, the survey, or the event of a woman reaching menopause or becoming sterilized. Sex composition was analyzed in 3 ways: a model with surviving sons as continuous variable, a model with at least one son and one daughter, and a model indicating more sons or more daughters. Time periods were represented as dummies for the period before 1970 and after 1982. Other controls were for maternal age, educational status, work status, and paternal occupation. The procedure by Arnold was used to evaluate the impact of sex preference on fertility. The results showed conflicting patterns for the impact of son or daughter preference on subsequent births. The likelihood of another child was higher among those with parity of 3-4 and predominant sons, which indicates daughter preference; however, at parity of 7-8 with no son or at least one son, the likelihood was higher. The pattern among Indians was also confused, because son preference was only evident at one parity transition (parity 4-5). Among Chinese, son preference was evident at all parities beyond the first two in the first model. With just one son, the likelihood of a subsequent birth was greater; with just one daughter, the likelihood of another birth was also greater. With an even number of sons and daughters, there was a greater likelihood for a subsequent birth. In the analysis including time period, the evidence supported a greater son preference after 1970, but a similar preference between 1970 and 1982 and after 1982. Maternal age, additional educational attainment, and employment reduced the likelihood of a subsequent birth. Father's nonagricultural occupation reduced the hazard rate for Chinese at lower parities and for Indians at most parities and had an insignificant effect among Malays before 1970. The effect of son preference affected only 4% of Chinese fertility.
Women's rising employment and the future of the family in industrial societies.
A critical analysis was provided of the economic independence hypothesis and Becker's theories of marriage and family behavior. Historically, there have been assessments of the fit between women's labor force participation and patterns of marriage formation, divorce, and fertility, in order to determine how much coincidence played a role. Also examined were how well the theories of women's economic independence explain delayed marriage, nonmarriage, or both. Empirical evidence at the micro level was used to indicate the extent of support for economic independence theories. Specific attention was directed to Gary Becker's specialization theories; it was posited that specialization might actually put families and marriage at risk. Recent trends have shown a tremendous decline in men's labor market position, which theories need to begin addressing. The specialization-trading model of marriage of marital relationships inevitably leads to a prediction of a decline in marriage. Low fertility means reduced need for women's specialization in home production, and a low productivity population. A more adaptive family strategy for a modern industrial society would be based on both parents working. Increased women's employment serves as a substitute for the work of their children, for enhancing social mobility, and as a stabilizing factor in the family's economic equilibrium over the development cycle. When men's economic position and its impact on marriage behavior is modeled by Wilson and Neckerman, a threshold effect emerges where, for instance, the rise of black female-headed families in the US is considered reflective of the decline in the marriageable supply of men. Census data on moderately well educated and less well educated males indicated a deteriorated labor market position between 1950 and 1980. 1) Men's labor market declines accelerated after 1970. 2) 25-34 year old male non-graduates as well as very young men experienced labor market declines. 3) Male high school graduates also suffered declines in employment, particularly Blacks. These three trends occurred throughout the declines in prime marrying ages. Chinhui Juhn revealed that men's unemployment declined over time, and, once out of work, there was little reentry into the work force. Deterioration in earnings was also evident. Earnings ratio data can obscure relationships. Men's declining earnings are effecting the ratio, because women's earnings have remained stable since the mid 1980s. Even the economic position of college graduates, who experienced income declines in the 1970s, does not explain the continued rise in delayed marriage by the 1980s.
How many people can the earth feed?
A requirement, based on realistic possibilities and human capabilities, for an adequate global food supply is wealthy nations' altruism in greatly expanded transfers of efficient farming techniques and modification of unsustainable diets at home. The energy equation also needs to be changed, as another means of achieving a sustainable pattern of living. Phaundler in 1902 estimated that 5 people per hectare of land using traditional farming methods and recycling organic matter would support 11 billion people. Meadows et al. in 1972 reaffirmed the 11.5 billion figure based on 1970 average yields and decline in cultivatable land. Most, if not all, estimates rely on poor countries not being short of food for all people and modest redistributions alleviating existing deficiencies, and the large potential for reducing food waste. The estimation of this article was based on assumptions that conform to biophysical realities, including consumer, economic, and political factors in food production. The lack of reliable data hampers accurate assessment. Official land use data generally underestimate actual cultivated area. Errors arise in reporting the output of continuous crops and incomplete harvests. Guesses are used for reporting harvest and postharvest losses. Errors in developing countries could mean the difference between malnutrition and a basic diet. The UN Food and Agricultural Organization estimated per capita food supply to be 2700 kcal/day in 1990, or 2500 kcal/day in poor countries. Comparisons of supply and consumption have been made and disparities found. Determination of food energy needs is complicated. If heights and weight ideals were attained, the mean food energy intake would increase by just less than 8%. To eliminate worldwide stunting, an increase of 10% would be needed. Thus, an adequate average would probably be around 2200 kcal/day and availability would be 800 kcal/day; global entitlements to food account for the current malnutrition and hunger. For increased food output, the answer is more efficient management of land, water, and nutrients. A combination of approaches yields the best results: appropriate planting times for soybeans can raise production by 50%. Food energy consumption could achieve gains of 22% through better agronomic practices, 7% through higher fertilizer intake, 7% through irrigation waste, 6% through reduction of postharvest losses, 8% through reduced end use waste, and 10% through healthier diets.
Population growth and food production: recent global and regional trends.
Per capita cereal production has declined in North America, Oceania, and Latin America in the past 10 years. In sub-Saharan Africa drought and rapid population growth accounted for the slight decline in cereal production per capita. Increases have been experienced recently in North Africa and West Asia. Even Latin America showed increases, if Argentina is excluded. Access to food supply may account for the UN Food and Agriculture Organization's estimate of about 15% malnourished globally. Global trends show that between 1951 and 1992 rice, wheat, and coarse grain (cereals) production increased, but varied annually. The increase was from 290 kg in the early 1950s to 371 kg in 1984, a peak year, with declines to 355 kg in 1990. Regional trends showed peaks in Africa in 1967 and a decline of 25% by 1990. In Eastern Europe and the former USSR declines were 8%. In Latin America and North America, the peaks were in 1981-82, and declines of maybe 4% occurred by 1990. Europe peaked in 1984 and declined by 9% by 1990. The traditional cereal exporting countries are North America and Oceania (US, Canada, and Australia). These countries account for 20% of the cereal production and 6% of the population. During the 1980s, in the US, cropland for cereal production declined by 12%. Latin American declines were attributed to population growth, land degradation, and the effects of the debt crisis. Argentina accounted for 25% of regional production and experienced a 40% decline in cereal exports. North Africa and West Asia imported about 33% of cereals, which were primarily fed to livestock. In sub-Saharan Africa, which has had droughts and civil unrest, it is uncertain whether the high food aid has contributed to the failure of domestic production. Overvalued exchange rates, poor transportation, marketing, storage, and support services account for some of the region's food supply problems. Low export prices have had an effect worldwide. Cereal production in South, Southeast, and East Asia has been strong, and the deficits in China around 1959 to 1964 and in India during 1965 and 1966 are not likely to reappear. The USSR benefited from low world prices and doubled the volume of imports by 8% between 1981 and 1992. Cereals account for about 50% of total human caloric intake. About 3% of declines in world harvests of cereals between 1981 and 1992 were due to a change in crop. The general conclusion was that food production was in line with population growth.
China's experience in population matters: an official statement.
The description of the demographic situation in China and the directions of the population policy were given in an official statement made on March 28, 1994, by Peng Yu, China's representative to the 27th Session of the UN Population Commission. China's population was over 1.18 billion in 1993 and 27% of the total population is of reproductive age: 324 million people. The median age is 25 years. Arable land area is 7% of the world total, but population is 22% of the world total. The per capita land area is .08 hectares. International migration will have little impact on reducing population. Arable land, exploitation of resources, and the standard of living have been affected by rapid population growth. Population numbers have also impacted on housing, education, employment, medical care, and social welfare. Population policy aims to improve the quality of life for people. Government education programs are geared toward the introduction of notions of the interrelationships between population and development, as stated in the UN World Population Plan of Action. China's population policy is devoted to promoting late marriage and later, fewer, and healthier births, with prevention of birth and genetic defects. Policy advocates the practice of one couple, one child. Rural couples "with difficulties" are to be persuaded to have a second child only with proper spacing. National minorities are expected to establish their own population requirements according to their own conditions. Local governments have formulated regulations suitable for local conditions, conducted population education, and provided medical and health services. An integrated approach has been followed. Incentives and disincentives have been provided for increasing contraceptive prevalence. Total fertility has declined from 4.27 births in 1974 to about 2 in 1993. The birth rate declined from 24.82 to 18.09/1000 live births. The natural growth rate declined from 1.7% to 1.15%. The declines have contributed to socioeconomic advancement and enhanced women's status. Most rural people understand that population control aims to help people enjoy a happier life. Social security and economic opportunities have been provided in rural areas. A net increase of 14 million people annually is expected. About 25% of gross national product is consumed by additional births, which in the long run will affect investments. International support in family planning has been received and welcomed.
Controlling births and bodies in village China.
China has been able to achieve contraceptive usage of 60% or higher within a more 25 years through control of women by the state and its political and medical cadres. The process of accommodation involved not just acquiescence, but involvement of women in local cadres negotiating terms for informal rules that were desired. Local policy was a deviation from national and provincial family planning policy. Women's resistance had undesirable consequences: the greater risk of tubal ligations, repeated IUD insertions and extractions, frequent abortions, late-term abortions, and operations poorly performed in haste during birth control campaigns. Another consequence of the regulatory system was women's fight for upholding the patriarchal system and the desire for sons only. Even though the state was no longer directly controlling behavior, women and peasants embraced the state notions about family construction, social, and cultural behavior. The family became a political construction and the one-child policy dominated; the family became a family construction in that it acceded to family demands. The examination of family demography, particularly in the case of China, should include feminist and political economic literatures. The feminist literature would draw on the examination of the human reproductive potential and the fight over whether the individual or state has control, of the state strategies of manipulation and acceptance of reproductive technologies, and of tradeoffs made by families in balancing reproductive decisions, health and safety, and ideal family sizes. A political economic study would focus on the state, the medical profession, and international agencies and their impact on fertility control and strategies of resistance to state control. The state in developing countries with the support of foreign governments and international agencies had directly affected family formation through their family planning programs. In the case of China, the state has been so strong that people have come to "internalize it, accept it, and even reproduce it in their daily lives." The evidence for this reality was presented for a village in Shaanxi province based on anthropological research conducted before 1989 and the Tiananmen Square massacre.
Wealth flow and fertility decline in rural Kenya, 1981-92.
Intergenerational wealth flows and emotional nucleation, as in Caldwell's theory, were examined in 1981 and 1992 in Kenya in order to determine the degree of change in fertility and the changes in the interrelationships. In 1981, Kenya still had marriage units firmly part of larger kinship groups; by 1992, there were many demographic, social, and economic changes. The Rural Budget Household Survey was conducted among 825 male household heads aged less than 55 years. Wealth flows were measured lineally (transfers to parents and children) and laterally (transfers to siblings and other close relatives), as measures of change impacting on fertility according to theory. Modern respondents provided the least parental support and desired, had, and lost fewer children than traditional respondents. Between 1981 and 1992, there were few changes in wealth flows, and, contrary to Caldwell's theory greater economic and emotional nucleation did not increase and facilitate fertility decline. Caldwell's theory of acceptance of new family size values and behavioral norms was not upheld in the change between 1981 and 1992 in transfers from children to parents. The proportion of respondents expecting regular financial and labor assistance from their children increased by 6% to 7%, but a decline did occur in the expectation of future housing assistance. Wives expected considerable support in 1992: 62% for regular financial aid, 63% for housing aid, and 78% for labor help; the question was not asked in 1981. The climate of declining economic opportunity and fertility was occurring while expectations of regular assistance were increasing. 78% of males expecting the highest regular assistance from children also supported family planning to delay the next pregnancy; 63% supported contraceptive use for ceasing reproduction. Wives expecting regular aid also approved similarly of family planning. those expecting more assistance desired, had, and lost more children. Family size desired declined by 2 children over the period, even for those expecting regular assistance. There was still the expectation of a bride price upon marriage of daughters. About 66% of fathers expected their children to complete secondary education. Emotional nucleation did not change over the time period; lateral transfers slightly increased. It is possible that in rural Kenya, as in Botswana, economic improvement could slow fertility decline, which was clearly evidenced without any change in intergenerational transfers.
Maternal mortality in developing countries: a comparison of rates from two international compendia.
A comparison was made between maternal mortality rates published by the World Bank in its World Development Report (WDR), 1993, with 1988 data and the UN's Human Development Report (HDR), 1993. Both data sources claimed the data was based on World Health Organization (WHO) data, but the two sets of figures were different. When rate differences of 50 points were taken to be exactly the same, HDR gave higher values for 26 countries, lower values for 12 countries, and the same values for 17 countries compared to WDR. Even the averages were different. HDR gave an average maternal mortality rate of 393/100,000 births for 55 countries, and WDR gave a figure of 346/100,000. When the data were weighted for the estimated number of married women in each country, the figures were 260 for HDR and 231 for WDR. The correlation coefficient between the two values was 0.70 or an R2 = 0.50. There was a less significant relationship between the two values for 23 countries with high maternal mortality rates (>450 in HDR); R2 = 0.18. The data in each volume were reported exactly the same or similarly as in the case of time period. WDR reported that data ranged from 1983 to 1991 by country, and HDR stated that data were of uncertain unreliability. A comparison of the WHO's Maternal Mortality: A Global Factbook, 1991, and WHO's definition according to the 9th and 10th Revisions of the International Classification of Diseases (ICD) indicated some variance with the WDR definition. The WHO definition was given in full with the notation that the ICD 10th revision included pregnancy-related death within 42 days of the end of pregnancy and regardless of the cause of death. WHO did not produce its own figures, but based its figures on prior studies and statistics. Reliability of maternal mortality rates is dependent on reliable maternal mortality and birth data. Reporting anomalies are footnoted, where extremely divergent from actual mortality. A comparison of WHO published figures and HDR and WDR figures indicated that, for Benin, WHO and WDR agreed on a rate of 161, while the HDR figure of 800 was close to an 809 figure based on a hospital study, which not representative. There were differences in the two data sets in the countries selected for inclusion, and the reasons were not apparent. The suggestions were to liberally use technical notes, to coordinate and agree on international publication of figures, and to provide the best estimate from a wide range of estimates and qualify with a footnote.
Lessons from a repeat pregnancy prevention program for Hispanic teenage mothers in East Los Angeles.
The conclusion of this quantitative and qualitative evaluation of 350 mothers delivering at Women's Hospital in East Los Angeles and recruited between April 1989 and December 1990 was that basic ethnographic research on teenage sexual and reproductive behavior is needed. Target groups of Hispanics, for instance, may not be homogenous and may require multiple strategies. New interventions should accommodate the effects of poverty, the influence of significant others, and the cultural meaning of relationships, pregnancy, childbearing, contraceptive use, and gender roles. Concern focused on the notion that limited program effects can be considered trivial. The point was made that bilingual mothers who had been in the US for some time and desired upward socioeconomic mobility were helped by the program. Also, the program developed referral resources in child care, school programs, employment, housing, emergency aid, and services for physical and sexual abuse. Additional funding was able to provide part-time work experiences in the clinic for a few of the teenagers, which provided more social support, solid work experience, and incentives. Through the use of qualitative data, counselors were able to prioritize teenage needs and thus supply needed food and housing before contraception. Qualitative data also helped to distinguish several different groups of Hispanics: those recent immigrants who wanted to be wives and mothers; bilingual adolescents desiring economic advancement; throw-away kids involved with drugs and gangs; and Central American teenagers who fled war-torn countries and desired a better life. There were pressing needs related to poverty and social circumstances that interfered with family planning program implementation. Recognition of the different lifestyles helped to direct services in appropriate ways. The statistical demographic profiles were presented and indicated that these teenage obstetric persons had significant social, economic, and medical risks. Many were at risk of repeat pregnancy because of living with their partner and not using contraception. Most were high school drop-outs. There was a high probability that many were illegal immigrants. Postpartum program drop-out rates were very high. Only 37 out of 244 cases and 106 controls remained after 2 years and 105 cases and 16 controls after 1 year. Residential mobility and poverty were obstacles to follow-up.
Which is more important to high school students: preventing pregnancy or preventing AIDS?
The study aim was to examine adolescents' attitudes toward the importance of preventing pregnancy or preventing AIDS and the frequency of condom use among adolescents with different attitudes and demographic characteristics. Panel data was collected over a 5-month period in November and December 1988 and January and April 1989. The sample included 2896 10th-grade students in 8 public high schools in Dade County, Florida, who were administered an attitude, beliefs, skills, behavior survey. Sample populations included Blacks, Hispanics, and Whites. Measures were obtained for the importance of pregnancy or AIDS prevention, frequency of condom use, parents' educational status, worries about AIDS and pregnancy, family structure, interpersonal skills, and knowledge about AIDS. Sociodemographic data on the sample was reported. Respondents in steady relationships were more likely to be living with one parent and to worry about pregnancy; they also were less knowledgeable about AIDS, had lower grades, and were more likely to be female and older than average. Those in a steady relationship were sexually active and had their first sexual experience at an older age than those not in a steady relationship. 84% considered themselves very or somewhat at risk for HIV infection. 55% of females and 45% of males considered pregnancy and AIDS risk important. 7% of males versus 4% of females thought AIDS prevention was more important than pregnancy prevention. 48% of males and 41% of females thought pregnancy prevention was more important than AIDS prevention. Females without sexual experience were more likely to be equally concerned about risks. Fewer Whites reported pregnancy prevention as more important than AIDS prevention. Hispanics and Blacks responded similarly that pregnancy prevention was equal or more important than preventing AIDS. As knowledge of AIDS increased, less importance was attached to pregnancy prevention. Students who were not in a steady relationship, sexually inactive Black males, and sexually active Black females were more likely to be more concerned with preventing AIDS. Condom use declined with concern for pregnancy prevention. Males in steady relationships and more concerned with pregnancy prevention were most likely to use condoms.
The study population included 162 adolescent female clients at 4 California school-based health clinics in secondary schools, who used reproductive services at least once during the 1990-91 school year. The total population of family planning clients during this period at the 4 sites was 744. Students (201) were selected who had at least 3 months of family planning visits between the first and the most recent visit. The profile included 80% females, 63% Hispanic females, 25% Black females, 7% Filipino females, 2% non-Hispanic White females, 1% Asian or Pacific Islander females, and 2% of other ethnicity. Contraceptive use was measured as a ratio of the number of months of contraceptive use at every act of intercourse to the number of months of involvement in family planning services. A month without sexual activity counted as continuous use. The range of use was 0-29 months. Linear and stepwise regression analyses were performed. The results showed no significant relationship between client characteristics and contraceptive use. A significant relationship was found, however, between the number of family planning visits and contraceptive use. The greater the number of family planning contacts, the higher the contraceptive use ratio. Each contact increased use by 3%. Less consistent contraceptive use was associated follow-up visits within a month of the previous visit. The contraceptive use ratio was not significantly related to availability of contraceptives on site, the type of health educator, the receipt of additional counseling or medical services, or dispensing contraceptives at each visit. Factors explaining contraceptive use were low at 7%. The inverse relationship at one-month follow-up may indicate that high-risk students are being identified, but the program is unable to convince student to maintain contraceptive use. Alternative approaches may be necessary to both identify high risk for contraceptive discontinuation users and to deal with poor contraceptive use. A study limitation was the selection process and the small number of subjects; the clinic's primary clients came for mental health or primary care visits. Student enrollment at the 4 schools was 9390 and almost 50% reported sexual activity, of which 33% reported frequent or consistent use of contraceptives.
The study population included 201 mostly White middle-class married couples residing in the San Francisco Bay Area in the US, who spoke English fluently and whose wife was aged 18-39 years and not currently pregnant. Spouses were interviewed separately and privately. The survey included questions on abortion decisions under specific circumstances and on the positive and negative motivations of childbearing: joys of pregnancy, traditional parenthood, satisfactions of childrearing, feeling needed, instrumental values of having children, discomforts of pregnancy, fears and worries of parenthood, negative aspects of child care, and parental stress. Demographic measures were religion, years of schooling, prestige in occupation, and income. The profile of respondents indicated a mean age of 31.6 years for husbands and 29.6 years for wives. Average educational attainment was 16.7 years for husbands and 15.9 years for wives. Average income was $45,900 for husbands and $25,700 for wives. 25% were Roman Catholic, 44% Protestant, and 21% nonreligious. 81% were Whites, 7% Asians, 5% Hispanics, and 2% Blacks. There were 7 options indicated for abortion. Greater acceptance was found among those who had had a previous abortion. In the least squares multiple regressions analysis, the findings indicated that there were no significant differences by parity and sex. There was support for the hypothesis that motivation to bear children was related to an unaccepting or restrictive attitude toward abortion. Negative motivations had a stronger effect on abortion attitudes. The implication was that those accepting abortion have as positive an attitude toward childrearing as those with restrictive abortion attitudes. Less restrictive or more open attitudes toward abortion were associated with lower scores on achievement and higher scores on affiliation, which would indicate a stronger orientation toward people and situations. Stronger ideological orientation would be reflected in those less accepting of abortion. Abortion acceptors scored lower on the childbearing scale with short-term impact (discomforts of pregnancy or joys of childbirth) and scored higher on long-term impact subscales. The suggestion was that counseling should focus on long-term consequences of childbearing, making certain the abortion seeker has not blown these factors out of proportion and has carefully considered the long-term effects, particularly adolescents.
Challenging biases against disability.
Concern was raised about the social activity and policy of governments and nongovernmental organizations in the treatment of physically and mentally handicapped women and children. Reproductive health services should be provided to disabled women, who can easily be taken advantage of by men willing to exploit women who cannot protect themselves. Poverty in conjunction with disability creates an even more vulnerable position for these women in society. Disabled women are treated worse than disabled men. Stories and examples abound of blind women being raped. Discrimination exists in the type of buildings and walkways accessible to the disabled in wheelchairs. There is a glaring lack of interest among reproductive health activists and human rights activists in addressing the needs of the disabled. Development planning is directed to those who are able. The goal should be to provide long-term assistance in housing, employment, and services with respect for the humanity and personhood of the disabled.
Utilization of trained traditional birth attendent.
Focus group discussions and personal interviews were conducted among community members, family planning workers, and traditional birth attendants (TBAs) trained in 1978 at an extension project site in Sirajgonj and Abhoynagar, Bangladesh. The aim was to assess knowledge, performance, and quality of care. Summary results indicated that TBAs were primarily aged 30 years and older and had been attending births for more than 5 years. Work load averaged 2-3 deliveries per month, or 60-93% of all births. Data from mothers delivering showed that TBAs delivered only 6% of all births in 1991; this fact was confirmed in focus group discussions. Most deliveries were performed by untrained family members or friends. An assessment of TBA practices indicated that 74% asked questions about frequency of labor pains and continuity and intensity of pains. Vaginal discharge was checked and urine and stool patterns assessed. Determination of the stage of labor did not involve abdominal examination. About 50% of TBAs practiced recommended hygiene of washing hand and cleaning nails. Most used boiled blades and thread to cut the umbilical cord. 62% reported that patients with complications were referred to female paramedics at the Family Welfare Center and 38% referred patients to the Thana Health Complex (THC). TBAs do not demand payment, but are usually offered money, food, saris, or invitations to birthing ceremonies. Many TBAs expressed the idea that TBAs were viewed by the community as government workers and thus avoided. However, community members did not corroborate this. Recommendations were to provide information in home visits about the availability and desirability of using trained TBAs and to train TBAs periodically in risk assessment, hygiene, and abdominal examination procedures. Obstetric services at the THC should be upgraded and TBAs encouraged to refer complicated cases to these centers. TBAs should have a working relationship with the staff at THC. Monetary incentives for TBAs could a strategy for better outreach. Money-making activities could include the sale of birthing bits to expectant mothers. TBAs identified for training should be selected based on government-established criteria. Further research is needed to determine the best way of increasing coverage of safe births.
Public policy update. Welfare reform and teen parents: are we missing the point?
The aim of teenage pregnancy prevention initiatives should be to provide sexuality education that is age-appropriate, medically accurate, and available at each grade level with a positive view of sexuality and information and skills that contribute to sexual health and the ability to make decisions. Abstinence should be included as long as it is not fear-based and is part of the promotion of responsible sexuality. Contraceptive information must be available to those already sexually active. Subsidized day care for children of poor adolescent mothers must be at the top of the agenda of services integrated with job programs and school-to-work initiatives. Quality child care can provide a solid foundation in personal health, negotiation, self-esteem, and individual rights and responsibilities. Quick-fix and punitive measures are out of place in programs that rely on growth in individual responsibility. An innovative approach to social welfare programming would include comprehensive sexuality education, reproductive health services, child care, health insurance, and job training. The Clinton welfare reform drafts combine elements of teen pregnancy prevention with punitive action. What is needed is greater investment in programs enhancing sexuality education, acceptance and understanding of sexuality, and access to affordable reproductive health services. The Clinton plan focuses primarily on the National Mobilization for Youth Opportunity and Responsibility, which is a national media campaign to educate youth about responsibility and the benefits of staying in school and delaying childbearing. About 1000 middle and high schools in high-poverty areas would be targeted. Opportunities would be offered to go to college or have access to job training. Controls would be placed on adolescents by requiring minor parents to live with a responsible adult, minor mothers to stay in school, and to limit disbursements for additional children while on Aid to Families with Dependent Children. Child support would be required of fathers. These key measures do not address the root causes of teen pregnancy. Teen pregnancy would decline if teenagers understood information on alternative to intercourse and sources and methods of contraception. Teenagers must be able to talk with partners about sexual limits and how to say "no" or avoid risky situations. Access to condoms or contraception must be available in the community at low or no cost.
Teens talk about sex: adolescent sexuality in the 90's. A survey of high school students.
The findings of an April 1994 national telephone survey of 503 high school students (252 males and 251 females) conducted by Roper Starch Worldwide were summarized. Although only 12% felt pressure to have sex with their peers and 78% reported having sex because they wanted to, over 50% of sexually active respondents also reported wishing they had waited. 62% of girls and 48% of boys wished they had waited until they were older before having their first sexual intercourse. Over 33% of respondents reported sexual activity. 25% had had oral sex and 4% had experienced anal sex. Only 8% reported no sexual experience whatsoever. More than 75% reported sexual activities such as deep kissing and petting. 75% indicated use of birth control always or most of the time. 80% used condoms all or most of the time. 57% used condoms to prevent AIDS or sexually transmitted diseases. 59% always used condoms to prevent AIDS or sexually transmitted diseases. 59% always used birth control. Those sexually active and not always using birth control indicated that the reason was unavailability of contraceptives at the time. 66% supported condom distribution in the schools. Age at first intercourse among sexually active youth averaged just under 15 years. 40% had their first experience at 14 years of age or younger. 2.7% was the average number of sexual partners among all sexually active youth. 21% had had 4 or more partners. 9 out of 10 adolescents with sexual experience found that sex was pleasurable. 81% of boys and 59% of girls agreed that sex was a pleasurable experience. 75% agreed to feeling good about sex education classes. 58% had classes in junior high school; 56% reported high school classes. Only 5% had sex education every year in school. The focus of most programs was on AIDS, abstinence, and contraception. 68% of girls and only 48% of boys felt comfortable talking with their parents about sex. 71% of girls and 45% of boys agreed that their last sexual experience was related to "being in love."
Family life and health in Costa Rica.
Costa Rica over the past 30 years has invested heavily in education at the primary and secondary level. 93% of the population is literate, which is the highest rate for Central America. Girls and boys equally attend schools, but only 40% graduate from high schools. Primary and secondary education is free and supported by a government that allocates 29% of its budget to education compared to 3.5% for defense. A university education is available for only $650 a year. For those too poor to afford tuition or books and uniforms the government will cover their expenses. The school curriculum is lacking in quality sex education, and sex education is not compulsory. Teachers' personal beliefs determine the content of classes. Sex education guides were banned by the Church after their introduction several years ago. A new guide was prepared which did not mention contraception but included moral content. The UN Fund of Population Activities in 1987 began funding an adolescent sex education program that distributed pamphlets about love, sexual responsibility, prenatal nutrition, and sexually transmitted diseases. Outreach to schools is provided on request, but students tend to be more accepting of the material than teachers. A recent reproductive health survey found that 15-29 year olds desire no more than 3 children, while those over 30 years of age desire 3-4 children. Availability of contraceptives is not as great a problem as availability of information. A gradual introduction of sex education beginning in the high schools was recommended. Teenage pregnancies have remained stable at around 17% of total births, which in 1993 were 82,000. Fertility in 1993 was 3.2 and about 75% of women in a union used some form of cheap, easy-to-get contraception. About 40% of women were married by 20 years of age. The growth rate was 2.3% and population was 3.3 million. Costa Rica is a small, beautiful, and biologically rich country, but suffers from very high rates of deforestation and urban air pollution. Leaded gasoline is still sold, and there is 1 car for every 12 Costa Ricans. Squalid housing in the Cristo Rey area of San Jose accommodates the poor. Per capita income of less than $2000 is high compared to Haitian standards. Family planning programs will be successful when couples understand they can control fertility, have contraception, and desire the advantages of a few children. Religious, cultural, and political attitudes prevent widescale acceptance.
This short presentation is a pictorial representation of women of the world and the Cousteau Society's recommendations for action that will assure women worldwide safer, fairer, and more equitable living circumstances. Women from Madagascar, Sumatra, Vietnam, Rumania, Banaba, and Peru are represented. The faces express hope, work activities, and indigenous cultures. Countries were urged to eliminate all forms of exploitation, abuse, harassment, and violence against women, adolescents, and children. Countries should strive to assure girls and women access to secondary and higher levels of education in addition to the goal of universal primary education by the year 2015. Unnecessary legal, medical, clinical, and regulatory barriers to information and access to family planning services and methods should be removed so that couples and individuals will have an easier time taking responsibility for reproductive and sexual health. Violence and discrimination against elderly people, particularly women, should be eliminated by governments. The daily burden of domestic responsibilities on women should be lessened by greater investments. Maternal morbidity and mortality should be reduced to tolerable levels, and disparities within and between countries and ethnic groups should be narrowed. Girl children must be valued beyond their reproductive and caretaking roles, and policy should be directed to encourage full social participation.
Philippines. The cardinal fights again.
Cardinal Jaime Sin, Archbishop of the Roman Catholic Church in the Philippines, used to enjoy the support of the political leadership of Corazon Aquino and was active in promoting the ouster of dictator Ferdinand Marcos. Fidel Ramos was elected President in 1992 and as a Protestant is campaigning for a national family planning service. Population growth is 2.5% and there are imbalances between population and economic goals. The environment has also been deleteriously affected by population growth. The health minister Juan Flavier has been actively working in rural areas to promote contraception. The Church expressed uneasiness concerning the Philippines' participation in the UN Conference on Population and Development scheduled for September 1994 in Cairo. The pope has been scheduled to visit Manila in January 1995. On August 14, 1994, Cardinal Sin was at the head of a rally to halt the government's birth control plans. The rally received the support of some legislators and the former president Aquino. The family planning program was labeled as "intrinsically evil." Teachers from private Catholic schools sent their pupils to the rally. The rally was meant as a visible demonstration to the Vatican that the Catholic Church still has some leverage in the Philippines. A meeting was planned between government officials and Catholics in order to discuss the principles the could be adopted at the Cairo conference.
Philippines. Church vs. state: Fidel Ramos and family planning face "Catholic Power".
Catholic groups and individuals united in a public rally in Manila's Rizal Park to decry a "cultural dictatorship," which promotes abortion, homosexuality, lesbianism, sexual perversion, condoms, and artificial contraception. Government spokesmen responded that condoms and contraception were part of government policy to spread family planning knowledge and informed choices among the population. Cardinal Jaime Sin and former president Corazon Aquino joined forces to lead the movement against the national family planning program in the largest demonstration since the ouster of Ferdinand Marcos in 1986. Also criticized was the 85-page draft action plan for the International Conference on Population and Development (ICPD) scheduled for September 1994. Cardinal Sin accused President Clinton of using the action plan to promote worldwide abortion. Under the administration of President Fidel Ramos, family planning funding has quintupled and the number of family planning workers has increased from 200 to 8000. President Ramos has gone the farthest of any administration in opposing the Church's positions on contraception and abortion, although years ago Fidel Ramos and Cardinal Sin were allies in the effort to push out Ferdinand Marcos. The population of the Philippines is 85% Catholic, and laws reflect the Church's doctrine against divorce and abortion. The current growth rate is 2.3%, and the goal is to reduce growth to 2.0% by 1998, the end of Ramos's term in office. The population target is in accord with demographic goals proposed in the UN draft action plan. The Vatican has opposed the language in the plan and may have encouraged other religious leaders to join those opposed to the "war against our babies and children." Sin said that contraceptive distribution was "intrinsically evil" and should be stopped now. Ramos's administration stated that their policies and programs are not "in the hands of the devil" and there is support for the Church on family values and abortion. Health minister Flavier has indicated that illegal abortion has become very common, and control of abortion is through family planning. The Protestant president will oppose abortion at ICDP.
Most British women use reliable contraceptive methods, but many fear health risks from use.
A National Public Opinion Poll was conducted in February 1992 in Great Britain and included 967 women aged 15-45 years out of 1753 drawn in the sample of electoral registrants in selected electoral areas. The sample underrepresented women aged under 20 years and those with less education. Use of contraceptives was limited to those women who were fertile, not pregnant or trying to be, and sexually active. 649 women remained at risk of pregnancy. 36% reported using oral contraceptives; 3% were using the pill with a barrier method. 21% used only barrier methods, of which 87% was condom use. 2% used a diaphragm and 10% used a mix of barrier methods. 10% used IUDs; 10% were sterilized. 16% of women's husbands had been sterilized. 2% used periodic abstinence; 1% used withdrawal. 4% were not using any method. 99% of women aged 20-24 years and 35-39 years used any type of method, followed by 97% aged 25-35 years. 91% of women aged 15-19 years and 40-45 years used any type of method. 87% without a regular partner used any type of method compared to 97% with a regular partner. 57% of women aged 20-24 years used oral contraceptives. 52% of divorced and 49% of single women used the pill compared to 26% of married women. 41% with a moderate education and 38% with a high level of education used the pill compared to 28% with less schooling. 27% of women aged 15-19 years used a barrier method. 32% without a regular partner used a barrier method. 11% of women aged 25-29 years used IUDs. The highest level of male sterilization was 23% among couples with a low level of education of the female spouse. 4% of highly educated women used periodic abstinence. Method use was dependent on reliability, lack of disturbance with sex life, and ease of use. Barrier methods were used because of problems with prior methods. 26% of women using barrier methods alone or in combination used the method as AIDS prevention. The perception of the pill's side effects was as follows: 73% attributed weight gain, 45% headache, 45% cardiovascular disease, 44% depression, and 41% cancer to pill use. 86% thought the pill contributed to regular periods and 84% thought the pill contributed to less painful periods or less heavy periods. 19% considered the pill a preventive measure for cancer. Condoms were thought to tear easily by 56%. 74% thought IUDs or sterilization contributed to abdominal cramps and had no benefits. 57% were embarrassed to buy condoms in a store. The 55% response rate was attributed to the sensitivity of the subject matter and length of the questionnaire.
Recommendations were made by the president of Negative Population Growth, Inc. to the Cairo Conference on Population and Development in an open letter. The tone was one of disbelief that the conference can successfully achieve its objectives of the low UN variant of 7.813 billion world population by 2050. Fertility would have to decline 61% in Africa, 34% in Latin America, 25% in China, 57% in India, and 44% in the entire world by 2025-30 in order to reach the low variant. The Cairo draft document calls for fertility reduction, gender equity, empowerment of women, and improved status of women as the means to reach dramatic goals in 30-35 years. The request was for the deletion of the goal included in the 20-year action plan for achieving the low variant. The draft document did not set a specific numerical goal, which it should have; the goal should be less than 8 billion. Ways other than those mentioned in the action plan should be used to achieve less than 8 billion population. The plan did not adequately respond to the crisis of population that now is 6 billion and growing at the rate of 90 million annually. Rights are well represented in the document, but there is little attention paid to responsibilities of individuals, nations, and international organizations to humanely stop growth. One right not mentioned is the right of all nations to make immigration policies consistent with population stability or reduction. The draft statement on family size desired and the right of free and responsible choice should be replaced with "because world population growth cannot otherwise be halted, no couple or individual should have the right to have more than two children." Even the Pontifical Academy of Sciences, which advised the Vatican from a lay perspective, stated that a birth rate of more than 2 children per family was unsustainable in guaranteeing the future of humanity, due to increases in life span and medical care advances. Family planning including contraceptive and abortion services and information must be supplemented with noncoercive incentives and disincentives to encourage couples to limit family size to 2 children. In order to realistically achieve the low variant, an average fertility of 1.7 by 2025-30 would be necessary, rather than the 3.2 at present. Subreplacement level fertility cannot be achieved without reducing desired family size in all nations including the US.
A fellow at the American Enterprise Institute remarked that population growth slowed from 1.73% to 1.57% during 1990 to 1994. In Eastern Europe alone population declined by 1 million in the past 4 years. Fertility decline is evident even in Africa and a rapid fertility transition has appeared in Iran. The data are based on figures recently generated by the UN and published in "World Population Prospects: 1994 revision." The projected medium fertility variant was 9.8 billion by 2050 and 10 billion in 2054. UN statisticians have reported that the real numbers are likely to be even higher despite their own reports of fertility decline. The UN believes that sustaining 2.1 children per woman at replacement level will not be allowed by countries. The more developed countries are now at or below replacement: Japan at 1.5, Korea at 1.7, Germany at 1.3, and Italians at 1.3. Large population numbers threaten stability and are related to famine, pollution, war, and animal and plant species decimation. The evidence from Rwanda and Bosnia is clear. A more desirable and realistic estimate should be 7-8 billion by 2050. World population in preparation for the International Conference on Population and Development is being publicized as a problem so that the UN and environmentalists can increase their funding and attain a high spot on the global agenda. The author's experience as part of the US delegation to the International Population Conference in Mexico City in 1984 led to the conclusion that these international policy conferences are really public relations events. Gloom and doom predictions are constantly being modified; for instance, what was the "coming ice age" is now "global warming." The world has survived thus far, while the numbers have been increasing. If the world does not prosper in the years ahead, it is unlikely to be due to too many people.
Reining in the world's galloping population.
World population is 5.66 billion and is expected, based on the UN medium variant, to reach 10 billion by 2050. About 50% of world population is aged under 25 years, and anticipated reproductive activity of this population would mean that, even with a family limitation of 2 children, population stabilization may occur in 50 or more years. Urgency in responding to population growth is necessary because doubling time is rapid; Africa will double its population in 35 years from 720 million to 1.6 billion, and Asia will grow in 35 years from 3.4 billion to 5.1 billion. The rate of growth is 94 million annually or 250,000 daily. 90% of growth is in developing countries. Rapid growth puts tremendous pressure on government to provide food, housing, jobs, and social services. Hope lies in the 180 million reproductive-age women who desire to space their pregnancies or to stop childbearing. Estimates are as high as 350 million who have no access to family planning. If contraceptive use rates increase from the present 55% to at least 60% worldwide, family size would be lowered to just under 3 per family. The Cairo Conference on Population and Development scheduled for September 1994 will focus on women's needs. Women's groups have helped shape the conference issues and strengthened their arguments for a family planning approach that emphasizes reproductive health throughout the life cycle and a wider range of contraceptive choices and counseling. Gender bias that is reinforced by custom, law, and government must be lifted. Resources, jobs, and educational opportunity must be provided for women. Thailand and South Korea are good examples of how empowering women with high-quality family planning programs and equitable social policies that provide women access to education, jobs, and credit can lead to lower fertility. Economic development and environmental protection are other beneficial effects of empowerment of women. Many empirical studies have found an inverse relationship between fertility and female education. Nafis Sadik, director of the UN Population Fund and conference chairperson, stated that population issues will be solved when couples decide for themselves that smaller families are in their own best interests. The responsibility of the international community is to provide the conditions that are conducive for couples to make that choice. For example, advertising campaigns have been successful in convincing men that it is more "macho" to have children with shoes and schoolbooks than children with none.
India's draft policy criticized.
Several women's groups in India have criticized the population policy which was finalized in draft form in May 1994. Criticism was directed at the wide variety of contraceptives to be offered through family planning services. The concern was that methods such as Depo-Provera, which some women's groups considered to be unsafe, would be made available. Women would be compelled to use unsafe contraceptives. Concern was also directed to the policy for "coercive disincentives" to slow population growth. The draft policy called for a reduced role of national government in implementation of policy. Family planning targets would be set by village councils who would understand local conditions better than national bureaucracies. An independent national population and social development council would oversee policy implementation. There was a proposal to disqualify legislators that have more than two children. The Central Ministry of Health and Welfare will be considering the draft proposal over a long period. There are 4 states with over 40% of India's population that have high levels of female illiteracy and child mortality and fertility. The current population is 913.7 million with a growth rate of 1.9%. Population is expected to reach 1.19 billion in 2010, which would make India the most populous country in the world.
About 70% of all abortions performed in Delhi, India, are terminations due to the fetus being female. Private clinics make a profit out of offering sex determination tests. The new bill (the Prenatal Diagnostic Techniques Bill) introduced in Lok Sabha by Deputy Health Minister Pawan Singh Ghatowatr would stop "sex determination shops" from helping parents and medical practitioners terminate female pregnancies. Prenatal diagnostic tests would be administered only to detect genetic and congenital abnormalities. Physicians would not be allowed to reveal the sex of the fetus unless it was linked to a sex disorder. Women's rights groups have campaigned for such a bill that forbids prenatal sex determination. Abortions based on the sex of the fetus are currently banned under Article 14 and 15 of the Indian Constitution as a violation of women's rights. The new bill would punish doctors who offer to identify the sex of the fetus by taking their names off the official medical register and imprisoning them for 3 years and fining them 10,000 rupees or 200 pounds. Pregnant women who undergo tests would also be punished with the same fine and prison term. Dr. Geeta Dwivedi, a medical physician with the Lucknow branch of the India Family Planning Association, reported that few tests are conducted for the sake of the health and well-being of the fetus. Female feticide is practiced because girls are viewed as an economic burden due to dowry practices and male children are valued for old age support and carrying on the family trade. The sex ratio in India is 927 women to 1000 men. The problem with the new legislation is enforcement, which would require oversight of as many as 2000 clinics in Delhi alone. It is anticipated that clinics would be uncooperative in complying with such a law because their self-interest is at stake.
IWAP will address gender issues.
The International Planned Parenthood Federation's (IPPF) International Women's Advisory Panel (IWAP) held meetings and offered some recommendations on a variety of topics, including the forthcoming International Conference on Population and Development (ICPD). A full report on their meetings will not be available until December 1994. The Federation Secretary urged members to be catalysts for social change. The meeting chairperson indicated that the cooperation arrangements with other IPPF international programs and medical advisory panels would facilitate IWAP's tasks. Papers were presented on quality of care and women's perspectives on reproductive health and rights. Discussion focused on the issues of women, holistic approaches to women's health, and the ICPD conference and the forthcoming World Summit on Social Development set for March 1995 and the Fourth World Conference on Women set for Beijing in September 1995. IWAP gave their support for the IPPF positions toward ICPD. IWAP urged IPPF to strongly and uncompromisingly support safe, legal abortion. The links between the forthcoming conferences were discussed. Family planning associations (FPAs) were viewed as key links in influencing country positions and declarations. Support was given for the International Advisory Medical Panel position on distribution of quinacrine pellets for female sterilization. The concern was for improper administration in IPPF or FPA unsupervised settings and with a lack of information. FPAs should encourage women to select another method. A separate statement was issued on the nature of women's health, as encompassing physical, mental, and social well-being of an individual throughout her lifetime. Women in family planning setting are frequently viewed only in terms of their reproductive functions, rather than in their physical and mental, occupational, environmental, and sexual roles. The statement provided FPAs with suggestions on how to implement holistic health services including increasing women's involvement in program design and delivery and training service providers to be more gender-aware. Regional task forces will be discussing gender equality and promotion that was only discussed preliminarily at the 3.5 day meetings. Strategies for mutual support and reinforcement of IWAP and the IPPF regional bureaus remain to be developed and will be the focus of next year's meetings in September 1995. At that time regional task forces and staff members will be invited to participate.
Minister Yadav inaugurates 17th FPAN Central Council Meeting.
The 17th Central Council Meeting of Family Planning Associations in Nepal was conducted over a three-day period for 120 participants. Participants came from the central office, the 21 branches, and 3 pilot projects. The Minister of Health, Dr. Ram Baran Yadav, provided an opening address. In Nepal, there is evidence that 94% of the population has some level of awareness of family planning services, but only 21% actually use family planning services. Dr. Yadav suggested that family planning programs be directed to village areas. Family health as a concept is not well understood among the rural population of Nepal. Meetings and workshops should be organized in rural areas rather than in the capital in order to increase program effectiveness. Dr. Yadav further suggested that it was up to the leadership in the Nepal Family Planning Association to coordinate and cooperate with nongovernmental organizations. The impact of population growth affects the balance between the environment and natural resources. National government has appropriated 20% of its total budget for health and education. National government has policy and program directives for establishing health posts in rural areas. The 20,000 skilled health personnel in Nepal do not adequately serve the health needs of the entire country. There is a need for better, more effective, quality health and family planning services. The target population should be rural women. Other government officials supported the view of grassroots provision of services. It was pointed out that collaborative efforts with NGOs had resulted in innovative programs.
The Scottish community based family planning and well woman clinic services -- a review.
The aim was to provide baseline information on each family planning and well woman clinic in the 14 health boards in Scotland between October 1992 and March 1993. Information was provided on the frequency, timing, staffing, and attendance at each clinic and on the service organizational structure and obstacles to delivery of health care. There was a lack of specificity in defining clinic, so that data was aggregated in terms of the number of doctor sessions per month within each health board. The findings indicated that of the 1472 routine sessions there were 408 sessions devoted to family planning, 127 devoted to well woman sessions, and 937 addressing a combination of family planning and health sessions. There were also an additional 140 sessions in specialist clinics, such as menopause or psychosexual clinics, which were available only in 7 health boards. However, even routine clinics could serve specialized needs. Most sessions were offered weekly, primarily on Mondays through Thursdays. Emergency family planning was provided in Glasgow and Edinburgh clinics on Saturdays and on holiday Mondays. The client flow was insufficient in other clinics to warrant weekend clinics. 63% of sessions operate during daylight hours. 38% provide evening services. 81% provide drop-in services, but 90% of appointments are scheduled. Only 2% would not see clients without an appointment. Specialist clinics had the most rigid scheduling system. Data by health board indicated a wide variation in type of services. The most frequent sessions tended to be combined. The number of sessions per month by health board varied with distribution of the reproductive age population, demand for services, and funding. Specialized services might in some clinics be provided as a target population rather than a service, as in the case of health needs of Asian women or those who are HIV positive. Attendance in a typical week was not considered an appropriate measure as service demand varied. The conclusion was that more populated areas had more clinics and a wider range of services, but community-based services were used to a varying extent. Clinic coordinators reported that other factors need to be considered, such as quality of service, venue of clinic, and managerial support at the board level. The lack of publicity of some rural clinics meant young women felt comfortable attending in an "anonymous" setting.
Creating new traditions in modern Chinese societies: aiming for birth in the Year of the Dragon.
This thesis posited that new traditions are being created among Chinese couples for timing of births according to the lunar zodiac calendar. The phenomena began in 1976, which was the year of the Dragon. Institutional case studies were presented for Taiwan, Singapore, Malaysia, Hong Kong, and China to show how institutional and motivational factors explained timing of births, but did not prove it inevitable. Examination was made of birth patterns prior to 1976 with high uncontrolled fertility and after 1976 when contraception, marriage, abortion, and coital frequency affected fertility. The conclusion was that zodiacal timing of births can be best understood in the context of historical, political, and institutional circumstances. Conclusions were drawn from results of survey data, other written records and news accounts, field work, and cultural and secondary source materials. Sun, Lin, and Freedman have noted that modern contraception has triggered a return to ancient cultural preference that was not possible in natural fertility settings, in a recursive fashion. Carlsson and McNicoll stress that adaptation or institutional change can reflect the continuation of traditional symbolism. Modernization theories do not adequately answer how abandoning the traditional regime of natural fertility would erase nonrational motivations to institute zodiac birth timing. The KAP survey of 4163 married women in Taiwan was used to analyze relationships between the rabbit-dragon-snake triplet and traditional characteristics (traditional life, parent arranged marriage, low education, traditional religion, belief in geomancy). There was no significant relationship; the only related factor was whether the mother was a Buddhist. Inclusion in the logistic model of maternal age, contraceptive use, and knowledge of reproduction proved to be highly significant; modernization was related to Dragon births. Predictive value of either modern or traditional characteristics was difficult. Field research was conducted in 1990-91 to find out what the folklore was and the extent of adherence. The 1987 abortion survey revealed that the Dragon year was indeed a favorable year for a birth for 10%. Ancient wisdom grows out of a belief that the proper timing of events is important. Schooling, popular media, family influences, and individual feelings about their sign affected how individuals found out about the symbols and assigned values. The geographic spread of the first baby boom in 1976 was argued as due to favorable demographic, economic, and social forces. That it did not appear in mainland China in 1976, but in 1988, was attributed to the cultural revolution (1966-76).
Data from the Chinese In-Depth Fertility Survey of 6654 ever married women aged 49 years and younger, from the Old Age Security Survey of 220 married couples, and records of the county family planning commission for Guangdong province were analyzed with descriptive statistics, analysis of variance procedures, multiple regression, and path methods. Analysis was for Guangdong province only. Findings indicated that fertility which violated current family size norms and family planning regulation in China was related to ideal family size, son preference, socioeconomic development, type of employment, area of residence, failed pregnancy, and fertility discussions between spouses. Age at marriage, which was positively related to socioeconomic (SES) characteristics, was negatively related to deviant fertility; positive influences were living with parents after marriage, failed pregnancy, and previous female births. Traditional pressure measures were related low SES, rural residence, nonstate owned employment, low educational attainment of parents, and living with parents after marriage. Urban and rural patterns were different. Educational attainment of parents did not influence fertility behavior in urban residents, which meant that area of residence affected not only the dependent variable but had an interactive impact on other variables influencing deviant fertility. Predictions of deviant fertility did not correspond to predicting number of children. Path analysis revealed that rural residence influenced deviant fertility through SES and ideal large family size. Negative influences on deviant fertility were also affected by SES and ideal large family size. There were 9 hypotheses tested. There was no support from the data that Chinese couples who have only female children are more likely than those with previous male children to have deviant fertility. No support was also given to the thesis that personal contact by family planning personnel with couples leads to greater likelihood of following new reproductive regulations than those not strongly approached by family planning workers.
"Forgotten" intrauterine device leading to actinomycotic pyometra -- 13 years after menopause.
A 59-year-old Indian woman presented with a case of a "forgotten" intrauterine device (IUD), which resulted in an Actinomyces israelii infection and pyometra. The patient described a two-month history of foul-smelling, bloody vaginal discharge accompanied by an intermittent, low-grade fever. She had been post-menopausal for 13 years. She had had a lippes loop IUD inserted 22 years earlier and had forgotten it, but had not presented any problems. Nothing abnormal was found during a general physical exam. However, during speculum examination a foul-smelling pus discharge through the cervical os was discovered. Some erosion to the anterior lip of the cervix was noted, and the blackened strings of the IUD were seen at the cervical os opening. Vaginal examination showed an enlarged uterus that was soft, with fornices being thickened and tender to palpation. The uterus was found to be retroverted. Further analysis yielded an Hb of 12.1 g% and a TLC of 13,000. The patient's urine was examined by microscopy and culturing. Both were normal. Also normal were her blood sugar, KFT, LFT, and chest X-ray. However, an ultrasound image showed an IUD in the uterus. A pyometra was also found. The pyometra was drained and the IUD removed. An infection of Actinomyces israelii was found following cytological examination of the pus discharge. An antibiotic course of 100 mg b.d. doxycycline was given for 14 days. During two follow-up examinations (2 and 6 months post-IUD removal), laboratory specimens from an endometrial aspirate and endocervical curettage were taken, but the only condition noted was an atrophic endometrium.
Reported is a female case study of a 40-year-old patient who 4 weeks previous had received a Norplant subcutaneous contraceptive implant. The patient presented at 4 weeks postimplant with blurred vision in her left eye. She further reported never having used hormonal contraceptives. Her vision continued to deteriorate over the next several months to 20/60 visual acuity. After examination by neuro-ophthalmologists at the University of Iowa Hospital and Clinics system, the following abnormalities in the left eye were reported: impaired color vision; a severely reduced critical flicker fusion rating (13 Hz); an abnormality in the temporal field (using Humphrey 30-2 program); and a 3 times greater light sensitivity. The fundus and the optic nerve heads appeared normal. Magnetic resonance imaging revealed a homogeneous mass along the medial sphenoid wing which continued into the left cavernous sinus and sella. Part of this mass crowded the left optic nerve opening (chiasm). During the subsequent 6 weeks, the patient's visual acuity continued to deteriorate to 20/100 despite removal of the Norplant implant. The tumor mass was surgically removed and pathologically examined. It was a meningothelial neoplasm and tested positive for progesterone receptors (125 fmol/mg of protein). It tested negative for estrogen receptors. Authors provide a discussion on the history of hormonal influence/agonist effects on meningiomas. The authors conclude that there is evidence which supports the theory that meningiomas may be subject to hormonal influence and may be stimulated by hormones to grow. They further conclude that their observations do not prove a cause-and-effect relationship and that further research is needed.
Risk factors associated with pelvic inflammatory disease of differing microbial etiologies.
The objective of this epidemiologic study was to compare various risk factors involving behavior patterns, lifestyle histories, and demographic characteristics to the prevalence of pelvic inflammatory disease (PID) both with and without sexual transmitted disease (STD) involvement. Risk factors used in this study for behavior patterns and lifestyle histories include: history of pregnancy, sexual activity, menstruation, douching, contraception, and any prior record of STD or PID. Demographic risk factors were: race, age, education level, and insurance status. Patients diagnosed with acute PID, and who had positive endocervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis, were considered eligible for this study. The authors analyzed data using both the univariate and multivariate (multiple logistic regression) statistical methods for data analysis. It was found that microbial organisms which cause STD were found in 65% of the 580 PID patients studied. In addition, N. gonorrhoeae was cultured from 55% of the patients, while 22% were found to be infected with C. trachomatis. Using univariate analysis to compare STD-associated PID versus non-STD-associated PID, it was found that statistical significance increased in STD-associated cases for black women (relative risk [RR] 1.76; 95% confidence interval [CI] 1.39-2.24); women who have had 2 or more sex partners in the past 2 months (RR 1.25%; 95% CI 1.08-1.45); women who do not practice any form of contraception (RR 1.36%; 95% CI 1.18-2.57); women who have a history of N. gonorrhoeae; women with previous PID episodes (RR 1.97%; 95% CI 1.39-2.80); and women who have had pelvic pain within the prior 3 days (RR 1.17%; 95% CI 1.02-1.35). Increasing risk factors for non-STD-associated PID include: current use of an intrauterine device (IUD) (RR 0.25; 95% CI 0.11-0.61), a history of IUD use (RR 0.82; 95% CI 0.68-0.98), and pelvic surgery within the past 30 days (RR 0.48; 95% CI 0.30-0.76). The authors conclude that black race was associated with STD-associated PID (odds ratio of 2.56; 95% CI 1.68-3.90) , while recent IUD use was correlated with non-STD occurrence of PID (odds ratio 3.87; 95% CI 1.30-11.53). Douching was not identified as a risk differentiating factor in this analysis.
The Centers for Disease Control and Prevention on emerging infectious disease threats.
This article provides excerpts from the US Centers for Disease Control and Prevention (CDC) report. This report suggests a strategy for the prevention of emerging infectious diseases in the US. This article is formatted into several sections including a problem section, a section on the burden of infectious diseases, followed by important emerging infectious diseases, and a section that reviews the status of drug resistance in microbial disease agents. The problem discussion section identifies the health policy of the US as being treatment-driven, reactive, and basically unresponsive. This has resulted in an inflexible public health system which is unable to react to emerging disease problems. In the section addressing the burden caused by infectious disease, the authors discuss the recent appearances of several infectious diseases and the social and economic impact on the US health care system. Several diseases are identified, including Chlamydia and its implications in causing infertility and human papillomavirus and its association with cervical cancer. New emerging disease threats and aspects which contributed to their emergence are reviewed. These aspects include new standards of health care, improved technology, changes in dietary habits, increasing size of the elderly group, increasing travel risks, and other societal changes. The authors conclude that the US is no longer isolated but part of the international community based on increasing global travel, commerce, shifting populations, and ecological changes. Antimicrobial drug resistance has also emerged causing widespread crisis. This has caused a higher death rate, an increase in hospitalization, and ultimately results in an increase in health care costs.
The objective of this study was to determine what potential involvement cytokines such as interleukin 6 [IL-6] and tumor necrosis factor-alpha (TNFa) have in the rapid course of perinatally acquired human immunodeficiency virus type 1 (HIV-1) in neonates. The study measured plasma levels of TNFa from adults, umbilical cord blood, and neonates from Zaire and North America, and then observed the expression of HIV-1 in chronically infected U1 cell lines. Plasma samples from 340 African and 301 North American subjects were collected and studied. Plasma from cord blood and neonates born to HIV-positive or HIV-negative mothers were collected for specific comparison. Blood plasma from adults, both HIV-positive and HIV-negative, were also taken for direct comparison. It was found that in vitro biologic effects could not be determined for neonates born to HIV-positive mothers or for HIV-positive adults because of the HIV antibody interference with the analysis. Plasma samples were assayed for TNFa using ELISA techniques and the data reported in pg/ml of TNFa. Virus expression was measured using a standard protocol for reverse transcriptase (RT) activity or p24 antigen and reported as counts per minute (cpm). All statistical analyses and subsequent comparisons were done using nonparametric tests (Epi Info statistical package). This study found that plasma TNFa levels were higher in Zairian neonates born to either HIV-negative or HIV-positive mothers than in uninfected Zairian adults (612 vs. 128 vs. 8 pg/ml, P < 0.001). Plasmas from neonates born to HIV-positive Zairian mothers also exhibited higher levels of RT in the chronically HIV-infected U1 cell line than was found in HIV-negative Zairian adults (1339 vs. 110 cpm, P < 0.001). These findings were repeated in similar North American cohorts, except that TNFa levels were markedly lower and a smaller difference was found among North American adults and neonates than was seen in a similar Zairian cohort. Based on these findings the authors concluded that markedly elevated TNFa plasma levels, as noted in this Zairian cohort, may play a significant role in HIV pathogenesis and disease progression.
No-scalpel vasectomy offers minimal invasiveness.
This paper describes the development of a minimally invasive, no-scalpel technique for vasectomy. Generally the use of vasectomy as a contraceptive technique has gradually risen over the past 2 decades. No-scalpel vasectomy is increasing as the technique of choice. Developed in China, the no-scalpel technique has been used widely there since 1974 on over 9 million patients. This procedure was exported to the US in 1985 with slight modification to account for racial differences. The procedure is described with the following highlights. The patient's scrotal skin is first shaven and the penis secured to the abdomen. The scrotal skin is then cleaned with a warm antiseptic solution. Avoided are cold solutions and air conditioning, which cause the scrotum to retract. The vas deferens is then isolated and anesthetized with Xylocaine, followed by "bringing" or delivering the vas through the scrotum using an isolation ring clamp and a percutaneous puncture. Once exposed, the vas is occluded using one of several methods. Topical antibiotic ointment and a sterile dressing is applied over the wound (puncture) site. It was found that no-scalpel vasectomy has a very low incidence of infection and associated hematoma. No-scalpel vasectomy also requires less operating time, which means less expense for the patient and reduced drain on medical assets. It was found to be less painful both during and after the procedure than has been reported for conventional vasectomy procedures.
High-compliance tuberculosis treatment programme in a rural community.
This article describes a tuberculosis (TB) treatment program which achieved a high rate of compliance and completion by close supervision in a supervised intermittent ambulatory treatment (SIAT) program in Zululand, South Africa. After patients had reported to a hospital for sickness and were subsequently diagnosed positive for TB, they were aligned with a SIAT center and a TB treatment site was selected. In most cases these assignments were chosen by the patient as a matter of personal convenience. In 1993, 36% of the adults diagnosed with TB were also infected with human immunodeficiency virus type 1 (HIV-1). Supervisors were selected to oversee each treatment site and were given responsibility for ensuring that patients took their medication. Supervisors also kept treatment records which were inspected by trained medical personnel. In cases where patients missed treatment appointments, the trained medical personnel would investigate. The SIAT program included a 6-month chemotherapy treatment procedure conducted at supervised sites which included hospital-run clinics and non-hospital operated health care sites. The author reports that a full and complete course of chemotherapy is a critical aspect in the management of TB. He reports that the SIAT program ensures a high compliance rate and that a high completion-of-treatment rate (60% vs. 18% pre-SIAT) is possible when using a community-based SIAT program against TB.
Review of ovulation return upon discontinuation of once-a-month injectable contraceptives.
This paper reviews the progress made in the determination of ovulation and specifically addresses the effects of returning ovulation after discontinuance of once-a-month injectable contraceptive preparations. Correlation between ovulation and the hormones estrogen, progesterone, and luteinizing hormone (LH) is well documented. It has served as the basis for many studies on determining ovulation mid-point and in evaluating the efficacy, safety, and time of returned ovulation when using various contraceptive methods and preparations. Current monthly injectable contraceptive formulations are discussed and used as comparison for the new generation injectables. New generation contraceptives in this study are preparations (combinations) of several compounds. The depot microcrystalline form of medroxyprogesterone acetate (DMPA) in combination with estradiol cypionate (E2-Cy) was studied. The authors conclude that these initial studies on the new generation combination monthly injectables indicate that these new contraceptives are highly effective in inhibiting ovulation, as well as allowing for predictable return of ovulation.
Metabolic effects of once-a-month combined injectable contraceptives.
This article describes the metabolic effects in women from the use of once-a-month combined injectable contraceptives. Areas of metabolism which may be affected by these contraceptives include lipids, carbohydrates, hemostasis, proteins, and vitamins. Regarding carbohydrate metabolism and the effect of monthly combined injectable contraceptives, no significant changes were evident. This study also reports that no significant change in lipid levels was found from the use of once-a-month injectable contraceptives. Effects on hemostasis showed a significant decrease in factor X (down 14%) and antithrombin III functional activity (down 20%). The effects on blood coagulation are unclear, as factor X and antithrombin III activity are antagonistic to each other. Most changes noted here stayed within the normal range and are thought to be of no clinical significance. Prolactin levels increased after each injection, but not persistently, as they gradually decreased over time. Normal prolactin levels were never exceeded. Further studies are suggested by the authors to study metabolic effects from injectable contraceptive use.
Acute pelvic inflammatory disease after tubal sterilization: a report of three cases.
The purpose of this paper is to describe three female patients all of whom had received a bilateral tubal ligation (BTL) and subsequently developed a case of acute pelvic inflammatory disease (PID). The first patient was a 24-year old black woman who had had a Pomeroy BTL 2 years earlier. She had a history of chlamydia and herpes infections. Laboratory findings included an oral temperature of 38.9 degrees Celsius, a white blood cell (WBC) count of 29,000/ml, and her abdomen was sensitive to touch. Neisseria gonorrhoeae and Chlamydia were cultured on Thayer-Martain medium and McCoy cells. The patient received twice daily 2g intravenous cefotetan and 100mg of doxycycline taken orally. The second patient was a 40-year old black woman who had received a Pomeroy BTL 11 years earlier. She had a history of gonorrhea. Examination and laboratory results found the WBC count of 13,000/ml and a ruptured left tuboovarian abscess (TOA). Peritoneal cultures recovered Bacteroides bivius and Mobiluncus species. A complete abdominal hysterectomy and bilateral salpingo-oophorectomy were done. Intravenous therapy included: ampicillin, 2g every 6 hours; gentamicin, 2mg per kg body weight loading dose, followed by 1.5 mg per kg body weight given 3 times daily; and clindamycin, 900 mg given 3 times daily. She received oral doxycycline for 10 days after hospital discharge. The third patient described was a 31-year-old white female that had had a status post BTL 3 years earlier. Her WBC count was reported at 21,900/ml, and she had an oral temperature of 35.5 degrees Celsius. Exploratory laparotomy showed an inflamed uterus and a purulent ooze in the cul-de-sac area. The patient was placed on intravenous ampicillin, gentamicin, and clindamycin in the same dosage rates as patient 2. Microbial culturing attempts were unsuccessful. PID following a BTL procedure is considered uncommon; however, a BTL procedure does not rule out PID when a patient presents herself. Hysterosalpingography (HSG) should be more completely evaluated for use after any PID treatment.
Ureteral injury during elective pregnancy termination: a case report.
This article reports on the 6th known case in which ureteral injury occurred in association with an elective pregnancy termination procedure. It is the 4th reported case in which the patient developed a ureterouterine fistula following a uterine dilation and curettage procedure for pregnancy termination. Here a 24-year-old woman presented to physicians with the following symptoms: tender uterus, enlarged to a 10-12 weeks' gestational size, moderate amounts of serous discharge from the vagina, cervical os open to fingertip size, right adnexal mass (8-9 cm), a white blood cell count of 11,600 per ml, and a hematocrit of 38.1%. Urinalysis was positive for pregnancy with nothing else noted. A posterior perforation was found on the lower uterine segment using diagnostic laparoscopy. Her fallopian tubes and ovaries appeared to be normal. Uterine injury following elective pregnancy termination is considered common as a complication of uterine dilation and curettage procedure; however, ureteral injury may not be noted at the end of pregnancy termination. This happens because ureteral injury may often be initially asymptomatic. This case demonstrates that, though considered rare, ureteral injury does occur. Further, this case serves to emphasize that surgeons cannot become complacent regarding this potentially serious complication.
This article presents the results of an open-label, noncomparative study in which the effects of a triphasic oral contraceptive (OC) containing ethinyl estradiol and gestodene were evaluated. The study used multiple lipid and lipoprotein parameters for evaluation in 25 healthy females. The mean age for the study group was 26.1 years, mean weight was 63.1 kg, and 4 study subjects smoked. All study subjects were recruited after each had requested oral contraceptives. Complete health histories and a physical examination were performed on each potential study subject prior to beginning the study. The following lipid parameters were determined for each studied subject: total levels of cholesterol, triglycerides, and high density lipoprotein (HDL) cholesterol; HDL2 cholesterol subfraction, HDL3 cholesterol subfraction, low density lipoprotein (LDL) cholesterol, apolipoprotein A1, and apolipoprotein B. Two pre-study samples were taken and analyzed. An average was determined and used as the study subject's baseline for each lipid. Serum lipids were again determined during the 3rd, 6th, and 12th treatment cycles (where one cycle is equal to one complete menstrual cycle). Mean serum lipid results from each treatment cycle were compared to the baseline figures using the two-tailed t test for paired samples. Statistical significance was based on a probability of less than or equal to 0.05. Triphasic OC containing ethinyl estradiol and gestodene significantly increased serum concentrations of the following lipids: total cholesterol, total triglycerides, total HDL, HDL3, apolipoprotein A1, and apolipoprotein B. No significant changes were found in HDL2, LDL, the total cholesterol:HDL ratio, or the HDL:LDL ratio. These all remained within the accepted normal range for each lipid. The authors conclude that healthy women taking this form of synthetic oral estrogen contraceptive do not increase their risk of developing atherosclerosis due to OC-induced lipid changes.
Infection with HIV, a risk factor for epidemic dysentery? A case-control study from Zambia [letter]
The authors report the findings of a case control study in Zambia. The study was designed to determine if there was any relationship between the dysentery epidemic in that country and the increasing prevalence of human immunodeficiency virus (HIV) infection rate. The casual agent of the dysentery was Shigella dysenteriae. To qualify as a case for study, a patient had to have tested positive for HIV, have had 3 or more loose stools mixed with mucus and/or blood, and have been between the ages of 18 and 50 years old. All patients were interviewed and given a physical examination, including the collection of a fresh stool specimen. In addition, venous blood was collected and tested for HIV antibodies. An odds ratio association between HIV infection (either negative or positive) and dysentery (again, either negative or positive) was determined to be 9.2 (95% confidence interval [CI], 5.0-16.9). No significant differences between dysentery patients and controls were found in sex distribution or distance from a patient's home to the health care facility. In addition, no difference was found in severity of dysentery between HIV-positive and HIV-negative individuals. The authors conclude that being HIV-positive is a risk factor for developing dysentery and that a high prevalence of HIV in a given population could also create an epidemic situation.
Dietary management of acute diarrheal disease: contemporary scientific issues.
This paper was presented as a part of a symposium given at the 1993 Experimental Biology Meeting, co-sponsored by the American Institute of Nutrition and the American Society for Clinical Nutrition. In addressing acute diarrheal disease in children younger than 5 years of age, this paper focused primarily on the dietary management aspects in that group. Most previous efforts concerning acute diarrhea have focused on rehydration of the patients with solutions containing glucose, carbohydrates, and key electrolytes. Nutritional aspects have only recently been recognized to be of significant importance in the treatment of acute diarrheal children. Diarrhea prevalence has a direct impact in children's growth. By using improved approaches in treating acute diarrhea, and thereby reducing the negative impact of nutritional complications, including nutritional loss, growth can be maintained even during times of illness. In this study, a regime of continuous feeding therapy immediately following rehydration therapy resulted in no loss in a child's growth rate, while delaying food therapy was associated with weight loss. It was also concluded that lactose-containing milk diets may be used, especially in cases of mild diarrhea. However, cases of severe lactose intolerance were found to contribute to further physiological complications and delayed health recovery. Breast-fed infants, it was concluded, could continue to breast feed, as they showed little intolerance problems. Improving and stressing continuous and proper nutrition during illness-free periods is very important for normal growth, improving resistance to disease agents, and in reducing the future negative impact of acute diarrheal episodes.
The recent use of mifepristone (RU-486) and sulprostone for abortion in France was evaluated in this study. Previous studies had reported an abortion success rate of nearly 97%. In addition, factors which could result in failure were identified during this retrospective study. There were 369 women who underwent the RU-486 induced abortion between 1989 and 1991. All women were examined and cleared of any conflicting factors for the purposes of this study. Every patient was given a single 600 mg oral dose of RU-486 and then, 48-hours later, given an intramuscular injection of sulprostone (250 ml). Every patient was observed for 4 hours at the family planning center and seen 14 days after drug administration. Personal and historical data on each patient was collected from physician interviews and standard questionnaire. Statistical analysis was completed using the statistical analysis systems (SAS) software package for chi-square (X2), Student's t-test, Cochran-Mantel-Haenszel adjusted X2 tests, and logistical-regression analysis. Pregnancy was confirmed in all women before admission into this study by measurement of the serum beta-hCG concentration and/or uterine ultrasound (US) scan. There were 25 abortion failures recorded (6.8%, 95% confidence interval [CI], 4.2-9.4%). Of these, 23 (92%) occurred in women who had serum beta-hCG levels greater than 500 IU/mL 2 weeks after RU-486 administration (odds ratio [OR] 42.3; 95% CI, 9.7-185.6%). Of those women who did abort, 42% expelled the conceptus within 4 hours of sulprostone injection. Complete abortions were recorded in 93.2% of the women. There was no significant correlation between sociodemographic or gynecological variables and abortion failures.
Human T-cell leukaemia virus-I/II infection in Equatorial Guinea [letter]
Reported is a study of the human T-cell leukaemia virus (HTLV) seroprevalence in Equatorial Guinea. Of the 1516 sera collected from the general population, 36 (2.37%) were enzyme immunoassay (EIA) reactive. Ten sera (0.66%) were positive for HTLV-1 and HTLV-II. Immunofluorescence assays (IFA) were less useful than EIA testing. Western Blot (WB) assays confirmed 8 HTLV-positives using a recombinant envelope protein (rgp21) which is found in both types of HTLV. A nested polymerase chain reaction (PCR) for DNA amplification was performed without any detectable HTLV DNA recovered. Within Equatorial Guinea the geographic distribution of HTLV prevalence ranged from 0.46% in the insular areas to 0.7% in the continental areas, with urban areas having a higher prevalence than rural regions (0.65% vs. 0.42%). These findings provide confirmatory evidence that HTLV-II is present in Africa and is not exclusively a New World virus. Blood transfusion might play a significant role in the spread of HTLV in Equatorial Guinea.
The epidemiology of HIV infection among injecting drug users and other risk populations in Thailand.
HIV infection and AIDS in Thailand had been increasing among injecting drug users (IDU) from approximately 1% reported in 1987 to over 40% in late 1988. Two genetically different viruses have been shown to cause HIV infection among IDU and individuals infected sexually. HIV subtype B is responsible for 67-78% of infections in IDU patients, while HIV subtype E is responsible for 96% of infections in sexually acquired cases. It appears that 2 separate epidemics are occurring simultaneously. It has recently been noted that the HIV subtype E frequency in the IDU individuals seems to be increasing. A stable, but high, HIV prevalence rate of 40% among IDU in Bangkok was found. The incidence, however, is higher than observed in IDU individuals from Europe or North America. This is believed to be related to the high turnover rate (70%) of IDU individuals seeking the Thai government's detoxification treatment program. This study also compared 2 methods for estimating seroconversion. Method one assumed that the study subjects had an equal risk of HIV seroconverting on any day between blood testing (midpoint analysis) and produced an artificially low incidence estimate at both the beginning and end of a study interval. Method two assigned an equal probability for each day of the study interval for the patient to seroconvert. According to the author, this produced a more realistic estimate of the incidence curve. The IDU infections are important but are generally considered a minor part of the HIV infection epidemic which is occurring in Thailand. Thailand's HIV-positive population offers an opportunity for a field study of vaccines, as well as an opportunity to field test and evaluate prevention methods and strategies.
Oral contraceptive use and risk of myocardial infarction: an Italian case-control study.
In this report, oral contraceptive impact on incidence for myocardial infarction in Italian women was studied. This study differs from earlier Northern European and North American studies in the pattern of oral conceptive use and disease incidence. This case-control study was conducted over a 10-year period and included women aged 18-54 years. 251 women admitted to coronary care units who were diagnosed with acute myocardial infarction were study candidates. Case controls were 475 women admitted to the same hospitals who were not suffering from acute myocardial infarction. Analysis was based on an a standard unconditional logistic regression from which were derived the odds ratios (OR) and confidence intervals (CI). It was found that 2.8% of the women with acute myocardial infarction were currently using oral contraceptives. Only 1.3% of the case control women were using oral contraceptives. Reviewing past usage showed that 17.1% of the cases had used oral contraception, while 9.7% of the controls had been past users. Risk of disease decreased after stopping oral contraceptive usage. Smoking substantially increased the risk for acute myocardial infarction (an increase of 6.1%; 95% CI, 3.4-11.0) in women taking oral contraceptives. Smoking alone accounts for approximately 50% of the acute myocardial infarctions in Italian women. Oral contraceptive use, in contrast, accounts for only 1% of these cases in Italian women.
In this study conducted in Burundi, sera from 485 hospitalized patients and 519 healthy subjects (total of 1004 sera) were analyzed for antibodies to human T-cell leukemia/lymphoma virus types I and II (HTLV-I/II) . Of this study group, 494 were females and 510 were males. The mean age was 35.3 + or - 13.4 years. Sera were analyzed/screened for HTLV-I/II virus using enzyme-linked immunoassay (ELISA) techniques. Sera that tested positive for HTLV-I/II antibodies were further analyzed using the Western blot (WB) technique. ELISA screening yielded 19 (1.89%) positives from the 1004 sera tested. WB confirmed that 9 of those 19 were HTLV-I positive. This was shown in the WB when proteins p19, p24, gp46, and recombinant protein tgp21 strongly banded in the testing gel. These results indicate that the rate of HTLV infection is low in Burundi (1.34%) and that all seropositives were infected by the HTLV-I virus. This study also demonstrated that variation within the immunodominant epitopes of the structural proteins of HTLV produced an altered binding affinity of the monoclonal antibodies against the env protein. Amino acids may also differ in the Burundi specimens compared to others studied given the lack of MTA-1 reactivity.
Depo-Provera. Department of Health report.
This article discusses depot-medroxyprogesterone acetate (DMPA), a long-lasting, effective, reversible, injectable progestational contraceptive. In October of 1992, the United States Food and Drug Administration (FDA) gave official approval for the use of DMPA in the United States. It is manufactured by Upjohn in single dose (150 mg/ml) vials for parenteral use. It has been evaluated and found to have high efficacy rates at 0.3 pregnancies per 100 women-years of use. Its mode of action may be multifactorial and includes ovulatory suppression, decrease in fallopian tube motility, atrophic endometrium development, and a thickened cervical mucus. Deep intramuscular injections are required every 3 months to maintain contraceptive effectiveness and stop excess menstrual spotting. DMPA effectiveness has been demonstrated within 24 hours after the initial injection was given. DMPA, when used as a progestin-only method, avoids estrogen-related side effects, while reducing the incidence of Candida and pelvic inflammatory disease (PID). However, DMPA provides no protection from HIV and other sexually transmitted diseases; therefore, a barrier method should also be used to prevent such infections. Some side effects reported include menstrual irregularities (mostly amenorrhea), weight gain, dizziness, depression, and moodiness. The author concludes that the key to a successful DMPA program is client selection, which should occur during a screening interview, and pre-use counseling.
Concerns raised in AIDS trials.
This brief article addresses the concern of ethical responsibilities which a vaccine company has toward the people of a country in which a new vaccine is being field-tested. In this example, the World Health Organization (WHO) has approved the field-testing of a new acquired immunodeficiency syndrome (AIDS) vaccine in developing countries. However, the feeling of one individual from the University of Oslo is that fairness in this matter is not guaranteed. Reidar Lie stated that little progress has been made in ensuring that, if the AIDS vaccine is successful, the vaccine will be made available to the test country's populace at an affordable price. Representatives from WHO have been assuring the public in general that justice will occur and that a memorandum of agreement will exist between WHO and the company manufacturing the vaccine. Without the memorandum, WHO will not endorse any vaccine trials.
Vasectomy and prostate cancer risk in China.
This paper reports the findings of a hospital-based case-control study that was conducted at major teaching hospitals in 12 cities in China. China reports the lowest incidence in prostate cancer of over 100 registries reporting cancer incidence. This investigation evaluated the relationship between vasectomy and prostate cancer and attempted to identify any etiological factor. A total of 138 study patients (index cases) were identified. Controls used in this study included a cancer control and a noncancer control from the same hospital, and 2 neighborhood controls. Chances of having prostate cancer were statistically determined by logistic regression analysis with age group adjustments made. The analysis reviewed 138 cases and 638 controls. Results indicate that, regardless of the variable control used for comparison, an increased risk of prostate cancer was associated with having had a vasectomy. Statistical odds ratio was 2.0 for hospital cancer controls (95% confidence interval [CI]; 0.7-6.1); 3.3 for hospital noncancer controls (95% CI; 1.0-11.3); and 6.7 for neighborhood controls (95% CI; 2.1-21.6). The authors conclude that, as reported for men in Western countries, Chinese men who have had a vasectomy are at significantly increased risk for developing prostate cancer compared to men who never have had a vasectomy. They report a near 2-fold increase in risk (vasectomy vs. non-vasectomy) in developing the disease. Conclusions about cause and effect are premature, but these findings warrant further investigation of several issues. These include: changes in the endocrine system due to vasectomy; systematic and local immunity changes after vasectomy; and other possible biochemical factors that enhance/inhibit cancer growth in the prostate gland.
Pediatric morbidity in a hospital of Kampala, Uganda from 1985 to 1990 [letter]
To analyze the return of health services to children in Uganda following the end of the civil war in 1986 and to determine the effect of the AIDS pandemic, pediatric hospitalization records were compared for 1985-90. Data were collected on the major diagnosis of the first 100 patients under 14 years old admitted each October. Chi-square analysis revealed that measles, postmeasles syndrome, acute gastroenteritis, and marasmus decreased significantly from 1985 to 1990 (reflecting the reinstitution of immunization programs and general improvement in health conditions), and AIDS and septicemia increased significantly. The major cause of hospitalization during the entire period was falciparum malaria (22% in 1985 and 28% in 1990). Since HIV can present with symptoms of a bacterial infection (and septicemia accounted for 14% of admissions in 1990), the AIDS figure of 16% in 1990 may be an underestimate.
Implementing the Cairo action agenda.
The decisions and actions which result from the 1994 International Conference on Population and Development (ICPD) will be critically important. They will determine whether 1) millions of people continue to be denied the right to choose how many children they will have and when to have them, 2) whether billions of people continue to live in grinding poverty, and 3) whether excessive consumption and rapid population growth will continue to degrade the earth's basic biological systems. The ICPD Program of Action provides a sound strategy for appropriate actions, but it is uncertain whether sufficient resources and the political will to mobilize those resources will be available to accomplish its goals. Since the individual must be at the heart of all development efforts, the focus of population policies must be improving the status of women, especially by educating young girls. The 2 areas of reproductive health with the most urgent needs are the provision of family planning (FP) services to unmarried young people and safe abortion. Today there is an epidemic of unwanted pregnancy, abortion, and sexually transmitted diseases among young people worldwide, and, during the past decade, a million women have died from unsafe abortions. We must recognize that 50 million abortions are performed annually, and we must provide the FP services which will minimize this need for abortion as well as make it safe for those who finally resort to it. The key to the success of the Program of Action is money. The international community has agreed that developed countries should provide about 0.7 % of their gross national product for development assistance, but only Denmark, the Netherlands, Norway, and Sweden are fulfilling this obligation. The international community has further suggested that rich countries should allocate 4% of their development aid to population assistance, but only Norway has consistently met this goal. The US, Japan, Germany, and the UK have recently made new funding commitments, but other countries have failed to do so. Whereas current FP expenditures are roughly $4-5 billion a year, the Program of Action recommends that these figures be increased to $17 billion by the year 2000. To meet these goals, donor countries must boost grants from $800 million in 1992 to about $5.7 billion by 2000. Multilateral lending institutions should increase concessional loans from about $200 million to $1 billion annually, and developing country governments and consumers will need to triple FP expenditures. By working together, we can raise more resources and expand good quality services to achieve the goals of the Program of Action.
What's happening. New and developing methods of contraception.
The new and developing contraceptive methods include Depo-Provera, which is injected intramuscularly every 3 months and has a success rate of over 99%. Depo-Provera may decrease bone density and increase the incidence of breast cancer, but it may also decrease the risk of uterine cancer. Disadvantages include menstrual irregularities and other side effects. The subdermal implant, Norplant, provides contraception for 5 years. The 6-capsule system was approved for use in the US, and the 2-rod system is undergoing clinical trials. The failure rate is 0.5-2.6%. Norplant is convenient, relatively inexpensive, and delivers hormones evenly. Disadvantages include the surgery required for insertion, menstrual irregularity, and other side effects. Several types of vaginal rings release silicone polymers for circulation through the vaginal wall. One contains levonorgestrel, remains in the vagina for 3 months, and has a 1-year failure rate of 3.7%. Advantages include patient insertion and removal and convenience. Disadvantages include many contraindications, expulsion, and discomfort during intercourse. Recently developed IUDs include the Copper T 380A (approved for 8 years of use in the US) and a levonorgestrel-releasing, T-shaped device (approved for 7 years of use in Finland). Failure rates are 0.5% and 0.3%, respectively. The IUD provides safe, effective, and longterm protection. There are many contraindications, however, and expulsions can occur. Other disadvantages are pain, heavy bleeding, pelvic inflammation, and uterine perforation. The patient-inserted Gynaeseal diaphragm, which is undergoing trials with no failure rates reported, is composed of 3 preassembled interlocking components which allow menstrual flow to collect in a pouch. Advantages are its combined usefulness as a tampon and a disposable diaphragm. The only contraindications are physical abnormalities, and no disadvantages have been reported. The cervical cap is a small thimble-shaped barrier which fits tightly across the cervix. It is 93.6% effective (excluding user failures) at 1 year. It requires less spermicide than a diaphragm and can remain inserted for 48 hours. There are many contraindications, however, and it is difficult to fit. The Fem Cap, shaped like a sailor's cap, is currently under study and may provide advantages over other types of cervical cap. The female condom is a polyurethane sheath with 2 flexible rings; one to fit over the cervix and the other to remains outside the vagina. Efficacy is comparable to other barrier contraceptives. This device protects from sexually transmitted diseases and viruses, and it can be removed immediately after intercourse. Disadvantages include discomfort and awkwardness to use.
15 interviews with family planning (FP) acceptors in various regions of China are reported. The people present their views on the optimum family size and report on which FP methods they are using. Most have only one child, and none has had an unwanted pregnancy. Whereas some of the couples express a belief that a 2-child family is best, they counter that desire with the economic reality of being unable to provide for more than one child and the determination to do the best they can for their child. They report on changing attitudes, on discussions which center around who is getting rich rather than who is having sons, on saving for old age and insuring the life of their child rather than depending upon sons for old-age support, on the ability of women to participate fully in the work force, and on the benefits and health services they have received.
Hormonal implants: contraception for a new century.
Subdermal contraceptive implant systems release low, stable amounts of progestins. Norplant has been used by more than 3 million women, and more than 60,000 have participated in clinical trials. Insertion requires 5-minutes of careful work. The mode of action is the suppression of ovulation by levonorgestrel. Norplant is 99% effective over 5-years of use. There are disagreeable side effects, however, including acne, weight gain, and menstrual irregularity, which is the greatest cause of discontinuation. First-year continuation rates range from 76-90%, and fertility returns promptly upon removal (which can be done in 5 minutes but may take as long as an hour). Implants which would be less obvious subdermally and which would biodegrade are under investigation. Other favorable features would be disposable insertion devices and the use of less androgenic progestins to reduce side effects. Norplant 2 implants, currently regarded as a 3-year system, offer some advantages such as being less conspicuous and easier to insert and remove and are under study for 5-year efficacy determination. Implants releasing desogestrel and other progestins are undergoing clinical trials which are revealing bleeding irregularities similar to Norplant but a possible reduction in other side effects. Degradable implants must be removable during their active life if the user desires. The Capronor implant, which biodegrades, is quicker and easier to remove than Norplant but has the same side effects. Biodegradable subdermal pellets, composed of 10% pure cholesterol and 90% norethindrone, are the size of a grain of rice. Comparative trials are underway to determine the size, number of pellets, and cholesterol/hormone ratio to obtain serum norethindrone levels above the contraceptive threshold but lower than oral contraceptives. Disrupted bleeding patterns in the first few months return to normal. The 4-pellet system has been most effective in preventing pregnancy, but removal can be complicated by fracture of the pellets. These systems under investigation will likely address all of the problems of inserts except insertion and bleeding.
Cervical cancer screening in Kenya.
Available data on cervical cancer in Kenya has shown that the age at diagnosis has decreased from 46 years in 1960 to 40 in 1990. Since 32% of women are greater than para 5 (vs. 70% of cancer patients), high parity may be a risk factor. In 1980, 62% of patients were Stage 3 or 4, and 28% were Stage 2, vs. 53 and 35%, respectively, in 1990. Thus, 85% of patients require radiotherapy, and many receive no treatment. Based on these data, screening to identify a high-risk population took place in a number of locations. CIN (of any grade) prevalence was 3.5% in a rural population and 1% in an urban clinic. CIN III prevalence was less than 5/1000. The correlation of high parity to abnormal Pap smears was confirmed. Cytological evidence of human papillomavirus (HPV) also highly correlated with CIN-positive smears. This finding led to a reassessment of 22,648 Pap smears taken between 1983 and 1987; 20% revealed HPV infection. A further pilot study in Nairobi used 692 Pap smears collected in one month: 78% were of good quality, 6.4% were Class III, and 0.1% revealed CIN III. 52% showed evidence of infection, largely bacterial. To provide screening nationwide, 30 cytotechnicians were trained at the University of Nairobi. One year after training, 10 trainees had read no slides, 15 had read less than 500, and only 1 had read more than 1000. Reasons for the lack of output were the scarcity of necessary supplies outside of urban areas and the many tasks assigned to technicians which demanded their time. Slides submitted by the trainees for follow-up showed a high correlation with the reading by the cytologist. However, it is not cost-effective to train personnel who are not going to be able to put their skills to use. A study of client-perception found that most women would like to have a regular exam and Pap smear, but only 61% knew where to obtain one, and only 21-35% knew cervical cancer symptoms or understood the benefit of screening. To improve screening in Kenya, all health personnel should be taught to visualize the cervix at every opportunity, opportunistic Pap smear-screening should take place, and various training programs should be developed.
The 150 million pregnancies each year result in 500,000 maternal deaths, 20 million unsafe abortions, and longterm disabilities for 15 million women. 3 million newborns die within a week of birth, largely due to poor prenatal and delivery care. In addition, families are devastated by maternal deaths which double the death rate of surviving sons and quadruple the rate among surviving daughters. The centrality of the mother to the family's well-being makes it remarkable that mothers fail to receive the necessary resources to have a safe pregnancy and delivery. The explanation for this lies in the subordinate social status of women. Son preference leads to a devaluation of girls and to a higher infant and childhood mortality rate among girls. Girls who do survive suffer malnutrition and do not receive the iron-rich foods they need from puberty to menopause. The only avenue to social status fulfillment open to many women may be having too many children. Thus, the number of years of education a woman receives is in inverse proportion to the number of children she bears. Status is not the final determinate of maternal mortality, however, and the provision of appropriate health care will ultimately decide survival probabilities. Despite the Safe Motherhood Initiative of 1987, little progress has been made even though the necessary interventions are well-known: 1) the provision of family planning (FP) opportunities, 2) the provision of prenatal care, 3) making basic emergency obstetric care available to all, and 4) ensuring that childbirth is attended by a person capable of recognizing and responding to an obstetric emergency. It is being increasingly recognized that a continuum of integrated social and health interventions will be necessary to reduce maternal mortality. Safe motherhood programs will not require large-scale investments in infrastructure and human resource development because the appropriate technologies do not involve expensive drugs or equipment and because new vertical programs are not necessary. What is necessary is a revitalization of current maternal-child health/family planning programs to provide the best preventive and curative care possible. This care would prove to be one of the most cost-effective public health interventions.
Cervical cancer screening in Thailand.
As female life expectancy has increased in Thailand, the mortality rate from cancer has increased from 10.5 to 24/100,000 from 1970 to 1980. Cervical cancer, which is the most common type, constituted 31% of all cancers in women between 1971 and 1980. This situation led the Ministry of Public Health (MOPH) to establish a policy of early cancer detection in 1989 by integrating Pap smear screening in the activities of family planning centers. This screening reaches 20-30% of women 30-60 years old. Because there was a lack of well-trained cytologists working for the MOPH, training courses were conducted in 61 hospitals. The false-negative Pap smear experience for 1987-91 at Chulalongkorn Hospital was analyzed in 1992. Of 330 cases of proved malignancy, 142 were abnormal according to the cytological exam, and 52 were false-negatives (43 caused by errors in taking the smear and 9 by interpretation errors). The results of this study led to improved quality control.
Treatment of preinvasive cervical lesions.
Various techniques are available for appropriate localized treatment of preinvasive cervical lesions. Cryotherapy, for example, involves freezing the cervix with either carbon dioxide or nitrous oxide to cause necrosis of the tissue. An inexpensive double freeze technique can be easily performed without anesthesia and is safe during pregnancy. The disadvantages are a 10-14 day post-treatment watery discharge and lack of precision about the exact amount of tissue ultimately destroyed. Carbon dioxide laser treatment involves very expensive equipment and results in a smoke plume which necessitates a smoke evacuating system. The main complication is a 4.8% rate of cervical bleeding. Electrocautery using older units can be extremely painful. The Semm cold coagulator minimizes pain and complication with a 90% success rate. The LEEP technique involves applying a very high frequency alternating current and thin wire loop electrode to the cervix. This technique allows a specimen to be obtained. It can be performed under local anesthesia, but the equipment is relatively expensive and also requires a smoke evacuating system. The main complication is a 4% perioperative bleeding rate. Success rates for these procedure are comparable, but expenses and complication rates vary considerably. Cryotherapy has become less common in the US, but it offers good cure rates with a good cost-benefit ratio.
Cervical cancer screening: role of human papillomavirus (HPV) testing.
While the incidence of cervical cancer has been reduced by about 75% from the 1940s to the 1980s, this preventable tumor has not been eradicated, and cervical cancer is the leading cause of death in many countries. Efforts to develop a uniform nomenclature for preinvasive lesions began in 1961. Disagreement about whether all dysplasia progressed to CIS persisted until most investigators concluded that mild dysplasia is unpredictable. The Bethesda System of classification was proposed in 1988 and offers 2 categories: 1) low-grade squamous intraepithelial lesions (SIL) and lesions which show evidence of human papillomavirus change only and 2) high-grade SIL. Management of a patient with an abnormal Pap smear is 1) colposcopic evaluation or cone biopsy; 2) if a successful colposcopic examination is abnormal, a directed biopsy to rule out invasive cancer; and 3) treatment based on the location and extent of the lesion. Since many intraepithelial lesions will regress spontaneously, this may represent overtreatment at some risk to the patient and considerable cost to the health system. Given the 20% false-negative rates of the Pap smear, another approach may be warranted. Using the Southern blot hybridization technique, papillomavirus DNA can be found in 90% of all SIL and 90% of all invasive squamous carcinomas. In patients referred for an abnormal Pap smear, the presence of high-risk human papillomavirus correlates very closely with the presence of SIL and is more likely to indicate the presence of SIL than a repeat Pap smear. Clinical trials will determine the usefulness of this technique in managing abnormal Pap smears.
Overview of cervical cancer and cervical cancer screening in developing countries.
Current data suggest that there are 450,000 new cases of cervical cancer each year and 300,000 deaths, mostly in poorer countries. Regional differences exist, but age distributions are similar with a rise in incidence starting in the early 20s, continuing in the 30s, and reaching a plateau at 40-50 years of age. The presence of HIV infections, especially HIV-2, may increase risk. The risk factors for cervical cancer (history of sexually transmitted disease, multiple sex partners, or a partner with multiple partners) are probably proxy indicators for human papillomavirus, which is indicated as the causal agent. Cervical cancer develops slowly, so screening and follow-up treatment could reduce mortality by more than 70%. A situational analysis revealed the problems with screening in developing countries: limited services available; failure to target at-risk women or limit frequency of screening; inadequate laboratory services, trained personnel, and Pap smear supplies; difficulty in follow-up and inadequate treatment; high cost; limited awareness of the problem; and cultural obstacles to provision of services. Strategies other than cytology (aided or unaided visual detection) are being considered to solve some of these problems. Cost effectiveness can be enhanced by screening less frequently, targeting older and at-risk women, improving accuracy, reducing cost of the tests, using less expensive treatments, and integrating services. Recommended strategies for low-income countries would be to assess the need for screening, educate policy-makers about cervical cancer, and implement a cytology-based pilot program to demonstrate client acceptability, disease identification, and cost-effective treatment. Middle-income countries (adequate urban and limited rural services) could initiate a targeted high-risk screening program in a limited area which integrates screening into existing health services and informs women of the need for and availability of services and could establish appropriate in-country cytology facilities. Upper-income countries could improve overall program participation, reevaluate the screening interval and age at first screening, improve cytology laboratory services, improve the availability of appropriate diagnostic and treatment services, improve outreach, and refine information systems for service delivery and data collection.
In the US, nearly half a million men undergo vasectomy each year. This chapter in a book on contraception opens with a review of the preoperative evaluation (counseling, assessment of the patient's medical history for contraindications, careful physical examination, and recordation of the entire consent process). The various surgical techniques for vasectomy are then described, including the no-scalpel technique for delivering the vas deferens for ligature or cauterization, the percutaneous technique used in China, and efforts to develop an open-ended (reversible) technique. The chapter continues with a discussion of the treatment of short-term complications (overall rate 1/1000) such as hematoma, epididymitis, infection, and chronic pain. Vasectomy failure is considered next, and failure rates are given of less than 1% for ligature techniques and 0.2% for techniques using multiple clips or fulguration. The local effects of vasectomy on the male reproductive tract are described, and the discussion of longterm systemic consequences of vasectomy is highlighted with 2 tables, one on the relative risk of developing various diseases (malignant neoplasm; benign neoplasm; endocrine, nutritional, and metabolic diseases; mental disorders; diseases of the circulatory system; diseases of the digestive system; diseases of the genitourinary system; and diseases of the musculoskeletal system and connective tissue) and one which summarizes studies investigating the association of vasectomy with cardiovascular disease. The final topic covered, vasectomy and genitourinary cancer, provides a table on the relative risk of prostate cancer after vasectomy in 4 previously published studies (relative risk = 0.5, 1.0, 1.4, and 1.0) and a table on the relative risk of testicular cancer after vasectomy in previously published studies (relative risk = 0.6 and 1.5). It is concluded that vasectomy is a safe, simple, and effective method which is not associated with any serious longterm adverse effects.
This document is the preface of a book on contraception written 1) to benefit those seeking and using contraception by educating practicing physicians, residents, medical students, and health workers and 2) to stimulate research on new and improved methods by focusing attention on one of the most important issues of the next century. The book includes chapters on the evolution of steroids and their contraceptive and therapeutic uses; the pharmacology of contraceptive steroids; oral contraceptives and their effects, the new progestins, contraception for those over age 35 and for adolescents, and how to choose an oral contraceptive; the safety and efficacy of the IUD, Norplant, injectable contraceptives, vaginal rings, and barrier methods; sterilization; AIDS and contraception; GnRH antagonists and antiprogestins; immunologic contraception; and future trends in contraception.
Evolution of steroids and their contraceptive and therapeutic use.
In this chapter of a book on contraception, the evolution of our knowledge about steroids is traced from the initial experiments of Arnold Berthold in 1849 through organ extraction, isolation, chemical identification, and synthesis. This information is presented in textual and tabular form with year, country, researcher, and discovery/contribution delineated. Development of the first oral progestational agent, ethinyltestosterone, is described and illustrated with a figure showing the importance of the ethinyl group on C-17 of the estradiol molecule for oral activity of steroids. The numbering system of the steroid molecule is also shown. The 3 events which acted to spur research, World War II rumors of German flyers receiving adrenal hormones to enhance survival, the discovery that clinical application of cortisone alleviates the crippling and painful symptoms of rheumatoid arthritis, and the realization of the necessity and general acceptance of family planning are then discussed. The early experimental work in hormonal contraception is presented with particular emphasis on the research of Gregory Pincus. The 1944 discovery by Ehrenstein at the University of Pennsylvania that a pregestationally-active compound could be produced by splitting off the C-19 methyl group from the biologically inactive isoprogesterone is illustrated in a figure. This discovery of the 19-nor (no radical) steroids made modern hormonal contraception possible. The final step in the original synthesis of norethindrone was taken by Djerassi, and a copy of the laboratory recording of the data is included. Further manipulation of the progesterone molecule is discussed along with practical methods of hormonal contraception, novel contraceptive combinations, and the postcoital concepts of interception and contragestion (with RU-486). After a consideration of multifaceted biologic properties of steroids and their clinical utilization, the chapter ends with a discussion of how current developments will affect future research.
This unedited version of the Programme of Action of the 1994 UN International Conference on Population and Development (ICPD) opens with a 15-point preamble which sets the stage for presentation of the 15 principles upon which the action plan was based. Each of the next chapters addresses a major issue which is broken into subcategories. The basis of action, objectives, and recommended actions are described for each subcategory. The overall theme of the ICPD was the interrelationships between population, sustained economic growth, and sustainable development, and that is the first major theme presented. The next major theme is gender equality, equity, and the empowerment of women. The third issue is the family and its roles, rights, composition, and structure. Population growth and structure is considered next, followed by the issues of reproductive rights and reproductive health; health, morbidity, and mortality; population distribution, urbanization, and internal migration; international migration; population, development, and education; technology, research, and development; national action; international cooperation; and partnership with the nongovernmental sector. Woven into these major themes are considerations of poverty; the environment; socioeconomic issues; special population groups; family planning; sexually transmitted diseases; HIV infections and AIDS; human sexuality; primary health care; maternal-child health; population information, education, and communication; research methodology and dissemination; and program management and resource development, mobilization, and allocation. The final chapter presents a follow-up to the ICPD with the basis for actions, objectives, and recommended actions given for national, subregional and regional, and international activities.
Pharmacology of contraceptive steroids.
This consideration of the pharmacology of contraceptive steroids begins with a review of the accidental addition of 17 alpha-ethynyl estrogens to oral contraceptives (OCs) which resulted from the 15% contamination with mestranol of the first 19-norprogestins manufactured. The mestranol caused nausea and other side effects, but, when it was withdrawn, breakthrough bleeding occurred, so it was reintroduced in a smaller dose which was eventually reduced to 20 mcg per tablet. Today, all except progestin-only OCs contain either ethinyl estradiol (EE) or mestranol (MEE) which is absorbed rapidly from the stomach. To illustrate a discussion of the range of pharmacokinetic values for single-dose EE administration, the values reported in the literature are displayed in tabular form. The bioavailability yields for EE and MEE are reported as having wide interindividual and intraindividual variations. It is pointed out that a confusing bioequivalence problem exists because most epidemiologists are unaware that 50 mcg of MEE is equivalent to 35 mcg of EE in an OC. Ethnic differences in enzyme activities of the liver, and possibly the intestine, may account for the differences found in the different proportions of sulfate and glucuronide conjugates which appear among populations in studies of urinary EE metabolites. Different degrees of oxidative metabolism are also seen from country to country. A general discussion continues about the biological activities of progestational compounds which are presented in tabular form. Bioassays have been found for all of them, but some may be irrelevant to oral contraceptive formulation. The complexity of these various biological activities is mentioned as is the goal for new OCs (to be metabolically neutral and to have no effect on carbohydrate metabolism, plasma lipid levels, etc.). The general discussion continues with comments on the complexity of receptor affinity and the potency of progestational compounds and how this is properly defined. Rozenbaum's primer of steroid chemical structure is said to be useful, and norethindrone and levonorgestrel are defined as the reference compounds for the 2 classes of progestins. Finally, the pharmacokinetics and metabolism of norethindrone, levonorgestrel, gestodene, desogestrel, and norgestimate are discussed.
Final touches put on conference arrangements, documentation.
This article details arrangements for the September 1994 International Conference on Population and Development (ICPD) as of July 1994, including the conference schedule and logistic information for participants. As of June 1994, the ICPD draft Programme of Action was available in the 6 official languages, and more than 10,000 copies had been distributed. Other key documents approaching completion were the rules of procedure, the provisional agenda with annotations, and the note on the organization of work. The World Population Plan of Action's fourth review and appraisal had been submitted. This document summarizes population activities since the 1974 World Population Conference. This review will be discussed at the ICPD, revised again, and released in October 1994. The Report of the Secretary-General of the Conference Containing a Synthesis of the National Reports of Countries on Their Experiences in Population and Development Strategies and Programmes has also been finalized.
Oral contraceptives effect on glucose metabolism.
After a brief review of the introduction of oral contraceptives (OCs) for fertility control and the first reports of the effects of OCs on carbohydrate metabolism (which spurred other investigations), this chapter of a book on contraception summarizes the literature over a 30-year period and outlines how information gained from these studies led to the modification of OC formulations to reduce metabolic and other adverse effects while maintaining the efficacy of pregnancy prevention and, thus, improving the overall risk/benefit ratio. The discussion of high-dose OCs is illustrated with 2 figures showing mean values for blood glucose and mean values for plasma insulin during an oral glucose tolerance test on 21 women before and after 3 years of use of a high-dose OC. The effects of estrogens and progestins on the insulin receptor are discussed, and 2 figures are given for mean blood glucose values and mean plasma insulin values determined in 28 women before and one year after taking 0.35 mg of norethindrone/day. A review of the studies of women with both prior gestational diabetes and existing insulin-dependent diabetes found that minimal changes occur with the low-dose OC. Since currently-marketed steroids have doses which are as low as possible, the only changes predicted are those which will occur upon introduction of the new progestins (gestodene, norgestimate, and desogestrel) which have little or no androgen activity and which preliminary studies indicate cause no significant alterations to carbohydrate metabolism.
President Mubarak, Turkish Family Planning Foundation receive UN population award.
On June 14, 1994, President Hosni Mubarak of Egypt and Vehbi Koc, President of the Turkish Family Health and Planning Foundation (TFHPF) received 1994 UN Population Awards for outstanding work in increasing public awareness of population problems and their solutions. Mubarak was chosen for his national and international leadership in population issues, and the TFHPF was chosen for its achievements in improving the quality of family planning services in Turkey. In his presentation address, UN Secretary-General Boutros Boutros-Ghali noted that the awards not only honor the individual recipients but also signal the continuing concern of the UN about achieving a peaceful balance among concerns of population, the environment, and development. Thus, the 20-year International Conference on Population and Development Programme of Action will seek to integrate population concerns into every area of development. Mubarak accepted the award as recognition of Egypt's success in confronting population problems by striving for comprehensive development and by introducing policies to persuade people to participate freely in population programs. Koc reported that the TFHPF supports alternative and innovative solutions to the social and economic problems caused by rapid population growth and constructively influences national population programs and policies.
High court nominee confirmed by Senate committee.
On July 19, 1994, the 18-member US Senate Judiciary Committee unanimously approved President Clinton's nominee for Associate Justice of the US Supreme Court, Chief Judge Stephen Breyer. If confirmed by the full Senate, Judge Breyer will replace recently retired Justice Harry Blackmun, author of the Roe vs. Wade decision. When asked during the proceedings about whether a line could be drawn to determine a state's interest in the regulation of abortion services at different points during pregnancy, Judge Breyer replied that the finding in Roe vs. Wade has been the law for at least 21 years and that the law was recently upheld in Planned Parenthood vs. Casey. He refused to answer specific questions on how the law applies since he anticipates that those questions will be the subject of litigation in the future. During his career, Judge Breyer was involved in 2 abortion-related cases. In one, he joined an opinion which struck down restrictions on abortion counseling and referrals by family planning clinics receiving federal funds. In the other, he dissented from a court reversal of dismissal of a challenge to Massachusetts's parental involvement requirement. The only heated exchange during the confirmation hearing occurred when the Judge was asked if he would consider it a conflict of interest to rule in environmental pollution cases since he has holdings in Lloyds of London, which insures clients against asbestos and pollution claims.
Oral contraceptives and plasma lipoprotein metabolism.
This chapter of a book on contraception describes the hormonally mediated lipid and lipoprotein metabolic alterations and effects of commonly used combination oral contraceptives (OCs) within the general context of lipoprotein metabolism and the relationship of lipoprotein parameters to cardiovascular disease. The discussion starts with a consideration of plasma lipoprotein metabolism and its relationship to cardiovascular disease. Particular attention is paid to apolipoprotein B-containing and high density lipoproteins. The effects of OC hormonal components (both estrogens and progestins) on lipoprotein metabolism are considered next. Discussion of the effects of combination OCs on plasma lipoproteins is highlighted by tables which 1) compare OC users and nonusers in terms of lipids and lipoproteins, 2) compare past and current users with nonusers in terms of lipoprotein concentrations, and 3) show percentage changes in lipids and lipoproteins from baseline to 1 year for 3 different progestins. In summary, it is reported that studies to date have not established the extent to which OC-induced lipid and lipoprotein changes may influence the risk of cardiovascular disease, but the potential for atherogenic lipoprotein changes should be considered when evaluating the metabolic effects of OC use. Whereas OC-related reductions in high-density lipoproteins (HDL) would cause the most concern in this regard, the new low-dose OCs generally result in small and probably minimally significant changes in HDL in healthy, nonsmoking women.
What do women want? Issues of choice, control, and class in pregnancy and childbirth.
This article presents a report on research into the type of childbirth experience US women want and actually have. The choices women have and the amount of control they can exert over the experience are dictated by advanced technology, medical institutions, medical ideology, and social class. A comparison was made among middle-income women who are not health professionals, middle-income women who are health professionals, and poor women. It was found that the middle-income women who are not health professionals held a wide range of views about the role of technology in childbirth. These women were primarily concerned with making choices which would allow them to have some control over the course of their pregnancies and subsequent childbirth. Their strategy in facilitating control was to choose a physician who would serve as their advocate within the medical system. Middle-income health professionals depended on their knowledge of the system to achieve control over their experience. Poor women had no expectations of being able to control their health care and were mostly concerned with receiving continuity of care. The implications of these findings and, more emphatically, of the increasing permeation of technology in the labor and delivery room, are discussed in terms of the services provided by hospitals and the role and training of those who provide the services, the obstetricians. It is noted that many obstetricians are dissatisfied with their practice, with key decisions being dictated by hospital administrators and insurance companies. Whereas it has been suggested that patients may be better served if obstetrics and gynecology adopt a preventive or even a primary health care focus, training programs are moving in the other direction by emphasizing the development of subspecialties. Finally, if the impending economic transformation of the health care system occurs following the single payer approach used in Western Europe and Canada, it will be possible to eliminate the current 2-tiered system which results in separate and unequal care for the poor.
This report identifies and discusses the central issues, problems, and contradictions in the population debate in order to provide background information for the 1994 International Conference on Population and Development and a basis for the development of Denmark's population policy. The introduction describes the 2 basic contradicting indicators of the unprecedented global annual growth rate of 93 million people and the equally unprecedented rapid decline in the total fertility rate in developing countries (from 6 in 1950 to 3.6 today). The next section deals with the links between population and development, including the risk of demographic traps and production and consumption traps. 6 major trends in population and sustainability are explored in terms of regional and national differences. Contradictions and myths in the population/development debate are then discussed. The third section of the report presents the demographic context including a short overview of population theories, the most recent global demographic projections, and the most important fertility determinants (infant and child mortality, the status of women, and the quality of services). Section 4 provides a discussion of the different approaches and rationales for the establishment of global and various national population policies and family planning (FP) programs. The final section is concerned with the transition from FP to sexual and reproductive health and rights. This discussion covers the role of vertical FP programs, integrated maternal-child health and FP services, and the transition to more comprehensive reproductive health services. Sexual and reproductive health is then considered within the gender framework and from a human rights perspective. Charts with data on population projections, the prevalence of contraceptive use in developing countries, and the total fertility rate since 1960 are appended.
Immigrant earnings differentials and birth-year effects for men in Canada: post-war-1972.
"This paper investigates immigrant earnings differentials for males in Canada and how these earnings have changed over time leading up to 1972 with workers' year of birth. The paper uses the 1973 Job Mobility Survey, which contains a direct measure of work experience reported independent of age. Thus, using age as a birth-year index, it is found that cross-sectional earnings differentials of immigrant men have widened since the later 1960s relative to those of native-born workers." (SUMMARY IN FRE) (EXCERPT)
[AIDS and the future of Africa]
The authors first note that the lack of data makes it difficult to assess accurately the demographic consequences of AIDS for Africa. Some basic trends have emerged, however, including the existence of major geographical differences in the impact of AIDS, the spread of the infection through the major communication centers, and the spread of the disease to rural areas. The primary paths of transmission are among heterosexuals and between mother and fetus. The authors also note the rapid spread of AIDS among younger women. The high rate of infection raises the prospect of a second demographic transformation with major negative consequences for the continent as a whole.
Gender wage gap in Malaysia and Taiwan.
"Using nationally representative samples of women in Malaysia and Taiwan, we examine the extent to which [male-female earnings differentials] match those observed in other countries, and weigh which theoretical perspectives best explain the observed labor market outcomes. We emphasize micro and macro-level economic factors, beginning with the supply side and a standard human capital framework, continuing with demand side factors that influence how women are drawn into different parts of the labor market, and then concluding with an examination of the effects of institutional structure and government policy in both countries." (EXCERPT)
[On the number and composition of elderly people, 1960-1990]
"Hungary's population increased moderately between 1960 and 1980, then it has been decreasing every year. However, within this the number and proportion of those over 60 years of age--particularly of females--increased right along, even after 1980. The study follows up the socio-economic and demographic characteristics of this population group...." (SUMMARY IN ENG AND RUS) (EXCERPT)
Population and family in the Low Countries 1993: late fertility and other current issues.
This 1993 volume is the ninth in a series on population and family in the Low Countries (Netherlands, Belgium, Luxembourg, and the French departments Nord and Pas-de-Calais). Articles are included on late fertility, the second demographic transition, reasons for mortality differences in Europe, urbanization in the Netherlands, and children in developing countries. (ANNOTATION)
Trends in population and family in the Low Countries.
This collection of brief articles by various authors "presents an overview of what has actually happened in Belgium and the Netherlands in the field of demographically relevant topics. First of all, the reader will find two tables with some relevant data for both countries. After the separate contributions on population and vital statistics from Belgium...and the Netherlands...,a short intermezzo is dedicated to the initial 'postponement' and ultimate 'catching-up' process of childbearing: the ageing of fertility....Recent data for the two 'low' countries [are compared]." (EXCERPT)
Overcrowding and mortality from airborne infectious disease: the case of Stockholm 1895-1925.
The author uses data from housing censuses taken between 1895 and 1920 to examine the factors affecting the marked decline in mortality that occurred in Stockholm, Sweden, over this period. The tentative conclusions drawn are that the relief from overcrowding that occurred during this time period was not the most important factor affecting mortality, and that improvements in sanitation may have had more impact. (ANNOTATION)
[When people born in French overseas departments return home to retire. A survey of intentions]
"Almost half of...over-45s born in French overseas departments and living in mainland France had plans to return overseas by the year 2000. The desire to return is more clear-cut among the 50 to 54 year olds. The younger people have yet to think seriously about retirement, whilst a number of the oldest individuals have already made definite plans." Data are from a survey carried out in 1992. (SUMMARY IN ENG AND GER AND SPA) (EXCERPT)
Refugee migration and local economic development in Eastern Zambia.
"This article examines the local socio-economic impact of the arrival of Mozambican refugees in the Eastern Province of Zambia. Previous studies of forced migration elsewhere in Africa have suggested that not only stresses, but also positive gains for local development may be felt in areas hosting significant numbers of refugees. It is suggested here that an appropriate framework from which to analyze the impact of refugees is to focus separately on the effects of population increase on the one hand, and the specific characteristics of refugees on the other. Using this distinction, a model is developed of potential beneficial changes resulting from the arrival of refugees. Key assumptions of this model are then identified to be of relevance to policies designed to promote local economic development under conditions of refugee migration." (EXCERPT)
[Agrarian overpopulation and household structure in Saguenay (1881-1931)]
"Our paper investigates the effect of land shortage in the Saguenay region [of Quebec, Canada,] upon the household structures, more precisely on the frequency of a) complex structures, b) celibacy, c) cohabitation with strangers (non-relatives). The data come from 28 parish censuses of the period 1881-1931. For each of these three indicators, findings show that the saturation of arable land did not entail significant changes." (SUMMARY IN ENG) (EXCERPT)
How many Americans? Population, immigration and the environment.
This study concerns issues of population growth, immigration, and the environment in the United States. "We will first examine the connections between population growth and the environmental, resource and social issues that already confront the nation. We will then project population patterns for the United States in the twenty-first century, if present demographic patterns continue and if the nation does nothing about them. We will also look at how such a rate of growth and eventual population size will affect the environmental and social problems already confronting us....We will [also] explore alternative population scenarios....Our purpose is to illustrate the need to consider all three demographic variables--fertility, mortality and immigration--if population growth is to be stopped....We will...offer suggestions on how fertility might be reduced and immigration controlled. Finally, we will speculate on what kind of society would emerge--economically, politically and socially--under a no-growth scenario, and we will describe what seem to us certain preconditions, involving social behavior and the nation's view of itself, if our society is ever to come to grips with the population issue and attempt to steer the direction of future change." (EXCERPT)
Gender concealed, gender revealed: the demography of Canada's refugee flows.
"This paper offers a first step toward revealing the position of women in refugee flows to Canada, using unpublished data obtained from Employment and Immigration and from the Immigration and Refugee Board. These data confirm the male dominated nature of refugee settlement in Canada and the lower representation of women in refugee admission and in the refugee claimant process." (EXCERPT)
[Population prospects in the Czech Republic (demographic prognosis to the year 2010)]
"Computation of the [Czech Republic] population prognosis based on the 1991 census results was carried out in 8 variants....All variants of prognostic computation suggest that round the year 2005 there will be attained the maximum population numbers." (SUMMARY IN ENG AND RUS) (EXCERPT)
Mother-headed families and why they have increased.
"The goals of the book are twofold. The first is to bring together information on the past and present prevalence of mother-headed families in [developed] countries....The second goal is to consider the various explanations (economic, demographic, cultural, sociopsychological) that have been offered for the recent increase, and to see...what they imply for the future....Chapter 1 considers the role of divorce and separation....Chapters 2-4 consider out-of-wedlock births as a source of mother-headed families, particularly since the stabilization of divorce rates in the 1980s....Chapter 5 discusses widowhood....The second part of the volume (chapters 6-8) offers a critical discussion of various theories of the family and of parenting that might explain the various changes in the prevalence and status of mother-headed families that have been described." (EXCERPT)
This dictionary, which is also available in French, provides definitions of the terms used in the 1991 census of Canada. The terms are organized alphabetically under the general concepts of population, family, household, housing, and geography. (ANNOTATION)
How good are subnational projections as forecasts?
"This article examines how accurately subnational population projections for England of about ten years earlier predicted populations in 1991 as measured by the recent mid-1991 population estimates based on the 1991 Census." The results suggest that subnational projection taken about 10 years ago were fairly successful in predicting 1991 populations. (EXCERPT)
Combined analysis of mortality in three United Kingdom nuclear industry workforces, 1946-1988.
"Mortality during 1946-1988 has been analyzed in 75,006 employees of the United Kingdom Atomic Energy Authority, the Atomic Weapons Establishment and the Sellafield plant of British Nuclear Fuels. All-cause mortality was 19% lower than national rates among workers monitored for external radiation exposure and 18% lower among nonmonitored workers. Cancer mortality was also lower than national rates...." (EXCERPT)
Bohemia after the Thirty Years' War: some theses on population structure, marriage and family.
The author analyzes the impact of the Thirty Years' War on population structure in Bohemia. Preliminary results are reported from "a joint research project involving the University of Vienna, Charles University in Prague, and the State Central Archives in Prague [which] is exploring socioeconomic dimensions of population change in mid-seventeenth-century Bohemia in order to test older assumptions and to develop new insights." (EXCERPT)
The challenge of population aging in mainland China: a demographic accounting.
Recent trends in demographic aging in China are reviewed using data from censuses taken between 1953 and 1990 and the 1987 1-per-100 Population Sampling Survey. Sections are included on the age composition of the elderly population, dependency ratios, life expectancy, sex distribution of the elderly, and regional differences. Particular attention is given to the policy implications of current and future trends. (ANNOTATION)
[Agricultural migration in Mali]
An analysis of migration patterns in Mali is presented. The author concludes that "rural migrations in Mali tend to be from North to South, involving mainly the peoples of the sahelian regions and those dwelling at the northern edges of the sudanic areas. The results demographically speaking in the South are large concentrated pockets of population." The problems posed by the these migrations for development planning are noted. (SUMMARY IN ENG AND GER AND SPA AND ARA AND DUT AND CHI) (EXCERPT)
Will America drown? Immigration and the third world population explosion.
This is a collection of papers by various authors, most of which have been adapted from articles published in the Conservative Review, focusing on the perceived negative impact of large-scale illegal immigration in the United States. The editor concludes that "only a drastic change of government attitude, a radical revision of prevailing laws regarding the acceptance of immigrants, especially 'political refugees,' the 'rights' of illegal immigrants, a system of centralized identity cards for legal residents tied to a computer network like credit cards, and a concerted effort to make the smuggling of illegals unprofitable to the smugglers, can possibly save America. Otherwise this country, along with all other Western nations, will eventually be drowned by the rising tide of humanity...." (EXCERPT)
How serious is ageing in Sri Lanka and what can be done about it?
"The objective of this article is...to examine the demographic characteristics and emergence of new challenges of the fast growing elderly population in Sri Lanka." Results indicate that "the combination of low fertility and increased survival in Sri Lanka during the last four decades ensures that there will be large and rapid increases in the elderly population. Although the traditional family support system for the elderly still exists, modernization has an adverse impact on the care and support traditionally provided by families....The study examines possible socio-economic implications of ageing to enable policy makers to be prepared for problems that are likely to emerge." (EXCERPT)
Visualising the geography of the population with the 1991 census.
"The argument that conventional maps give a misleading visual impression of spatial information about a population is not new....However, the techniques which can be applied to tackle this problem have recently improved as the provision of large datasets and access to microcomputers has spread. This paper presents new and arguably less misleading maps which have been devised by an innovative computer algorithm to visualise 1991 Census data [for Great Britain]." (EXCERPT)
[The problem of the relationship of preference-migration]
The author examines migration preferences and behavior in the Czech Republic in the 1980s. Factors considered include age, economic status, and sex. (SUMMARY IN ENG) (ANNOTATION)
[The population of France in 1993]
This is a review of the demographic situation in France and in the world in general. The author notes an acceleration in the decline of fertility and nuptiality and a continuation in the process of demographic aging in France. (ANNOTATION)
Determination of a feedback vector that generates a non-decaying oscillation in a model population.
"The parish registers of Penrith, Cumbria, [England] have previously been used to provide the records of a model population of value to theoretical population biologists, particularly in the determination of oscillations and computer modelling. The registers contain information on named individuals, so permitting the extraction of further information of the population dynamics of the community. The derivation of a feedback vector by Ackerman's pole placement technique illustrates the expected age-specific gains/losses to the female breeding population (by immigration/emigration and by unmarried women) for any deviation from the steady-state population level to maintain the long-wavelength oscillations in births and deaths." (EXCERPT)
Predictions from time series analysis of the oscillations in parish register series.
An alternative method to family reconstitution for the determination of demographic parameters from parish registers is proposed and illustrated using data from Penrith, England, for the period 1550-1750. "It is suggested that some of these functions may be estimated by the application of conventional time-series analysis to the aggregative annual totals in the registers of baptisms, marriages and deaths: (i) age of mother at birth of median child; (ii) estimations of fertility function; (iii) mean age at marriage; (iv) estimations of mortality function; (v) factors governing the population boom; (vi); the patterns of population dynamics that might be found and the detection of steady-state conditions in communities in England in the sixteenth and seventeenth centuries." (EXCERPT)
Some problems concerning the study of urbanization in the modern world are examined, with particular reference to methodological pitfalls inherent in the need to examine urbanization in both time and space. Belgian examples are used to illustrate the validity of estimates of urban population size, the selection of spatial criteria in demographic analysis of urban populations, how to distinguish urban from rural populations, and how to estimate rates of urban population growth. (ANNOTATION)
A dynamic migration model with uncertainty.
The author presents "a dynamic version of the Harris-Todaro migration model where a finite population of infinitely-lived Bayesian agents choose consumption and migration decision rules as a function of their histories. The agents do not know the production functions in the two sectors and learn about them through wage draws that they receive from the stochastic production functions. The government knows the true production functions but is uninformed about the agents' beliefs, and the actual wage draws they observe. The government maximizes its welfare function using wage subsidies in the two sectors, and a migration tax. We solve the agents' dynamics programming problem, and then use the solution to solve the government's dynamic programming problem. We study the effects of government policies on the population distribution, and illustrate the model by numerically solving a particular parametric example." (EXCERPT)
"The relation of diet to mortality is examined using the data of the Italian rural cohorts of the Seven Countries Study, a prospective investigation of factors related to cardiovascular disease. The present analysis includes 1,536 men aged 45-64 years, whose dietary habits and food consumption, including alcoholic beverages, were measured in 1965....Large differences in survival probabilities were observed for different dietary patterns....The dietary pattern that corresponded to the lowest mortality rate...was: more than 2,800 [calories per day], with more than 41% of the calories coming from carbohydrates, more than 9% from proteins, between 16% and 23% from unsaturated lipids, and between 13% and 19% from alcohol." (EXCERPT)
Changes in nuptiality in Czech lands and Slovakia, 1981-1988.
"During the period between the World Wars differences in the age at first marriage and proportions married in the Czech and Slovak areas of the Czechoslovak Republic showed the two to be distinct regions. In the Post-World War II period, however, differences in both measures have diminished and have almost disappeared, suggesting homogenization of demographic behavior. Current ages at first marriage have fallen to the levels interwar demographers believed to be conducive to family instability." (EXCERPT)
A new look at racial differentials in local residential mobility.
"Using data from the 1985 American Housing Survey, this analysis takes an in-depth look at racial differentials in intrametropolitan mobility [in the United States]." The results indicate that "although blacks are more likely to move than whites, no racial difference remains when pre-move household and housing variables are added to the equation. However, tenure and location interact with race in the prediction of local mobility. Black city renters have particularly low chances of moving while black suburban owners have particularly high chances." This paper was originally presented at the 1993 Annual Meeting of the Population Association of America. (EXCERPT)
Understanding why households move: a comprehensive analysis of reasons for moving.
This study examines residential mobility in the United States. The author "presents a comprehensive analysis of reason for moving, asking the following questions: 1) What types of moves are most frequent? 2) Is there a way to group reasons that would be both substantively meaningful and analytically useful? and 3) Is reason for moving associated with household characteristics, such as household composition or tenure status?" (EXCERPT)
College grad, poverty blacks take different migration paths.
Differences in internal migration trends among blacks of different socioeconomic status are analyzed using data from the 1990 U.S. census. (ANNOTATION)
The author examines the relative weight of pull and push factors affecting rural-urban migration in Turkey. Data are from the 1970, 1980, and 1985 censuses. "The results of this study indicate that, for the Turkish case, the effects of migration on urban growth had been contrary to those found in the developed countries, but that, as Turkish development increased over the time period 1965-85, the effects of migration increasingly came to resemble those of developed countries." (EXCERPT)
The relationship between premarital cohabitation and the stability of subsequent marriages is examined using data from a 1985 survey of 3,200 Swedish men born between 1936 and 1960. Using multiplicative hazard models, the author shows that "previous cohabitors, compared to noncohabitors, tend to be at much greater differential risk of dissolution at all durations of marriage. In addition, we found that age at marriage, marriage duration, and child(ren) are among the strongest determinants of the risk of marital dissolution." (EXCERPT)
Bibliography on migration: German and English language literature.
This unannotated bibliography presents literature in English and German on migration for the period 1985-1993. It is organized geographically by region, and is global in scope. Indexes are included for authors, organizations, series, journals, and for subject and region in both languages. (ANNOTATION)
Mortality and health care planning in China's cities.
"In this paper, socioeconomic factors affecting mortality and spatial pattern of health care planning in China's cities are analyzed to promote an understanding of Chinese health conditions and health care planning." Data are from the 1987 Statistical Yearbook of Chinese Cities. The results show that the cities with higher mortality have a higher provision of health services, and that the Chinese authorities have been able to focus efforts on developing health services in relatively backward areas. (EXCERPT)
Population migration and the changing world order.
This volume is a product of a symposium held in January 1993 at the Institute of British Geographers' Annual Conference in London, England. The focus was on the impact of the end of the Cold War and the Gulf War on global migration trends. "The symposium sought to review the ways that these and other broad political and economic changes of the previous few years, associated with what was being fashionably described as the 'new world order', were affecting population movements, and also how these movements were themselves active factors in the shaping of the changing world order." The 16 papers are divided into sections on migration within the developed world, migration to the developed world, and migration within the developing world. (EXCERPT)
[Family and household projections, 1990-2010]
Projections of families and households are presented for Hungary up to the year 2010. (ANNOTATION)
The 1990 census count of American Indians: what do the numbers really mean?
"Despite self-identification of race, the 1970 and 1980 United States censuses each contain overcounts of the American Indian population. This paper examines the 1990 count in order to determine if such error persists. Several sources of demographic data are employed in finding evidence of an overcount that varies by age and geographic region, but not sex. Available evidence suggests international migration, changing racial identification, and inconsistent reporting of race on birth certificates, death certificates, and the census are responsible for this disagreement between the enumerated and estimated American Indian population." (EXCERPT)
Stepfamilies and stepchildren in Great Britain.
"This article analyses data from two surveys--the Omnibus Survey and the General Household Survey--which provide information on stepfamilies and stepchildren in Great Britain. It is estimated that there were about 500 thousand stepfamilies with dependent stepchildren in Great Britain in 1991; around one in 15 of all families with dependent children....The article also describes a life table analysis to estimate the proportions of children who would become stepchildren by certain ages, were 1991-92 age-specific transition probabilities to persist unchanged." (EXCERPT)
[Old age and research on aging in Switzerland]
This study, translated from the original German, concerns demographic aging in Switzerland. Based on a review of the published literature, it concentrates on the main findings of current research and their implications for social policy. Chapters are included on demographic aging, the socioeconomic position of the aged, theories on aging, the life cycle and personal development of the elderly, medical aspects of aging, and policies for helping the aged. (ANNOTATION)
Historical models of the central European family: Czech and Slovak examples.
"Preliminary research on the history of family and demography among Czechs and Slovaks in the pre-modern period suggests that these central European peoples shared both western and eastern characteristics, but also that results depend very much on the geographical location of the community being analyzed, on its nationality composition, and its socio-economic characteristics. Using internationally accepted analytical techniques such as family reconstitution and household-structure analysis, research continues on a wide range of sources such as ecclesiastical registers, household listings, and the population sources known as status animarum." (EXCERPT)
[Uncertain prognosis of European family evolution]
The author discusses past and future changes in the family in Europe. "During the years 1965-1985 demographic characteristics of...Western Europe indicate decline of fertility, nuptiality, growth of the number of divorces as well as growth of illegitimate deliveries....Family sociologists consider the present changes as [a] phenomenon of transformation of the Western-European family." (SUMMARY IN ENG AND RUS) (EXCERPT)
The impact of immigration on the Social Security system.
"This study examines the entire foreign-born population and the legal immigrant, illegal alien and amnesty alien sub-populations [in the United States] separately in order to calculate the current Social Security balance (a deficit) between contributions paid and benefits received. The ultimate costs to the system of post-1970 immigration, which can only be fully assessed after individuals reach retirement a variable number of years into the future, are also estimated." (EXCERPT)
[Population estimates as of October 1, 1993].
Population estimates by age and sex are presented for Japan as a whole and for individual prefectures for 1993. Separate estimates are included for the foreign population. (SUMMARY IN ENG) (ANNOTATION)
[International migration in Hungary]
The author reviews trends in international migration in Hungary. "The first part of the paper gives a short overview of the migration movement of the past centuries and those historical events which might influence the present migration processes....The second part concentrates on the [most recent] events. Using the existing statistical data [the author] shows the main trends, the types and characteristics of migrants and reflects [on] some policy implications as well as the possible reasons [for] the opinions and behaviour of the public." (SUMMARY IN ENG) (EXCERPT)
In and out of marriage: Irish and European experiences.
Most of "the papers published in this collection were read at a Conference held by the Family Studies Centre [Dublin, Ireland] in June 1991....All the papers are concerned with issues arising out of changes in family organisation over the past few decades." Chapters are included on marital separation in Ireland; the Italian experience of divorce; the reform of child support in Great Britain; the concept of household in social security; poor families in the Netherlands; single parents in Ireland; and theoretical and practical issues in family policy. (EXCERPT)
Recording the epidemiologic transition in Germany, 1816 to 1934.
"This paper argues that it is difficult to detect the epidemiologic transition in Germany using recorded cause of death statistics. National statistics become available relatively late during the mortality decline. These statistics fail to measure cancer and heart disease until much later. The recorded statistics are further marred by the poorly defined cause of death 'old age'. This paper discusses why German city, state and national governments established systems for collecting cause of death statistics. It examines differences in systems for recording mortality statistics as well as in cause of death classifications." (EXCERPT)
The demographic situation of Hungary in Europe.
An analysis of recent demographic trends in Hungary is presented in the context of recent developments occurring in Europe as a whole. Separate consideration is given to marriage, fertility, mortality, and population change. This publication is also available in French. (ANNOTATION)
Parental views on gender and schooling: qualitative evidence from rural Thailand.
"The present study provides an analysis of qualitative data on the attitudes and opinions of rural parents [in Thailand] about educating sons and daughters past the primary level. The focus is on issues related to the sex of their children." The data are from a series of focus group discussions held in 1991 and 1992. (EXCERPT)
Population ageing and fertility: some implications for Thailand.
"This paper begins with an explication of the impact of past and future fertility trends on the population process of ageing stressing several important features of the situation that are often overlooked or misunderstood. It then examines the implications of fertility decline for the familial system of support focusing on coresidence elderly and their adult children." (EXCERPT)
Using qualitative data for understanding old age security and fertility.
"This paper considers the contribution that qualitative data generated through the focus group method might contribute to our understanding of the old [age] security motive and fertility relationship. The primary example used to illustrate this comes from Thailand and centers around the question of how Thai fertility could have declined so sharply in only a few decades while expectations from children regarding assistance in later years remained intact." (EXCERPT)
New Zealand's ageing society: the implications.
This is a collection of studies by various authors on aspects of demographic aging and its consequences for New Zealand. The first part looks at theories of aging, the characteristics of the elderly, and health and social issues related to aging. The second part considers policy implications concerning housing, income support, and institutional care and community services for the elderly. The third and final part looks at specific subgroups such as women and the Maori population, and at the political aspects of demographic aging. (ANNOTATION)
Patterns of suicide and homicide in America.
"The present book presents an examination of the variation in the suicide rate of the continental states of the U.S.A. It uses the theory of suicide proposed by Durkheim (1897) to explain societal suicide rates and follows him in applying it to regions within a nation." Comparisons are made with homicide rates. The method of data analysis employed is factor analysis. (EXCERPT)
Drinking behavior in relation to cause of death among U.S. adults.
"This study examines drinking behavior in a nationally representative sample of U.S. adult decedents aged 25 through 64 years and its association with cause of death." Data are from the 1986 National Mortality Followback Survey. The results indicate that "daily drinking, binge drinking, and heavier drinking were each associated with an increased likelihood of injury as the underlying cause of death. Persons who were young, male, Native American, or divorced or separated were more likely to drink frequently and heavily." (EXCERPT)
The past and future of urban histories examining China's modern period (1840-1949).
An analysis of urbanization in China from 1840 to 1949 is presented. Sections are included on modern urbanization, the structure and function of cities, urban politics and culture, and suggestions for future research. (ANNOTATION)
Fertility, family size, and structure: consequences for families and children.
These are the proceedings of a seminar held at the Population Council in New York, June 9-10, 1992, on the consequences of high fertility at the family level in developing countries. Among the topics given high priority were "the consequences of high fertility for children's educational opportunities and their time use, and for intra-family inequality, particularly as it relates to sex and birth order." The 14 papers are divided into five sections that deal with the costs and benefits of children, qualitative approaches concerning parents' perspective, child health and nutrition, children's education and work in changing societies, and the consequences of sustained high fertility. (EXCERPT)
[Household projections up to 2020]
Changes in the number of individual households and in their characteristics in France are projected up to the year 2020. The results show that the number of households will continue to grow but at a decreasing pace over time. Households will also become progressively older, divided, and smaller. (ANNOTATION)