Empowerment and family planning in Bangladesh.
A 1992 survey of 1500 women (1300 married and under age 50 years) was conducted in Bangladesh. Women who participated in 1 of 2 nongovernmental programs which provide small business loans for women (the Grameen Bank and the Bangladesh Rural Advancement Committee) were compared with women who were not members but lived in villages served by the programs and with women who were eligible but lived in villages where the loans were not available. It was found that Grameen Bank membership had a significant positive effect on the use of contraceptives and on the rate in which the level of contraceptive use increased. The greater economic independence enjoyed by the Grameen Bank members is a factor in the increased contraceptive usage as is the promotion by the Bank of a small family norm. Empowerment indicators for women in Bangladesh include mobility, economic security, the ability to make purchases, freedom from domination and violence within the family, political and legal awareness, and participation in political activities. Women are able to achieve their fertility goals by participating in programs that decrease their social isolation and their economic dependence on men.
Abortion funding cutoff will likely cost Michigan far more than it saves.
In November 1988, Michigan voters approved a referendum that restricted state Medicaid funding of abortions to situations where the woman's life was in danger. The funding restriction saved taxpayers approximately $7 million in 1991, but researchers estimate that about 4130 births in 1991 could be attributed to the cut-off of abortion funds. Michigan's birth rate, which had remained a stable 15/1000 during the 1980s, rose to 16 in 1989 and 16.5 in 1990. This increase of 5.7% from 1988 to 1989 and 3.4% from 1989 to 1990 can be compared to increases of 1.6 and 2.9% for the 2 periods in Indiana and a decrease of 1.5% and increase of 1.7% in Ohio. If all of the increased births in Michigan were attributable to the new funding restriction, then 13,000 additional births occurred in the first 18 months of the policy. Attributing one-half to two-thirds of the increase to the policy results in an annual increase of 4350-5800 births. The Michigan Department of Social Services estimated an increase of 2120 births in 1989 and slightly more in subsequent years. The estimated Medicaid expenditures for these births ranges from $11 to 30 million. Support costs during pregnancy would be $1.4 to 3.8 million. The continuing annual cost of providing public assistance to women affected by the funding cutoff was estimated to be $7.7 to 21 million. With a mean range of 5 years of assistance, the shared state and federal costs of the abortion funding cutoff would range from $50 to 139 million. In 1991, therefore, Michigan saved about $7 million in abortion funding and spent $23-63 million in state funds to support the families of the babies. These figures are affected by inflation, but the cost/savings ratio is likely to remain the same. It is also possible that many women affected by the cutoff of funds could and did pay for an abortion themselves, but other costs to society, such as abuse, neglect, drug addiction, crime, public housing, and food stamps, were not figured into the calculations.
From 1988 to 1991 in Thailand, social marketing techniques were used to promote the consumption of vitamin A-rich foods. The project was conducted among 134 villages and involved approximately 122,000 people. Participants exhibited significantly improved knowledge, attitudes, and practices; a substantial improvement was obtained in the vitamin A and nutritional status of the target population; and the interventions had a high potential for sustainability. This book serves as a case study of the process used in Thailand to control vitamin A deficiency at the district level through dietary diversification. It describes the challenge of fitting a nutrition communication program into a community. While it is unlikely that the products and elements described can be transferred to another community, the process can be shared. The first part of this book describes each stage of the project: preliminary research, project design, formative research and audience segmentation, communication program development, program implementation and monitoring, and evaluation. The second part highlights several of the essential elements needed to undertake dietary diversification projects using a combined nutrition communication/social marketing approach. The important processes and lessons presented here can be applied to other nutrition programs.
Women, sexuality and AIDS in Brazil.
Family planning (FP) programs have traditionally paid scant attention to the context in which sexual relations occur or to women's status in society. With the need to practice safer sex by using barrier contraceptives, particularly the condom, becoming more and more crucial in order to avoid HIV infections and other sexually transmitted diseases, the ability of women to negotiate successfully for condom use has gained attention. Men need to use the condoms to protect women, but women are often placed in social contexts which make it impossible for them to insist upon its use. Women are also placed at risk by societal norms which allow men to have many sex partners while requiring women to remain monogamous. FP programs have also placed more emphasis on high technology contraceptive methods, which foster a degree of dependency on the FP services, than on barrier methods which the women themselves could control. This is especially true in countries of the South where the emphasis is on reducing population growth. FP programs, which often represent the sole social service available to women, must reformulate their role to promote greater awareness and negotiating power in women. Women worldwide are demanding access to safe contraception and abortion and wide recognition of reproductive rights. Encouraging women to become active participants in reproductive and sexual choices will lead to radical changes in gender relations. FP policies should not only work to empower women, they should also reevaluate contraceptive methods on the basis of the risks of HIV infection and give priority to the barrier methods which combine contraception and prevention of disease.
Which contraceptive methods are suitable for the older woman?
This discussion considers contraceptive options for older women (over age 35 years) in terms of efficacy, safety, tolerability, reversibility, coital independence, and protection from sexually transmitted diseases. The discussion is illustrated with figures showing the number of births to older women in the US, maternal mortality rates according to age in the US, abortions/1000 live births by age in the US, failure rates for contraceptive methods (per 100 woman years) by age, the lowest expected and typical failure rates for various contraceptive methods, the safety of various contraceptives for women aged 35-39 years (death rates/100,000/year), and the mortality risk according to oral contraceptive use and smoking status. Information is then presented on various methods to prevent pregnancy if contraception fails, including the Yuzpe method, administration of Danazol, use of Mifepristone, and insertion of IUDs. The percentage of women beginning menstruation on given days in relation to expected onset of menstruation is illustrated schematically for the Yuzpe method and administration of mifepristone postcoitally. Treatment with Nonoxynol-9 following unprotected intercourse to reduce the possibility of sexually transmitted disease is mentioned. New contraceptives which are on the market or are under study include FlexiGard, a new type of IUD; hormone-releasing IUDs; injectable steroids; implants; vaginal rings; and skin patches. Finally, mention is made of new male contraceptives in the form of injectables, implants, and vaccines as well as the contraceptive use of gossypol.
Doing a feasibility study: training activities for starting or reviewing a small business.
This manual presents a series of activities which enable women in developing countries to perform a feasibility study in order to examine various business options and carefully determine which one is economically feasible. Whereas, the facilitator must be able to read the book, the program is designed to be used by women who are illiterate as well as those who can read. The manual opens with notes to the facilitator and information on planning a program (appropriate meeting places, necessary materials, possible schedules, etc.). Part 1 introduces participants to the concepts of a feasibility study using a story and a series of posters to depict the experiences of a group of women. The 6 steps of a feasibility study (choosing a product, determining if there is a market for the product, deciding how the business will operate, calculating business expenses, estimating sales income, and deciding if the business is a good idea) are then presented. For each step, several learning activities are given. Part 2 of the manual, "Doing a Feasibility Study," presents tips for the facilitator and discusses ways of obtaining necessary information and how to decide on a business. Training activities and guidelines for each subsection enable women to conduct their own research, analysis, and decision making. Participants end with a concrete business plan. Each learning activity is organized according to purpose, time, rationale, preparation for the session, and steps to follow. This allows facilitators to refer to the manual during sessions.
Social network influences on contraceptive use among Cameroonian women in voluntary associations.
A study of women's networks in Cameroon was undertaken 1) to contribute to the theory of the diffusion of innovation by determining how information circulates among individuals in informal associations, 2) to demonstrate the feasibility of using network methods to understand informal associations and their use in program design, and 3) to demonstrate how social networks function in the diffusion of health information. In this study, the role of interpersonal communication and behavior change was measured using the association between personal network characteristics and contraceptive use. The members of 9 women's groups (total 495 women aged 15-45 years old) were interviewed in 1993. Each woman's personal network was identified and then the woman was asked whether she thinks each correspondent named 1) approves of family planning, 2) uses a contraceptive methods, and 3) encourages the use of contraception. It was found that perceptions of network approval, use, and encouragement of contraception were associated with an individual's contraceptive use. Awareness and use of a specific method also correlated with awareness and use of that method by a woman's personal network. Heterogeneity in personal network characteristics was associated with the use of traditional but not of modern contraceptive methods, and network support was related to continuation. Since these data show that perceptions of network support of a health-related behavior are associated with that behavior, planners should encourage people to talk about health practices to accelerate diffusion of information.
This workshop was presented in Baltimore, Maryland, in the fall of 1992 as the latest in a series designed to provide high-level training to strengthen the skills of individuals involved in the design and management of health/family planning IEC (information, education, and communication) programs in developing countries. The 3-week workshop covered such topics as behavior change, the communication process, audience identification, interpersonal communication, message design and media selection, strategic planning, evaluation and monitoring, rumor and crisis management, cost sharing, social mobilization, enter-education, and management. Based on a pre/post-test evaluation, the 32 workshop participants showed a marked improvement in their skills. Participants also gave the workshop a very high evaluation and made the following recommendations. 1) Efforts to recruit participants for the next workshop should focus on division managers and those in a position to make policy decisions. 2) More African case studies should be developed to illustrate topics. 3) The time allocated to the social marketing session and the research and evaluation session should be extended. 4) The "Simulation of Communication Planning Exercise," an interactive software program used in the English-language version of this workshop should be incorporated into the French workshop format.
University students' decisions related to abortion issues.
A pilot study was undertaken to determine the "yes" or "no" responses of 167 university students to whether abortion should be allowed in 15 hypothetical situations. 90% believed that abortion should be legal. 89% would allow abortion in cases of rape, 94% in cases where pregnancy was harmful to a woman's health, and 74% in cases where pregnancy was harmful to mental health. 74% believed that fathers should bear half the financial burden, but 50% believed that the father's signature should not be required. The respondents were just about evenly divided with respect to economic hardship, if the pregnancy was unwanted, if the mother was unmarried, if the mother was over 40 years old, and whether or not the government should fund abortions for low-income women. If no contraception was used, only 38% would approve of abortion versus 53% if contraception failed. If the mother was an adolescent, 55% said abortion was acceptable, and 44% said it was not, but 63% felt that parental consent should be required for women under 18 years old.
Combining HIV and STD services in Trinidad and Tobago.
In Trinidad and Tobago, a client-based needs assessment was made of the Queen's Park Counseling Center and Clinic in order to assess sexually transmitted disease (STD)/HIV services from a client point of view, to explore patient information needs and perception of case management and care, and to identify strategies to improve and expand clinic activities. The study used qualitative and quantitative methods (focus groups, interviews, surveys, and patient flow analysis) and revealed that STD service clients were relatively well served. The STD treatment protocols, patient flow systems, and doctor-patient relationships have been mimicked in the newer HIV-services unit, but they have not adequately addressed the needs of these clients, especially those who are HIV-positive or have AIDS. The needs of HIV/AIDS patients include doctors trained in sensitivity issues, clear treatment protocols, empowerment in developing survival regimens, counseling, promotion of support groups, food, clothing, and shelter. It was concluded that when HIV programs are added to existing STD services, the advantages include the opportunity to help prevent HIV transmission and to introduce behavioral interventions, but the disadvantages include a new demand on limited resources and greater patient expectations of the doctors.
Unnecessary injections increase the risk of AIDS transmission [letter]
Among 2953 drug prescriptions at 2 primary health centers in India, 1406 were for injections (474 vitamin B complex, 465 parenteral antibiotics, and 165 analgesics, with 60% given for placebo effect). 355 patients received tetracyclines, which are poorly absorbed through injections, and the drugs were only properly indicated for 15 of these patients. The primary health center nurse used 10 glass syringes and 25 needles to administer 150-200 injections/day over a 3-3.5 hour period. It is, thus, impossible to guarantee adequate sterilization of this equipment. Whereas the health center doctors were aware of the danger of AIDS transmission through injections, they felt immense pressure from their patients to prescribe injection. Because disposable material is not financially feasible for Indian health centers, the supply of needles and syringes should be immediately increased to improve chances of adequate sterilization. In addition, an intensive medical information campaign should warn prescribers and patients alike of the dangers of AIDS transmission in order to reduce the number of injections.
Sexuality education in Brazil.
The development of a comprehensive program of sex education in Brazilian schools is described in the context of Brazil's culture and traditions such as the Carnival. The influence of Catholicism is explored as is the effect of the behavioral restrictions called for by scientists concerned about sexually transmitted diseases. The Brazilian response to homosexuality is described, and the emergence of a public discussion of sexuality in the media is traced. It is noted that improvements in the status of women have been held in check by a public ridicule of feminism and by the strength of the traditional patriarchal structures which dominate the culture. With this picture given of how the issue of sexuality fits into Brazilian life, the 1980s initiative on the part of the Work and Research Group for Sex Education is described. Opposition to this effort has largely taken the form of passive resistance; even the Catholic Church has not officially protested the sex education program. Details are provided about 1) the selection of teachers, teacher training, and weekly supervisory teacher meetings; 2) the way in which parental permission for student participation was gained; 3) the implementation of the program; 4) the successes achieved; and 5) the difficulties encountered. Finally, it is noted that plans were made to expand the sex education project from the Sao Paulo area to 6 additional large cities in 1994. Also planned is the publication of the Brazilian Guidelines for Comprehensive Sexuality which will explain the sex education methodology and be extremely valuable in the establishment of new projects.
Female genital mutilation, which is practiced in more than 30 African countries and in the Middle East and Southeast Asia, has recently been the object of media attention in the US. An illegal immigrant in Portland, Oregon, asked a judge to grant her asylum so that her 2 young American-born daughters could avoid a return to Nigeria where they would be forced to undergo removal of the clitoris in a ritual more than 3000 years old. The judge granted a suspension of deportation and opened the door for the woman to attain US citizenship. Meanwhile, 2 women members of the US Congress introduced a bill to ban the practice of female genital mutilation in the US, and US women's groups have rallied around efforts to ban the practice in its originating countries. These actions have led to a debate about whether this concern arises from humanitarian grounds or represents efforts to impose the values of one culture on the other. Those opposing female genital mutilation consider the practice torture, child abuse, and as wrong as customarily enslaving people. Those who defend it maintain that efforts to change it are just a form of cultural imperialism imposed by people (Americans) who have a great deal of violence in their own society. The defenders of this traditional practice believe that if Americans are so concerned about the quality of life for African women, they will increase their aid to Africa. Meanwhile, little girls will continue to be subjected to this procedure which is performed without anesthesia and is extremely painful and which results in chronic urinary tract infections, severe trauma at childbirth, pelvic infections, painful intercourse, and a higher risk of HIV infection.
Female genital mutilation, which has been performed on 85-114 million girls and women, mostly in Africa, presents a great threat of HIV infection. The operation can occur at various ages but is most frequently performed between age 4 and 8 years. The severity of the mutilation can range from the excision of parts of the clitoris to the excision of the clitoris and the labia minora and majora and the stitching together the remaining sides of the vulva, with only a small hole left for urine and menstrual blood. This method, known as infibulation, as well as the unintended infibulation which results from the healing of methods which remove less tissue, causes extreme problems during intercourse and child-bearing. Female genital mutilation is carried out by traditional practitioners in unsterile circumstances without any anesthesia. The health consequences of the procedure were severe even before the risk of HIV increased their life-threatening aspect. Mass circumcision of this sort has been conclusively linked with the spread of the AIDS virus, and the trauma of cutting open an infibulated woman for intercourse or child birth also increases the risk of infection. While the threat of HIV may convince some people to change this practice, it is unlikely to have a great impact because this practice is bound up with issues such as the status of women in society, female sexuality, and sexual health. Female genital mutilation will not be adequately addressed until these issues are faced.
The history of steroidal contraceptive development: the estrogens.
Our understanding of estrogenic activity began in 1912, when Adler and Fellner in Vienna and Iscovesco in Paris obtained the first ovarian extracts and Haberlandt concluded that ovarian interstitial tissue inhibits ovulation during pregnancy, through the 1920s when Fellner produced sterility in rabbits and mice and Allen and Doisy isolated crystalline estrone. By 1930, Reiprich correctly assigned the antifertility action of the estrogens to pituitary inhibition. The testing of estrogenic materials for a variety of gynecological disorders continued in the 1930s, with researchers seemingly unaware of the earlier ovulation inhibition work. In 1936, Kurzrok predicted the prospects for hormonal sterilization in a paper that was largely ignored. Research continued on the use of estrogen to treat dysmenorrhea by inhibiting ovulation. At this point, contraception was not one of the many possible applications of this procedure under consideration. In 1945, Albright identified the potential of ovulation-inhibiting doses of estrogen as a contraceptive. His suggestion was also doomed to oblivion. Since none of the estrogens at that time were consistent in their ovulation-inhibiting effect, clinical trials would have been disastrous. In 1960, clinical trials with the 19-norprogestins took place in Mexico City. The oral contraceptives (OCs) were "contaminated" with mestranol, and research revealed that the ethinyl group has a special role in potentiating gonadotropin-suppressing action. This led to the development of "sequential" OCs, which in turn were replaced by monophasic formulations of lower dosage. By 1975, the dosages were reduced even further. Debates over proper dosage were confounded by the fact that mestranol must be demethylated to become biologically active. It is now known that plasma ethinyl estradiol levels are comparable from a single oral dose of 50 mcg mestranol and from 35 mcg ethinyl estradiol. Current research continues with the 11 beta-methoxy ethinyl estradiol, which is 10 times as potent as ethinyl estradiol and has some unusual metabolic features because it does not form oxidative metabolites.
The author of this letter is responding to some of 32 letters written in response to an essay the author published about abortion. The author believes that abortion is such an emotionally-charged issues that it prevents many people from reading what is actually written on the subject. He sets some critics straight about his intent and challenges the apparent cost-benefit analysis used by others to justify abortion on demand. Critics who reject the author's view about when a morally significant human life begins would seemingly favor a strict legal ban on all abortion, which is a situation not found in any nation in the world. What the author is asking for is the development of a moral environment in which decisions about life and death are taken seriously. He believes that this is virtually impossible in the US. Finally, the author believes that arguments that life begins at conception will not reestablish abortion as a moral issue, and that matters might change if people were asked to see, and not merely to imagine, an 8-week human fetus.
Federal anti-violence law used to respond to anti-choice threats.
On January 6, 1995, a temporary restraining order was filed in US District Court in Missouri against an anti-abortion activist who "has engaged in an escalating practice of threats and physical acts to intimidate and interfere with employees and patients of Planned Parenthood clinics." The activist was restrained from approaching within 500 feet of a women's health clinic that provides abortions and to cease making threats against clinic staff and patients. A January 17th date was set for a hearing on a preliminary injunction pending the outcome of a civil action against the activist. Also on January 6th, attorneys for the Justice Department in Ohio filed a motion for a preliminary injunction against an anti-abortion activist who allegedly threatened the lives of a physician who performs abortions and of his wife, a nurse. This suit is the first filed by the Justice Department based on the new Federal Freedom of Access to Clinic Entrances Act (FACE).
Family planning IEC project in Ghana: impact on Ghanaian males.
As part of a larger study to evaluate a family planning (FP) information, education, and communication (IEC) public sector project undertaken by the Ministry of Health in Ghana from September 1987 to April 1993, this report presents findings from 1990 and 1991 on the extent to which the IEC project reached Ghanaian males, the degree to which the IEC audience increased as the project progressed, and the degree to which the IEC project influenced male FP knowledge, attitudes, and practice (KAP). After presenting background information on the larger FP/IEC project, which was developed in 6 stages (situational analysis, training of service providers, IEC material development, an initial campaign in 3 regions, a second campaign in the same 3 regions, and expansion of the campaign country-wide), the methodology of the substudy (sampling, timing of data collection, and survey instrument and procedures) was detailed along with the results in terms of sociodemographic characteristics of the 625 men sampled, FP/IEC reach, the effect of campaign length, the current use of modern FP methods, and current condom use. It was concluded that both the nation-wide IEC effort and the localized intensive tri-regional campaign were effective in transmitting FP messages to men. As was to be expected, men in the regions where the intensive campaign occurred received more exposure than men in the other regions. A single additional year of campaign development resulted in 26% more men exposed to FP method leaflets, 28% to method booklets, 16% to posters or billboards, 13% to a FP television drama, and 25% to the theme song. In addition, 25% more men reported participating in a FP community mobilization activity. It was concluded that there was a significant increase in men's FP KAP as the length of the campaign increased. This success should be shared by all the organizations promoting FP in Ghana.
Half the world, half a chance. An introduction to gender and development.
A descriptive analysis was provided of how discrimination actually operates within different societies. An explanation was provided for why women are disadvantaged and why development efforts have failed to help women. Many illustrations from Oxfam's experiences were given to show how women can be part of social changes to improve their lives. The first chapter defines gender as the male and female characteristics attached to biological sex, which change over time and include the roles of both men and women. The following chapter addresses the issue of development as a gender issue. The Association of African Women for Research and Development voiced in 1985 the position that the major problems in Africa were "external domination and misplaced priorities of existing development strategies." There has been complete neglect of traditional forms of cultivation for local production, mostly by women, in favor of export markets. The assumption has been that only paid labor produces value. The obstacles identified by women were international development, the local context of unjust social structures, oppression and repression and inequalities of power, colonialism, environmental damage, the debt crisis, the lack of investment in the poor, and unequal impacts of development. Development Alternatives with Women for a New Era (DAWN) has proposed that poor women's perspectives offer a needed orientation to development analysis. How much power women have to set their own agendas is an ignored issue. Chapter 3 focuses on reproductive and productive work, which is devalued or ignored in the model of development for male headed households. Female subordination that is mediated by class and race is addressed in chapter 4. Women have gained some economic advantages in the manufacturing industry, but it has been at the expense of low pay, lack of job security, and exploitation. Chapter 5 focuses on nationality, class, and race as oppressive to women. Both chapters 4 and 5 provide case studies. Development at the crossroads, as the topic of chapter 6, presents the perspective that there are a number of crises: poverty, lack of food and water, cash crops versus food, urban migration, population pressure, environmental damage, and war and civil conflicts. Chapter 7, on reassessing the role of women, emphasizes that empowerment of women to bring about greater equity should be the aim of development. The practical issues of women in development are exposed in chapter 8, and chapter 9 discusses maintaining faith in the ability of humans to direct their own destiny individually and collectively.
This volume updates a prior 1990 publication on Sex, Population, and Politics. It includes a discussion of population growth, population aging, the sociology of sexuality and population, sex and religion in history, abortion without extremisms, the nature of the opposition of the Roman Catholic Church to birth control, and an appendix on practical ways of promoting birth control (publicity, campaigns, language and slogans, funding, motivations, and humor). The author was trained in philosophy and theology at the Pontifical Gregorian University of Rome. Each chapter is part of a larger publication. The position is taken that overpopulation and false remedies must be addressed with contraception. Aging of populations is viewed as population maturity and as a tool of "populationist" societies. Social change is key to population change. Abortion should be approached without extremes.
Reversing the spiral: the population, agriculture, and environment nexus in Sub-Saharan Africa.
Recommendations are made to promote small family size and family planning according to cultural and agricultural/economic incentives and to create demand for sustainable agricultural technology and eliminate open-access land tenure. A market for fuelwood should be created and environmental degradation reduced through multiple policy changes, agricultural intensification, and land tenure reform. Environmental action plans should be generated and urban policies formulated based on spatial plans and the integration of population, environment, and agriculture. Community and individual management would be encouraged. Gender issues and risk perceptions of local people are important. Social organization is very complex and attention must be paid to the organization of production and consumption, decision making, and access to resources. Over 50% of African countries have instituted some form of macroeconomic and agricultural policy reforms. Kenya, Uganda, Tanzania, Botswana, and Mauritius have made progress toward fertility decline, environmental protection, and agricultural growth. In many countries major efforts are still needed. Forest cover is decreasing at a rate of about 2.9 million hectares/year. Market-based agriculture has not advanced very rapidly due to lack in agricultural research, inappropriate agricultural marketing and pricing, and poor transportation systems. Increasing crop area has been the solution to increased population. Women are at the center of agricultural production in Africa and have heavy pressures on their time from the multiple roles of childbearing and rearing, family maintenance, and income-producing activities. Political and economic elites have gained access and control over open-access land and nationalized ownership to favor private investors and public projects. Fuelwood had been considered everyone's right, and markets for fuelwood have suffered. The African traditional production methods, land tenure systems, fuelwood provision, building materials, and gender roles were well suited only to low population size and growth. Degradation of environmental resources has been the result of rapid population growth and other factors such as civil wars and poor rural infrastructure.
Country statement submitted by the government of Austria.
About 7% of the total population of 7.9 million in Austria are international migrants, mostly from the former Yugoslavia and Turkey. Austria has also received displaced persons and illegal immigrants. OECD has recommended that Austria and other European countries contribute at least 1% of public development aid to population related projects. Austria has been increasing its contributions to reach this recommendation as one means of responding to migration pressure. A comprehensive foreigner and immigration policy has been devised which distinguishes between refugees and asylum seekers and displaced persons and other immigrants. Legal settlement is dependent on the socioeconomic capacity of Austria. Austria has also been active internationally in conferences and agreements. Migratory gains between 1981 and 1991 have contributed to a population growth of 3.2%. Smaller birth rates have contributed to an increased older population aged over 60 years (20.3% in 1991; 6.8% aged 75 years and older). In 1987, the total fertility rate was 1.43 children and the net reproduction rate was 0.68. Family policy has redistributed income to favor low-income families and granted generous maternity leave. The general policy direction is for further increased education about contraception and expansion of services for young people. Free condom distribution is currently being piloted in schools. Life expectancy has been increasing and in 1991 was 72.6 years for males and 79.2 years for females, mostly due to reduced mortality among the aged.
Country statement submitted by the government of Canada.
Over the period 1990-95 Canada is committed to an active immigration program compatible with global economic trends and social, humanitarian, and economic objectives. Improvements are being made in the management of refugees and immigration. 16% of the current total population of 27 million are permanent immigrants. 250,000 immigrants will enter the country in 1995 based on a predetermined quota set in the 1990-95 five-year plan. Canada's immigration policy and programs are affected by the global economy and the need for new skills and experience, the increase in irregular, uncontrolled migration, and the lack of balance between demand for opportunities for immigrants and supply of immigrants, and other factors. The approach to immigration is two-faceted: to accommodate migrants effectively, humanely, and efficiently and to reduce emigration pressures and incentives and improve conditions in home countries. Canada's policy in international affairs is to use international cooperation to achieve better management of immigration. International cooperation is needed in response to economic deprivation, conflict, environmental degradation, rapid population growth, protectionist trade policies, and the debt burden. Canada has had below replacement fertility since 1972, even with a rising birth rate in 1990 to 1.82. Canadians exercise free individual choice in family planning practice, and collective responsibility for protecting the global environment and resources must also be respected. Abortion has been available since 1988, but not as a source of contraception, and contraception since 1969. Mental incompetents are protected against unlawful sterilization by the state for nontherapeutic reasons. Mortality and infant mortality have declined since 1980. Life expectancy is 74 years for men and 81 years for women. Canada has given support for population related activities in family planning and maternal and child health, basic data collection and analysis, institution building with funding through multilateral and bilateral agencies and nongovernmental organizations. Total disbursements for 1993 were $37.7 million. Future training will be conducted on sustainable development. The recommendation was that the European Conference for the 1994 Conference on Population and Development in Cairo be directed not just to European concerns.
Country statement submitted by the government of Cyprus.
Total population in Cyprus in 1991 was estimated at 714,600 persons, with an average annual growth rate of 1.2%. Population aged under 15 years was 26% of total population, and 10% was aged over 65 years. Cyprus has had considerable emigration: in 1960-61 after independence, in 1964 with civil unrest, and in 1974-76 with the Turkish invasion and occupation. The most recent crude marriage rate was 9.1/1000 during 1988-91; marriage age increased to 24.1 years for females and 26.9 years for males. Fertility declined to 2.37 during 1987-1990 and then increased to 2.41 during 1988-91. Life expectancy was 74.1 years for males and 78.6 years for females. Cyprus has a population growth rate of over 1% and the government perceives population size as too small for fulfilling labor needs. The 1989-93 Development Plan proposed a high growth rate and return of emigrants. Immigration is restrictive and must fulfill requirements for not competing with Cyprian labor needs. Recent measures were passed to increase the tax allowance for large families, to provide for the housing needs of low income families, to extend maternity leave, and to promote the establishment of nurseries near industrial zones. Contraception is allowed but does not have government subsidies; abortion is allowed under certain restrictions, including the psychological or mental health of the mother. Sterilization is permitted with spousal consent, but not encouraged for young women or women with no children. Government policies aim to expand infrastructure, promote healthy life styles, and provide a National Health Scheme. Cyprus is a recipient of foreign aid.
Country statement submitted by the government of the Czech Republic.
Since the Czech Republic was newly created in January 1993 there has not been any attempt to stipulate desirable population levels. Population policy has been discussed, but the concern, if any, is for the aging of the population. Migration has been primarily from Slovakia; the numbers have declined since the 1950s to about 1000 from Slovakia and about 3000 from the rest of the world. The estimated illegal immigration is around 5000/year. There were an estimated 90,000 illegal immigrants in the Czech Republic in 1993. The German policy to return illegal emigrants to the nearest safe country from which the emigrants came could make the Czech Republic a dumping ground. The typical pattern is marriage, and out of wedlock births stood at 9.8% in 1991, mostly to single women. The divorce rate has increased to 40.8/100 new marriages in 1991; the highest rates were among women aged 20-29 years and men aged 25-35 years. The typical age at marriage is 19 years. Fertility is not likely to exceed 2 children/woman. The abortion rate is very high and almost equal to the birth rate (92.0/100 births). There is limited contraceptive awareness and usage. Legislation is being drafted with some restrictions on abortion and withdrawal of free abortions. The life expectancy is 67-68 years for men and 76 years for women. Decree no. 273 provides for government promotion of healthy life styles through prevention and primary health care. Regular health examinations are required for all children. The goals in 1993 were to implement intergovernmental health agreements and to draw laws on public health protection, chemical substances, health services, provision of health care, mandatory employment injury insurance, abortion, and legal protection of health resorts. International cooperation in development was considered beneficial.
Country statement submitted by the government of Denmark.
Denmark does not have any population policy to influence the size, growth, or structure of the population. The aim is to assure all citizens reasonable living conditions and guaranteed rights during unemployment, illness, or old age. The growth rate is zero, and fertility is 1.68. The proportion aged 65 years and older has increased to 15.6% of total population. Immigration policy is directed toward discouraging the numbers, particularly refugees from the former Yugoslavia, and providing assistance to reduce economic motives for departures. Migrants in Denmark are strongly encouraged to integrate into Danish society. Free counseling for family planning, abortion, and infertility treatment has been available to women since the 1970s. Abortions are 1 in 3 births and are free. During the 1980s, unmarried mothers and cohabitation have increased. Day care facilities are publicly subsidized. Mothers and fathers have maternity/paternity rights. The future agenda is to provide flexible working hours and nursing days. The 1989 health promotion program aimed to reduce infant and child mortality, to reduce the number of disabled, and to enable the aged to maintain their quality of life. The emphasis was on prevention of accidents, cancer, and cardiovascular disease and promoting healthy dietary habits. The government aims to reduce the social and health impacts of alcohol use and to limit the harmful effects of smoking. Development assistance has grown for support of population related activities. There has been recognition of the linkages between sustainable development, women's participation in development, and population issues. Population support requires that family planning programs be integrated into the existing health and educational system, and services must not involve any coercion. Danish development supports improvement in women's status, living conditions, and reproductive health care. Regional urban planning and sustainable human settlements development are supported.
Country statement submitted by the government of Finland.
In the 20 years following World War II, Finland's population growth declined markedly. Recent increases confirm fertility at 1.79 for 1991, which is higher than it has been since 1970. Fertility is expected to increase until 2010. The country is very homogenous: the largest minority are Swedes, who comprised 6% of the population in 1991, and Lappish people. There are integrated labor markets between Sweden, Finland, Norway, and Denmark. Migrants with Finnish origins from the former Soviet Union have increased. Refugees numbered 6000 in 1993. Finnish family policy strives to secure close and firm human relationships for children and family members, to improve economic conditions for families, and to secure the preconditions for balanced population development. Family type does not determine the nature of family support. Parental leave amounts to 263 week days and is 66% of annual income. Child home care for children under 3 years of age and municipal day care are provided. Men's life expectancy was 71.4 years in 1991; women's was 79.3 years. Infant mortality was low at 6/1000 in 1991. Cardiovascular diseases are a primary cause of death; declines have occurred in this disease group since 1970. Accidents and suicide are very high in Finland compared to other Nordic countries. Lower social classes have a higher mortality rate. Future emphasis will be on outpatient treatment, promotion of health prevention, and a balance between health care and illness treatment. Finland's position is that rapid population growth is related to poverty and slow socioeconomic development. Increased levels of education and gender equality are viewed as necessary for poverty alleviation. Improvements in basic health care also contribute to social development and thus slower growth. International funding has increased and was 85 million in 1991. Development and population related aid will be reduced in 1993 to 0.4% of the gross national product.
Country statement submitted by the government of the Republic of Estonia.
Total population in Estonia is about 1.6 million, of whom 26% are foreign-born, 61.5% are ethnic Estonians, and the remaining are non-Estonians. The sociocultural heterogeneity has been used politically as a measure of ethnic inequalities. Total fertility declined to 1.7 in 1991, the year of independence. The life expectancy is 66.2 years for males and 75.0 for females. The new government will be challenged to building a new social security system for the aged under poor economic conditions. There will be voluntary resettlement of immigrants from the Soviet period; if reunification of families occurs, immigration will increase. Immigration had declined between 1990 and 1993, but illegal immigration increased. Marriage, sexual, and reproductive patterns are similar to Scandinavian models. Cohabitation accounts for 60% of first unions. Abortions exceed the number of live births. Family planning is limited and abortion is used for fertility regulation. Current problems are a sufficient supply of adequate housing and longterm social security. Mortality patterns are similar to European patterns, with the exception of the high levels of accidental and violent deaths, which constitute 16.4% of all male deaths and 5.0% of all female deaths. Cardiovascular disease and cancer mortality is high. The draft Health Protection Act aims to improve life style, reduce environmental pollution, and prevent disease. Prior to World War II, data collection and analysis was very detailed and efforts will be made to improve data systems. Limited funding has prevented more rapid processing and implementation of data collection.
Country statement submitted by the government of Germany.
Total population in Germany was 80.2 million in 1993, and population is below replacement level. The age structure of the population reflects labor shortages and increased aging. Demographic changes will impact on production, income and wealth distribution, and social services. Recent tax changes have provided for compensation for home-based nursing care. Out-migration from the German Democratic Republic (GDR) occurred throughout its existence; the Federal Republic of Germany (FRG) absorbed 12 million Germans before the Berlin Wall was built and experienced foreign immigration until 1973 and after 1980. In 1991 and 1992, 700,000 asylum seekers were received. Demographic pressure and economic disparity account for the foreign migration. Since 1990, Germany has been engaged in efforts to stem the flight from home countries and is promoting voluntary return of destitute refugees and asylum seekers. The integration of legal foreigners would be facilitated by limiting migration from non-EC countries. Unemployment is high and there is no demand for foreign labor. In 1989, total fertility was 1.4 in the FRG and 1.6 in the GDR. Due to social changes, there has been a decline in marriages of 50% between 1990 and 1991, a decline in divorces of 70%, and a decline in births of 40%. Since 1972, the European pattern of increased one person households, single parent families, and consensual unions has appeared. Households of married couples with children decreased. Family policy supports child care under the age of 3, and over the age of 3 in educational institutions. Life expectancy was 72.5 years for men and 79.0 years for women in the FRG. In the GDR, life expectancy was 70.1 years for boys and 76.4 years for girls. Infant mortality was low for both territories at 7.5 and 7.6 per 1000 live births. Prevention of chronic diseases with early diagnosis and treatment, emphasis on nutrition, and information dissemination on AIDS are public health measures in effect. Germany has contributed to development cooperation with developing countries with a focus on population policy. Development efforts have supported a linked approach of provision of family planning and improvement in social and economic conditions with protection of the environment. Voluntary family planning and choice of a wide variety of methods is the backbone of efforts to provide services with respect for human dignity and cultural and religious traditions. Slowing population growth throughout the world is viewed as a means of coping with environmental problems and providing a future for generations to come. Germany has provided support to, among others, Bangladesh, Kenya, Tanzania, Zimbabwe, Burkina Faso, and the Caribbean countries.
Country statement submitted by the government of Hungary.
Hungary has both below replacement fertility and high mortality. There has been a deterioration in the stability of families, with a high divorce rate. Population policy is aimed toward reducing the population decline and providing a more favorable age structure. The objective is to reduce mortality, increase fertility, and strengthen material and social conditions of families. Due to resource limitations, the government will rely on the moral renewal of society. An Office of Refugee Affairs was established in 1989. In 1991, there were 75,000 refugees or displaced persons, including ethnic Hungarians. Many new arrivals are from the former Yugoslavia. Marriage and remarriage have declined since the mid-1970s. There is postponement of marriage and first and second births. 87% of children are born to married women. Family policy, since 1992, provides for free prenatal care and pregnancy allowances, at the same time regulating abortion. Social allowances are given to families with children for child raising. Male mortality is particularly high among those aged 30-59 years. High mortality was attributed to life style risk factors and mental hygiene, level of health care, and the role of environmental factors. Hungary is very interested in international cooperation within the European Community and gives support to population activities.
Country statement submitted by the government of Ireland.
Ireland's government considers that population size, growth, and structure are reflected in policies to secure a reasonable standard of living and to guarantee rights in the case of unemployment, disability, sickness, or old age. In 1992, legislation established family planning services through health services. Guidelines have been issued on sex and family life education. The Health Department has a comprehensive health promotion program for improving health status, for targeting specific groups and illnesses, and encouraging healthier life styles. Maternity benefits to those with insurable employment are available for 70% of wages, and tax benefits are available to low-income earners. Ireland supports the full and equal participation of women in the development process and agrees with the European Community's guidelines on family planning programs. A first-time contribution to the UN Population Fund was made in 1993, and further contributions are under consideration.
Advances in human reproductive ecology.
Human reproductive ecology pertains to reproduction biology and changes due to environmental influences. The research literature relies on clinical, epidemiological, and demographic analysis. The emphasis is on normal, nonpathological states and a broad range of ecological conditions. This review focused on the importance of age and energetic stress from ecological conditions rather than dieting or self-directed exercise in changing female fecundity. The literature on male reproductive ecology is still small but growing. J.W. Wood provided a comprehensive overview of the field. Natural fertility, as defined by Henry, is the lack of parity-specific fertility limitation. There is evidence that fertility can vary widely in natural fertility populations. There are consistent age patterns among different natural fertility populations. Doring found that there was higher frequency of anovulatory and luteal insufficiency in cycles during perimenarche and perimenopausal periods. Infertility studies have shown declines in pregnancy rates in women over the age of 30 years. Ovum donation evaluations have found both uterine age and ovarian and oocyte age to be related to the probability of a successful pregnancy. Basal follicle stimulating hormone and the endometrial thickness are important predictors of ovarian capacity and related to age and declining fecundity. Much of the literature on fecundity is derived from women with impaired reproductive physiology. In Lipson and Ellison's study of healthy women, average follicular and average luteal estradiol values declined with increasing subject age. Low follicular levels were correlated with smaller follicular size, low oocyte fertilizability, reduced endometrial thickness, and low pregnancy rates. Comparisons across populations have shown that populations experience declines in luteal function with age, but levels of luteal functions varied widely. Chronic conditions which slow growth and delay reproductive maturation may impact on lower ovarian function throughout adult life. There is a range of ovarian function along a continuum due to energetic stress. Evidence from the Lese in Zaire, the Tamang of Nepal, and Polish farm women outside Crakow suggest that workload affects ovarian function. Luteal function and ovulatory frequency is lower when women are losing weight. Among the Tamang losing weight between seasons there was evidence of lower ovarian function during the monsoon season. Polish farm women who work very hard in summer had lower ovarian function. The effect of lactation on amenorrhea appears to be due to the energetic stress on the mother in the intensity and duration of suckling. Women in poorer nutritional status may require more intense suckling. Seasonality of energy balance may be related to seasonality of female fecundity and conceptions.
Three nondeterministic models characterizing the interaction between population and conflict were described: 1) differential growth between ethnic or religious groups with a history of antagonism to the other; 2) lateral pressure of population size and growth leading to resource scarcity (Choucri and North); and 3) the impact of population size and growth on scarcity of renewable resources, which increases the size of marginal and impoverished groups (Goldstone). Discussion centered on the third model and specifically on the effects of population growth on cropland, water, forests, and fish in selected illustrated examples. Human-induced environmental change in quantity or quality of a renewable resource has been found to be determined by the product of total population in the region and use per capita of each of a range of technologies; and the vulnerability of the ecosystem to activities. When resources are degraded or depleted, social effects such as migration or increased impoverishment can turn to armed conflict within receiving regions or the same region in a feedback loop. Ideational factors are important: the resource distribution, the social distribution of wealth, the economic and political incentives to consume and produce material goods, family and community structures, perceptions of stability, historically rooted patterns of trade and interaction between societies, coercive power, and metaphysical beliefs. The conditions that exacerbate inequalities are the lack of democracy and equity, the low purchasing power of poor people and the resource undervaluation, and resource overexploitation. Environmental scarcity can be supply induced, demand induced, or structural and interactive and reinforcing. The consequences of these conditions may be the shift of resource distribution in favor of one group of powerful elites or resource capture, or migrations to marginalized land or ecological marginalization. Environmental scarcity can reduce economic productivity and increase financial and political demands on governments and revenues decline. The linkages between scarcity and conflict are mediated by each country's specific physical, political, economic, and ideational features. Recent research has shown that economic crisis must be "severe, persistent, and pervasive enough to erode moral authority." Other ideational features mediate the impact of scarcity on conflict. The options are to use resources more wisely or shift productivity to other resources with technical and social ingenuity.
Relative spousal status and child health in Sub-Saharan Africa: the case of Ghana.
This study expands the literature on the impact of gender relations on fertility decision making, and more specifically on child health and mortality. Decision making in sub-Saharan African households is vested primarily in males. Power in relations is traditionally derived in African societies from sources such as age, income, family, and kin group status. Modernization effects have increased women's level of education and occupation. This study examined the impact of women's power on the health status of children as measured by child inoculations: Caldwell's hypothesis about gender relations. Data were obtained from the 1988 Ghana Demographic and Health Survey on a representative sample of 4488 females aged 15-49 years and a subsample of 943 coresident husbands. 726 couples had a child born within the 5 years preceding the study. Controls included rural-urban location, mother's knowledge about access to inoculation centers, the presence of other children in the household, and child's age and sex. Preliminary analysis revealed that health card status was unrelated to education. 56% of women in higher level occupations had health cards for their children, while 48% of men in higher level occupations had health cards for their children. In the multivariate analysis, the findings were that those in professional occupations, regardless of whether the wife or husband, were more likely to have inoculated children. In the full model with controls and joint status of socioeconomic factors, the positive relationship between women's status and child health prevention was not supported. Female schooling becomes significant, and male advantage in education was associated with children's higher odds of having health care. An unusual finding was that male children had lower odds of being inoculated. Female familiarity with the inoculating health center, age of the child, and urban residence were statistically significant. The caveat is that the measure of women's power might reflect only potential rather than real power differences. The suggestion is that both spouses have an interest in the welfare of children. Further clarification of the role of women in decision making on health issues is needed, as well as analysis that considers the context of family relations, time, and place. Continued efforts should be made to improve access to health services for rural, poor, and uneducated people.
Teenage pregnancy: seeking patterns that promote family harmony.
Adolescents are at increased risk of pregnancy when they assert independence from parents, when their cognitive orientation interferes with prediction of long-term outcomes, and when they act out of family discord. The US teenage pregnancy rate is 96/1000 persons aged 15-19 years. The suggestion is that education programs have failed to address adolescents' developmental orientation. Previewing is one counseling methodology that could help the teenage become aware of outcomes. 1 out of 5 million sexually active adolescents become pregnant each year. The case history involved a white Caucasian teenager from an intact, upper middle class suburban household who had an abortion at the age of 14 years. The teenager became pregnant again and miscarried within 2 months of the abortion. She received a psychiatric evaluation and expressed the desire to have a baby and the feeling of still being the baby in her family, having 2 older siblings. The family history of marital discord was described. Family and individual therapy were arranged. The example of dialogue between the teenager and therapist indicated the teenager's inability to convey cause and effect sequences in a coherent fashion. The teenager's birth was an expression of unresolved conflict between the parents about a prior abortion. The power structure within the family was the following: the teenager and her mother allied against her father. The development of the teenager in the context of family conflict led to self-destructive behavior. The previewing techniques helped the teenager with her sense of mastery and control over her life, which replaced the need to challenge authority figures. The teenager learned how to articulate her needs for experimentation and the long-term implications of becoming pregnant. In the individual sessions, the previewing focused on details omitted in Jessica's perceptions in order to better predict future outcomes of behavior.
UN data was used to examine trends in urbanization in Western Asia (ESCWA region), to identify potential factors affecting urbanization, and to give an overview of the region's population policies. Over the past 40 years, the rate of urbanization in the region has been more rapid than anywhere else in the world. The world level of urbanization was 43% in 1990, in the ESCWA region it was 56%. By 1975, all countries in the ESCWA region experienced large urban increases, and the gaps widened between countries. The tendency was for increased changes with every five year period. Between 1960 and 1975, urban population growth was double or more than rural population growth, except for the United Arab Emirates. The pace of change slowed between 1975 and that projected for the year 2000. The gap narrowed between countries with high urbanization levels and those with moderately high levels. Increases in each 5 year interval were observed for South Yemen, Jordan, Lebanon, and Syria; decreases were observed with each 5 year interval for Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates, and North Yemen. Zero order correlations with the Spearman rank ordering technique showed a low negative relationship between population size and level of urbanization. Density and percentage urban in the largest agglomeration were positively and strongly related to urbanization. More densely populated urban areas were subject to greater urban increases. The total economically active population was weakly correlated with level of urbanization (0.692). The percentage engaged in non-agriculture and services were more strongly correlated (0.830 and 0.714, respectively). Smaller populations tend to have more advanced nonagricultural employment. Per capita gross domestic product was strongly associated with the percentage urban (0.709), but weakly associated with the percentage urban in the largest agglomeration and not at all related to population density. Urbanization and infant mortality were inversely related (-0.681). Infant mortality was correlated more strongly with percentage economically active in services (-0.852) and in non-agriculture than density or percentage urban in the largest agglomeration. By 1990, Bahrain, Kuwait, Lebanon, Qatar, and Saudi Arabia had 80% of total population in urban areas. Egypt, Iraq, Jordan, Syria, and the United Arab Emirates had urban populations ranging from 50% to 79%. Most governments in 1990 viewed their population distributions as less desirable. Nine out of 13 countries in 1976 recognized a policy objective of redistribution. All countries have a policy for promotion of small towns and intermediate sized cities. Seven countries out of 13 have policies for development of "new" towns and are using the development of public infrastructure and investment subsidies to encourage new development. Iraq, Jordan, Saudi Arabia, Syria, and the United Emirates are channeling urban development investment to specific industrial locations.
Population spatial distribution policies in Egypt.
In Egypt there is a concentration of population and economic activities in urban centers, particularly Cairo. Urban areas are defined as urban governates (Cairo, Alexandria, Port Said, and Suez), capitals of governates, towns and market districts, and towns with no rural settlements nearby. 42% of urban population was concentrated in Cairo and Alexandria governates in 1986. Population growth in Cairo alone in 1986 exceeded total population of the 23 new localities added to cities with over 50,000 population. Cairo has a population density 5 times greater than Port Said. Cairo Planning Region has 25.5% of total population and 61% of total crime; unemployment was 17.3%. Quality of life differences cannot be explained by disparities between rural and urban areas or urban governates and governates of Lower and Upper Egypt. A conceptual framework for describing population spatial distribution policies is provided, although the emphasis is on the main features of policies rather than specific policies. Policies can be explicit and implicit; regional, urban, or rural oriented in their approaches to migration and human settlements; with a range of policy instruments such as subsidies, tax incentives, infrastructure construction, housing, social services, industrial and investment allocation; and reflected at the national, enterprise, and/or individual levels. Policy approaches are deconcentration of population away from cities and the Delta, reconstruction of Canal cities, redirecting encroachment into agricultural land, and reclamation and development of uninhabited desert areas. The master plan for Greater Cairo Region considered all four approaches. An effectiveness evaluation was made of some urban, rural, and regional policies. The conclusion was that there has been a concentration on demographic aspects at the expense of socioeconomic aspects. Efforts have been directed to the Cairo metropolitan area, which undermines redistribution in other areas in Egypt. Recommendations were to integrate urban and rural oriented policies, reducing push factors in rural areas and pull factors in urban areas, promotion of secondary and medium sized towns, promotion of industrial and commercial development from the bottom up, redevelopment of congested areas, decentralized planning, and development of new towns.
Population spatial distribution policies in Jordan.
An understanding of the population issues of Jordan must entail consideration of the border changes, particularly after 1948. Population in a short time tripled to over 1,100,000. Fertility declined slightly from 44/1000 in 1979 to 38/1000 in 1983. East Bank censuses have revealed population increase from 587,000 in 1952 to almost 2.7 million in 1985. Population growth in the East Bank was 4.8% annually until 1979 and 4.2% until 1985. Amman grew from 214,000l in 1952 to 1.5 million in 1985, which was 56% of total population. Most population concentration is in the northwest and has been affected by natural change, voluntary internal migration, and refugee movements. Urban population increased from less than 39% in 1952 to almost 61% in 1985. The rate of urbanization slowed after 1961 and stabilized by 1985. Rates varied over time and space, and governorate urban growth has converged in the recent past. Socioeconomic factors have affected the demographic patterns: 88.1% of enterprises and 95.7% of employment are located in the Amman-Zarqa area. Development has been constrained due to the uneven pattern of population distribution and rapid population growth. 15-20% of arable land was used for urban expansion; considering that arable land is only 6% of total land area, this meant a considerable loss for agriculture and water resources. Jordan does not have a population policy; population issues are considered within development planning. The 1981-85 Development Plan addressed the disparity in resources between regions, and the following plan emphasized integrated regional development and agriculture. The 1986-90 Plan included an immigration and emigration policy with the intention of controlling labor migration. Quality of life improved under these plans: the number of schools increased, school facilities were upgraded, and the number of health centers and hospitals expanded. The improvements in social development, infrastructure, and manpower are assumed to be sufficient to influence fertility decline.
Population spatial distribution policies in Kuwait.
Kuwait is unique in having had a small population and rich resources for development. Labor migration to Kuwait occurred when investment in development exceeded the available Kuwaiti labor population. In 1985, only 11% of residents were natives of Kuwait. The desert restrictions on land use have contributed to the development of a city-state. In 1985, 90% of total population lived in localities of 10,000 or more inhabitants. Kuwait City represents the core area for the entire Arabian Peninsula. The government, in an attempt to change the concentration pattern and relieve overcrowding, has invested in the new towns at Subiya and Al-Khiran. Further substantial investment will be needed in order to attract a large number of employers and real estate investors for building a strong economic base. The recommendations were to adhere to the approved Master Plan and Local Plans, to ensure proper management of physical infrastructure, and to ensure that the proper authorities have well defined responsibilities and relationships to other ministries and agencies. Population projection for Al-Khiran is for 300,000 population by 2010, which is larger than the 200,000 originally planned for in 1984. A new review of the national physical development strategy should be undertaken and policy change implemented to account for this growth and the integration into the national plans.
Determining male fertility through surveys. The DHS experience.
Demographic and Health Surveys (DHS) have been conducted in the late 1980s and early 1990s with samples of married men. Nine countries have conducted these surveys, of which six were in sub-Saharan Africa. Six countries, of which five were in Sub-Saharan Africa, included all men, regardless of marital status. The use of male respondents in the DHS has produced some methodological issues: the nature of the sample, the nature of the questions, field procedure changes, changed measures of data quality, and expected response rates. The survey results indicate that reports of contraceptive use may vary widely between men and women. In Tanzania, men consistently reported higher contraceptive use rates than women. In the age groups 35-39 years, men reported 33% use and women reported 13% use. In the Northeast Region of Brazil, contraceptive use rates of men and women were more similar; women tended to report higher rates up to the age of 40-44 years and men reported higher rates after 45 years. The tendency is for women to report using the pill, and men were more likely to report the sterilization of the wife. In Cameroon, contraceptive use among men was 20%; among women, 16%. Men reported condom use and periodic and postpartum abstinence. Women tended to report pill use. Ideal family sizes were different between men and women. Similar family size desires were reported in Burundi, Kenya, Northeast Brazil, and Tanzania. Men were not asked for birth histories, but for how many children they had by sex. The number of living children reported by men and women showed women with more children between the ages of 25 years and about 40 years and men with more children with increasing age. For married men after age 50, the average number of living children was almost 10 children in Kenya. This pattern is similar to the pattern in Ghana and was attributed to the practice of polygyny and the large age gap between spouses which can be 10-15 years. In Burundi, men reported more living children than women for all age groups. In Northeast Brazil, the children reports were similar for men and women, with women reporting a slightly larger number. The issue of men not living with their children increases the risk of men not knowing whether a child is alive or not or the age of the child, which makes for difficult assessment of data quality. Male interviewers were used to conduct the survey in order to assure more accurate responses.
Life expectancies and mortality rates were provided on the minority nationalities in China in the first half of 1990. For nationalities with a population over 1 million, data was provided for life expectancy, the total mortality rate, the standardized mortality rate, and the infant mortality rate. This data included 18 minorities: Mongolian, Hui, Tibetan, Uygur, Miao, Yi, Zhuang, Buyi, Korean, Man, Dong, Bai, Yao, Tujia, Hani, Kazak, Dai, and Li. Life expectancies for 47 minorities were under the national and Han average. The lowest was 51.45 years for the Wa. 20 minorities had values under 60 years, which amounted to about 25% of total minority population. About 80% of minorities had mortality higher than the national average. Infant mortality was about twice as high as the national and Han majority average. The range was between 10.1% for the Xibo nationality and 143.34% for the Wa nationality. The highest infant mortality was among 3 nationalities in Tibet and Xinjiang and 7 nationalities in Yunnan Province. The lowest infant mortality (lower than the national average) occurs among a population of about 12.67 million, of which 95% are Man, Korean, Xibo, and Dawu'er. 95.53% of total minority population are 18 minority groups with populations over 1 million people. Out of the 18 minorities, 2 are above the national average (Man and Hui), 1 is just 2 years under the national average (Zhuang), and 5 are at or below 60 years of age (Hani, Tibetan, Kazak, Yi, and Uygar). The remaining 9 minorities have a life expectancy ranging between 63.75 and 66.72 years. 4.58% of total minority population comprise 15 nationality groups with population between 100,000 and 1 million: Lisu, Wa, She, Lahu, Shui, Dongxiang, Naxi, Jingpo, Kirgiz, Dawu'er, Mulao, Qiang, Gelao, and Xibo. The Mulao, Xibo, and She groups are over 70 years life expectancy and the lowest life expectancies under 60 years include the Wa, Lahu, Lisu, and Kingpo from Yunnan Province. 15 nationality groups had a population from 10,000 to 100,000 and 7 had several thousand population. Life expectancies for the very small minorities follow similar patterns as other larger minority groups in the same geographic area. Standardized Life Loss Rates, where a high level indicates high child mortality, were also computed. Gender differences for the largest minorities were provided. Total and standardized mortality for females was below that for males. Female mortality lower than male mortality with similar life expectancy included the Man, Hui, Mongolian, Kazak, and Tu. Higher infant and child mortality for females included the Zhuang, Miao, Dong, Yao, Tukia, Yi, Buyi, Bai, and Hanni. Lower female middle age and elderly mortality was the pattern for the Korean, Buyi, Tibetan, Dai, and Yi. High reproductive age mortality occurred among the Uygur, Wa, Kirgiz, and Salar. Higher female elderly mortality than male mortality include the Qiang, Bulang, and Maonan. The highest level of health of minorities was in the northeast (10 million), which has a high minority population among the Man and Korean. The largest minority concentration is in the southwest with 30 million distributed over 5 provinces; minority health is low in this region. 7 million minorities with the worst health live in Yunnan Province. The lowest life expectancies occur among a population of 40 million, or 46% of total minority population: 11 groups in Yunnan, 4 groups in Xinjiang, the Tu in Qinghai, and Tibetans in Tibet, Sichuan, and Qinghai.
The effect of gender and other factors on early child mortality in China.
Proportional hazards models for first order and higher order births were used to examine the effects of sex and other maternal demographic covariates on infant and child mortality in China. Retrospective data were obtained for a 10% sample from the 1988 2% sample of fertility and contraception conducted by the State Family Planning Commission. The sample included 89,086 children born during 1965-79 and 1980-88 to women aged 15-57 years in 1988. The data set excluded mortality during the famine in the later 1950s and early 1960s. The results confirmed a significant effect of gender on early child mortality. Female survival is the greatest if the female is an only child. The mortality hazard is higher for a female child with an older female sibling. Sex discrimination was most obvious among second and higher order births. The probability of a second birth and a short birth interval was higher for mothers with a female first child. Socioeconomic factors had strong effects on first order births. Mortality was lower among children born in urban areas to mothers with formal education and employment in nonfarming sectors. Child mortality was lower among the majority Han nationality. Survival of second and higher order births was affected by prior infant or child mortality and preceding birth interval. A comparison of the two time periods of births showed that child mortality among first order births was lower during the 1980s. There was higher mortality among second and higher order births. Female child survival was similar or above male child survival in 1965-79, but female child survival was lower than male survival in 1980-88. The mortality hazard by sex for second and higher order births with controls was significantly different at the 5% level, but not apparent for first order births.
The population distribution pattern in Xinjiang autonomous region.
Population distribution in Xinjiang Autonomous Region in China follows a high-density horseshoe-shaped pattern of oases surrounded by mountains and desert comprising 70% of the territory. The Region has the largest geographic area of all provinces, has 15.8 million people, and a population density of 9.5/sq. km. 90% of the total population lives in the more than 500 oases, with a population density of 200 people/sq. km. About 80% of the population has lived in the northwestern part of the province over the past 40 years; density is 15.5 people/sq. km compared to only 3.2 people/sq. km in the southeast. Population concentration is affected by natural resource distribution (water), industrial and agricultural production, transportation, and immigration. Population density increased by 4.7 times in northern Xinjiang, 1.2 times in the south, and 2.9 times in the east. Population concentration is also affected by elevation patterns. The largest population (46.33%) is situated in areas 1000-1500 meters above sea level, with declines at either increased or decreased elevations. Population density declines as elevation increases. Most of the old oases were situated in basins between 500 and 1000 meters in the north and between 1000 and 1500 meters in the south. Areas below 500 meters in the north and areas below 100 meters in the south are desert. Population distribution varied among the southern slope of the Altay Mountains, the northern slope of the Tianshan Mountains between 100 and 2500 meters, the eastern part of the northern slope of the Tianshan Mountains, the southern slope of the Tianshan Mountains, the western part of the southern slope of the Tianshan Mountains, the northern slope of the Kunlun Mountains, in Pamirs and the eastern slope of the Tianshan Mountains, and old oases at 500-1000 meters in the heart of Xinjiang, where major transportation routes cross China.
The chaos theory and population planning.
A theoretical model, based on chaos theory, was described for explaining population growth under planned control with and without controls in China. The theoretical application to demographic issues demonstrated that irregular changes in population do not always stem from random changes. Populations can follow cyclic or noncyclic patterns without random changes. Chaos theory provides an alternative to regression theory, which assumes random fluctuations are irregular and noncyclical. Various theories have been offered about the relationship between population size and population growth rates. Verhust suggests that resource limitation and other factors restrict the maximum size of a population, and as population reaches the maximum, the growth rate lowers. The mathematical expression of Casti was used to describe Verhust's concept. Peitgen and Richter postulate that there is an upper limit to population size and population can exceed or go under the ideal upper limit. The mathematical expression of this notion shows that long-term population increase or decrease is determined by the initial value of the ratio of actual size of population to the upper limit of the ideal size and the population growth rate. The application of the Li-Yorke theorem may explain the chaotic locus of fluctuating cycles; the "tent" function may be used to express dynamic noncyclical functions as changes to cycles. The growth rate is the key feature of the long-term pattern. If growth can be limited within 1 and 3, total population will eventually reach a stable value. Population control can adjust the population's natural growth rate in order to reach the planned goal.
Marriage squeeze and two-sex linear population model.
A two-sex linear model is described for expressing the decline in age-specific female fertility due to difficulty in becoming married because of a shortage of men. The model is used to explain the standard state and the extent of deviation from the standard state to cause a marriage squeeze. The conclusion is that the two-sex linear model does not describe the dynamic process correctly; a nonlinear model with appropriate marriage functions should be used when a sex ratio anomaly causes a marriage squeeze. The model in this analysis is discrete and assumes that the age-specific preservation rates, percentage of females born to mothers of the "ith" age group, and age-specific fertility rates among males and females do not change through time. The male fertility rate of each age group is zero and no migration occurs. The analysis shows that within 50 years or a life cycle the sex ratio of the "ith" age group will deviate from the stable state sex ratio by no more than the asymptotic sex ratio at birth minus the minimum sex ratio among children born to mothers of the "ith" age group, regardless of the intensity of the disturbance; this would be less than the state sex ratio times 0.0026.
Fertility in the German Democratic Republic (GDR) and the Federal Republic of Germany (FRG) was around replacement level until about 1975, after which, even with population policies and family policy incentives, fertility has remained below replacement. It is likely that below replacement fertility will continue and be compensated by immigration. Uncontrolled immigration and integration of immigrants should be the future policy focus. In 1965, fertility was 2.54 in the GDR and 2.51 in the FRG; by 1975, fertility had declined to 1.54 in the GDR and 1.45 in the FRG. Fertility of the 1930 birth cohort was 2.20 in the GDR and 2.15 in the FRG; the decline by the 1940 birth cohort was 1.98 in the GDR and 1.97 in the FRG. Birth cohorts in 1950 had a fertility of 1.79 in the GDR and 1.5 in the FRG; there was a modest increase of 0.09 in the 1960 birth cohort. The GDR government intervened in the mid-1970s with measures to encourage fertility of 2 or 3 children per woman. Improvements in child care for working mothers continued until 1990; the state paid for 80% of child care facilities. Child care was available for children aged up to 10 years and older for the entire day. Women in the GDR had a labor force participation rate of 80-90%, and 90% of all children use the centers. In contrast, the FRG also encouraged development of child care facilities, but contributed only 40% toward costs. The FRG does not have a formal population policy, because of the history of pronatalist policies under Nazi Germany. Fertility has been 1.4 in the FRG for a number of years, and about 24% of the population has no children. The effect of the GDR's policies was a slight improvement in 1980 to 1.94, but also high rates of out-of-wedlock births, very early marriage, and a high rate of remarriage after divorce. Fertility continued to decline thereafter to 1.56 in 1989 and 1.31 for first and second children. The state may need children for stability and survival, but fertility had always been a family decision. Change is unlikely because contraceptives and abortion are easily available and the total costs of child rearing cannot be paid by the state. Women's roles have changed, and both men and women want to have options in their careers. There has been a decline in sociocultural pressure for children and greater acceptance of unmarried and childless persons.
Population policies and fertility trends in Hungary.
In Hungary, baby boom fertility was short and low. Government prohibition of induced abortions in 1953 contributed to a rising total fertility rate (TFR) of 2.97 in 1954, but a decline by 1962 to 1.8. During this period the abortion law was liberalized. In 1966, fertility rose slightly after family allowances were increased; TFR in 1968 was 2.06, and TFR remained stable until 1972. In 1973, government restricted abortion for married women with children and child care allowances were increased again. TFR increased and in 1975 was 2.38. Thereafter, TFR declined to 2.0 in 1980, stabilizing at 1.8. During the 1980s family allowances increased and abortion law was liberalized and became socially acceptable. Inflation was high and fertility was no longer affected by erratic policy changes. Cohort fertility followed a smoother pattern: birth cohorts of 1926-30 were below replacement level. Birth cohorts of 1936-40 had lower fertility. After 1940 birth cohorts stabilized with completed cohort fertility of 1.9. The analysis of the impact of population policies, such as on induced abortion, indicated that completed cohort fertility in 1953-56 was unaffected. Abortion policy appeared to have only changed the timing of first and second parities, but social effects were felt in overcrowding of schools and child care centers. The 1973 abortion restrictions had less impact. Stabilization of cohort fertility occurred during the 1950s, when family allowances increased. Family benefits appeared to have affected only families with up to 3 children. Educational levels were increasing through this period and by the 1960s women desired more children, but average fertility did not change. To achieve fertility at replacement level, it was suggested that substantial family benefits will need to be provided. It was recognized that this may not be possible politically or economically.
Social policy and recent fertility change in Sweden.
The replacement-level total fertility rate (TFR) for Sweden is 2.09. Fertility in 1990 was 2.13, and in 1991, 2.11. Fertility decline ceased during the late 1970s and started rising in the mid-1980s. The baby boom was not very big. Demographic adjustments in Sweden have been milder than other European countries following similar patterns, but may suggest the trends ahead for these same countries. During the 1980s fertility increased, particularly among women aged 25 years and older, and now among all ages. There was a shift to first child bearing at older ages: from around 24 years for the 1950s and 1960s cohorts to 27 years for the 1959-62 cohorts. The change in age of childbearing for different cohorts is graphically displayed. Strong period effects were in evidence. The evidence suggests that the demographic patterns were affected by low-key and indirect pronatalist social policies. The accomplishment of increasing fertility and increasing work force participation of women is remarkable. Social policies which have encouraged this pattern include expansion of public day care, child benefits, parental leave provisions, parents' right to part-time work, and public campaigns. Women's responses during the late 1960s and early 1970s may have reflected the pioneering role of women changing and reorganizing that constrained fertility. The preference for a two-child family has been stable and cohort fertility is just under 2. Permanent childlessness rates have not increased, and one-child families are not growing in popularity. The Swedish pattern is one of postponement and then accommodation. Maternity leave has been available since 1974 and benefit increases and extensions have improved over time, such that in 1986 the extended benefit leave was 30 months. This allows having two children 2 years apart and, thus, remaining on leave with the employer for about 5 years.
Consultation on population policies: an overview.
This overview of population policies pertinent to European demographic conditions focuses on the type of policies, the European below replacement pattern and reasons why, the influence of access to modern contraception and safe abortion, and the advisability of pronatalist policy. Population policy exist within a social and theoretical sphere, while practical couple decision making about child bearing is micro level and complex. Policy implementation of even ambiguous goals is constrained by administrative, political, technological, economic, and ethical factors. Pronatalist policies to encourage early marriage and larger families should not be confused with social welfare policies aiming to ease the burden of child bearing and rearing and only indirectly affect reproductive decisions. Hohn has grouped policies into 1) direct policies affecting nuptiality, fertility, immigration, or modern medical services; 2) indirect population policies such as social security, education, labor market, housing, regional planning, and women's emancipation; and 3) adaptation policies such as aging or integration of foreign immigrants. The suggestion by Demeny is that indirect policies may be more effective in a social welfare state. Demographic patterns in each country reflect historical, cultural, and religious traditions, and changes in lifestyles and perceptions of the family and value of children. Over the past 20 years, many countries have had below replacement fertility. Initially, governments did not interfere with personal reproductive decisions; later various family, work, and social policies were implemented with unknown effects on cohort fertility rates. Private reproductive decision making is and has been influenced by the emancipation of women, economic conditions, motivations, and private orientations. Immigration policies are interrelated with population policies. Pronatalist incentives and disincentives for voluntary reproductive behavior vary with the intentions of the planners. Reproductive technologies and safe abortion have improved a couple's decision making about child bearing and balancing resources. Past experience has shown that prohibiting contraception and abortion have had a limited impact on increasing fertility, and the long-term effects on unplanned and unwanted children can be negative and severe. The prospects for passing pronatalist legislation are not good when those with completed families are a powerful voting block and will be a financial burden as elderly and thus not willing to support the social, economic costs of larger families. There is a variety of alternatives possible. The recommendation is for WHO in Europe to continue the exchange of information on the demographic and social impact of population policies in Europe, publish a compendium, involve policymakers, and support further analysis of Hungarian data.
Demographic effects of population policies in Bulgaria.
Bulgaria's fertility has remained unchanged and independent from measures taken to encourage fertility. Demographic transition began in 1912 and stabilized around 1950. Changes in fertility behavior were affected more by quick changes of any kind. The results from the World Fertility Surveys have indicated that there has been no change in the preferred number of children, which is between 2.05 and 2.25. The suggestion was that this stable trend is unlikely to change due to a 10-15% increase in family income. Over the years family income has changed and improved and desires have remained constant. The incentives have been 10-15% of the mother's salary for the second child and about 20% for the third child, but these incentives do not compensate for the long-term cost of child rearing: 43% of family income for the first child, and succeeding children never more than 13%. The proportion of first, second, and third children has remained stable between 1978 and 1987. The rate of childbearing has remained stable. Opinion surveys have shown that in 1980-81 73.1% of women agreed that government measures including financial ones did not influence family decisions about fertility. On another question, 60-80% thought that some financial help could change their position on childbearing. The conclusion was that if financial measures were used to stimulate fertility, the measures would have to be compensation to the couple and not encouragement.
Population policies and fertility trends in France.
Fertility in France has declined during three distinct periods. 1) Fertility declined between the 1950s and the 1960s due to smaller family size of about 3 children or less and more first and second children. 2) The decline between 1960 and 1970 was reflected in no large families at all, the marked reduction in third order births, and some decline in second order births. 3) After 1970, there is reduced fertility at all birth orders and decline in the interval between marriage and first birth. Other patterns are for a decline in voluntary infertility from 18% to 11% and a slight increase after the 1975 generation. 40% of the decline of legitimate fertility is due to the decline in third order births. About 405 of married couples prefer a two-child family. During 1983-85 cohabitation occurred before 66% of first unions. Divorce increased rapidly and remarriage declined. Out-of-wedlock births have become socially more acceptable. The tax laws give the same allowances for income and family size regardless of marital status, which favors common law unions. Social welfare funds are being redirected to aging and health programs. France has been one of the few countries with explicitly stated demographic objectives, in part because fertility began declining in the later 18th century and by 1980 the net reproduction rate was below 1. Over this long period, considerable attention has been directed to family issues in associations and among experts such as Landry, Sauvy, and Bertillon. A coherent system of social protection and family allowance laws emerged following the economic crisis of the 1930s. The public has viewed the rise in births during the 1940s, followed by stabilization, as the result of effective probirth measures.
The trend in Europe and among industrialized nations is toward zero replacement or under replacement fertility; this is occurring regardless of size, geographic location, or political system. Within the European community, Ireland had the highest birth rate in 1990 (18.1/1000 population); but it represented a decline from the birth rate of 21.8 in 1970. Italy had the lowest birth rate in 1990 (9.9/1000 population), a decline from the birth rate of 18.1 in 1960. Replacement level fertility is considered to be 2.1 among European countries and the average number of children born to a woman in her lifetime is below this figure. A graph, by country, of the changes in the average number of children/woman in 1971, 1981, and 1989 shows that the average decline was from 2.43 to 1.80 in 1981 and 1.58 in 1989, which is a 12% decline. Average children/woman rose only in Denmark and the United Kingdom between 1981 and 1989. The Federal Republic of Germany had the lowest number of children/woman in 1971 and 1981. Sharp declines were experienced between 1971 and 1989 in Spain (55%), followed closely by Greece and Portugal. Although there is no consensus on what constitutes pronatalist policy and the proven effectiveness of policy incentives, some countries have tried to motivate their citizens to have second and third children. In October 1991, the Copenhagen Consultation on the Third Child in Europe considered demographic conditions in Europe and prepared scientific papers and recommendations.
The third child in the 1974 Hungarian marriage cohort.
Family formation decisions in Hungary can be best understood from an analysis of data collected in 1974 and reinterviews in 1990 among 500 couples. During this period the Hungarian government instituted a variety of pronatalist policies in order to influence production of larger families. There were initial fluctuations in fertility and then stabilization at low fertility. Debate has centered on whether pronatalist policies were effective. The data set has been transferred for analysis to the University of South Carolina. The first interviews involved detailed information on family and living arrangements, housing conditions, opinions about prospective fertility, and attitudes on child care allowances, contraceptive practices, and other items. Other demographic information from the marriage certificate was merged with the survey data set. The survey in 1977 included reinterviews and information on marital events, residential and work conditions, and reproductive events for each pregnancy. There were subsequent panels in 1980, 1984, and 1987. Preliminary analysis has shown some evidence for the impact of pronatalist policy on the timing of fertility rather than cohort total fertility. More detailed analysis of parity-specific patterns and the influences of school, work, and family contexts as well as pronatalist policies such as allowances is anticipated. The systematic data collection affords a wonderful opportunity to examine at the personal level couple decision making about family building over a 14-year period.
Births, marriages, divorces, and deaths for November 1993.
Trends in births, deaths, marriages, and divorces for 1993 in the United States are provided on a provisional basis. Comparison is made to provisional data from 1992. Births totaled 315,000 in November 1993 compared to 332,000 in November 1992, and the birth rate declined to 14.8 births/1000 population compared to 15.8 in 1992. The fertility rate was 64.9 live births/1000 women aged 15-44 years: a decline from 68.6 in 1992. The seasonally adjusted rate was 66.8 compared to 70.7 in 1992. Total fertility in the first 11 months of 1993 had declined by 1%; the birth rate, by 2%. For a 12-month period ending in November 1993, births declined by 1% in number and 2% in rate over the preceding year; the fertility rate declined by 2%. The rate of natural increase was 6.3/1000 population in November 1993 and a 7% increase for a 12-month period ending in November 1993. Marriages numbered 161,000 in November 1993 compared to 174,000 in November 1992. The marriage rate declined from 8.3 to 7.5. Marriages over the preceding 11-month or 12-month period showed a 1% decline. The marriage rate decline for the 12-month period was from 9.1 to 9.3 between 1992 and 1993. Divorces were 94,000 decrees, which was a 3% decline from November 1992. The divorce rate declined from 4.6 in 1992 to 4.4 in 1993, a 4% decline. For the 12-month preceding period, the divorce rate decline was from 4.7 to 4.6, a 2% decline. Deaths in November 1993 were 180,000 or 8.5 deaths/1000 population. The death rate for the preceding 12 months was 8.7 deaths/1000 population, 1% higher than the preceding year period. Infant mortality was 8.3/1000 live births, 2% lower. The provisional annual death rate ending October 1993 was 872.9 deaths/100,000 population, 2% higher than the preceding year period. The provisional age-adjusted death rate was 511.3 deaths/100,000, a 1% higher rate than the preceding year. The death rate increased for cerebrovascular disease, chronic obstructive pulmonary diseases, and HIV infection. Motor vehicle accidents and homicides decreased. The annual infant mortality rate ending October 1993 was 829.9/100,000 live births, 3% lower. Homicide was the second leading cause of death for black men aged 25-44 years (19% of total deaths in this age and race group), which was 7.8 times the rate of white men of similar age.
Birth and fertility rates for states: United States, 1990.
Detailed statistical tables provide data on birth and fertility rates by racial group (Blacks or Whites, and Hispanic Mexican, Puerto Rican, Cuban, and Other or Non-Hispanic Blacks and Whites) and states, regions, and the country as a whole. Table 1 provides data on maternal race (White or Black) by states for number of live births, birth rates, fertility rates, and total fertility rates. Table 2 provides state-level data for race (White and Black) birth rates in 5-year age groups and the total fertility rate by race; smaller adolescent age groups are provided. Table 3 provides birth rates by state and race (White and Black) by live birth order. Table 4 provides birth rates for unmarried mothers aged 15-17 years and 18-19 years and 5-year ages thereafter and race (Black and White). Tables for the detailed Hispanic groups are provided in tables 5 through 8, comparable to tables 1 through 4. States are included only if they had more than 1000 Hispanic origin births in 1990. Tables 9 and 10 provide birth and fertility rates for American Indian and Asian or Pacific Islander. The highest unmarried mother birth rates were among black mothers aged 20-24 years (144.8/100 unmarried women in the specified group), followed closely by black mothers aged 18-19 years (143.7). White unmarried mother birth rates were highest among those aged 20-24 years (65.1), followed closely by unmarried mothers aged 18-19 years (60.7).
Options for reform of the Tanzania abortion law.
The penal code of Tanzania makes it illegal to "unlawfully" perform or induce an abortion or to supply or procure any abortifacient to a woman for the purpose of procuring a miscarriage, whether or not the woman is actually pregnant. Women who are pregnant are forbidden from "unlawfully" inducing an abortion. It is also forbidden to destroy any fetus of 28 weeks age or more unless the life of the mother is at stake. These acts are punishable by imprisonment of 14 years, 3 years, 7 years, and life, respectively. There is no definition given of "unlawful" in this regard; however, Tanzanian abortion law is based directly on a provision of English law which states that it is lawful to perform an abortion to preserve life or physical or mental health. Because the Tanzanian constitution gives its citizens the same opportunities without discrimination, it could be argued that the restrictive abortion law prevents women from protecting their lives and health without restraint, whereas men are able to do so. This provision also admits the argument that the abortion law discriminates against poor women. The prohibitive language and uncertain interpretation of the law inhibits public delivery of pregnancy-related care and results in a high incidence of death, illness, and infertility. Legal uncertainty also shrouds the use of modern medical technologies to prevent implantation or provide postcoital protection against pregnancy, although it seems clear that a woman can use such methods herself before her pregnancy is confirmed (currently at 6-8 weeks from last menstrual period). Reform of the abortion law may be sought through the judicial, executive, or legislative branches of government. Legislation would provide an opportunity to consider whether or not to base abortion legality on such indications as eugenics, rape, incest, child spacing, socioeconomic, health, family status, family responsibility, contraceptive failure, adolescent age, or request of the woman. Administrative provisions should cover the qualifications of health personnel, health facilities, early termination, and contraceptive delivery. This proposal presents a draft bill to amend the Penal Code according to these considerations.
Ecuador trip report: the challenge of the rural areas.
A Johns Hopkins University/Population Communication Services (JHU/PCS) program officer traveled to Ecuador on November 6-18, 1994, to 1) work with the local JHU/PCS coordinator and a team of scriptwriters creating a soap opera on reproductive health and 2) discuss the guidelines for a new midterm communication strategy with the IEC (information, education, and communication) Technical Committee. The synopsis of the soap opera was completed, and production was scheduled for April 1995. During meetings with CEMOPLAF (Centro Medico de Orientacion y Planificacion Familiar) directors, the following goals were identified: 1) to decentralize IEC strategies and focus on the health centers which have fewer clients; 2) to develop different strategies for different centers; 3) to use central-level family planning (FP) staff to provide technical assistance for the development of the strategies at the clinic level; and 4) to focus on rural and indigenous areas where the contraceptive prevalence rate is 44% (vs. 66% in cities). During meetings with APROFE (Asociacion Pro Bienestar de la Familia Ecuatoriana) directors, agreement was reached for the hands-on development of communication campaigns (start-to-finish development of a radio campaign and training on the roles of research in communication campaign development) to promote FP services. APROFE also asked JHU/PCS for technical assistance in marketing rental of an auditorium for training activities and cultural events. The JHU personnel also met with a USAID projects specialist and learned that overall results of the evaluation of the FP program in Ecuador were very positive. It was noted that cost-effective methods of reaching rural, indigenous, and hard-to-reach urban groups were needed. Specific recommendations in addition to the above were to 1) conduct a workshop for clinic directors on the impact of communication in bringing clients to clinics, 2) test the feasibility of CHEMOPLAF charging a small fee for training services, and 3) hire a consultant to develop a pilot program for a television series.
Unsafe abortion is a leading cause of maternal morbidity and mortality worldwide. The most cost effective and medically sound treatment for early incomplete abortion is manual vacuum aspiration (MVA), but treatment must be extended to prevention through counseling and the provision of contraceptive methods. This will require a breakdown in the current barriers between curative and preventive care services, debunking provider misconceptions, and improving clinical counseling skills. In Egypt, where a rather restrictive abortion law is in effect and is strongly moderated by Islamic considerations, the availability of safe abortion services is limited, especially for poor women. Thus, many women attempt self-abortion, and there is a dearth of data on induced abortion. In order to examine the effectiveness of MVA and improved counseling of postabortion patients in 2 Egyptian hospitals, a pre/post-test situational analysis was performed. The clinical case management protocol featured vacuum aspiration, alternative pain control measures (rather than general anesthesia), and family planning (FP) counseling as well as information about miscarriage for women who desire to become pregnant. An intensive training program was used to introduce MVA, reproductive health care counseling, and available contraceptive methods to senior obstetric/gynecology specialists. Nurses were also trained in counseling techniques and patient interactions. Data were collected through structured observations of all clinical procedures for 296 postabortion patients during a 5-week period, interviews with all clinic staff and all postabortion patients, and a review of medical records. Information was tabulated on classification of the abortion (spontaneous, certainly induced, etc.), history of unwanted pregnancy, infection control procedures, medications administered postabortion, physician knowledge about postabortion warning signs, follow-up information provided to patients, patient knowledge about postabortion warning signs, FP counseling and information and FP intentions postabortion. These baseline results show a strong reliance on general anesthesia, which should be overcome, and incomplete physician and patient knowledge about follow-up warning signs. FP information was not routinely provided despite a clear desire for such information on the part of patients. Further information will be available at the conclusion of this study in early 1995.
Healthy People 2000 targets: increasing equity for special population subgroups.
"Healthy People 2000" is a prevention initiative which provides a national US strategy for significantly improving the health of the American people over the coming decade. Its goals are to increase the healthy life span of Americans, reduce health disparities among population subgroups, and achieve universal access to preventive services. 300 specific objectives support these goals, and 223 subobjectives are addressed to reducing the disparities among minorities and other special populations. For adolescents, half of the objectives are showing progress, including reducing alcohol and drug use, but 10 are worsening, including the number of 15-year-olds who ever had intercourse. 17 indicators for women have improved, and 12 have worsened. More women have received mammograms, but more are overweight. 17 indicators for Blacks are up, including a reduction in cirrhosis mortality, but 16 are down, including homicide for males and females. Fewer older adults have lost all of their teeth, but more have fractured their hips. More than half of the 31 indicators for American Indians and Eskimos have improved, including unintentional injury deaths, but 25% are worsening, including diabetes-related deaths. 16 indicators have shown progress for Hispanics, including a decrease in smoking and in the proportion with degrees in health professions, but tuberculosis is also increasing. Most of the 27 objectives for low-income people are improving, and only 5 are moving away from the target, including an decrease in those with a specific source of primary care, which indicates a need for health care reform. Most of the targets for people with disabilities are improving, although the number of people with asthma who are limited in activity is increasing. Only 1 of the 9 targets for Asians and Pacific Islanders, tuberculosis, is worsening. A midcourse Public Health Service review of the objectives led to target revisions, new special population subobjectives, and modified or new objectives. A revised document showing the revisions will be published in the spring of 1995.
As part of a larger project commissioned by the Henry J. Kaiser Family Foundation to assess the status of publicly funded family planning (FP) services in the US, this study examined the actual level of service delivery as reported by clinic managers and direct care workers. Information was gathered by questionnaires (388 respondents from 600 randomly selected clinics) on the following topics: 1) a description of the organization and size of the clinics in the sample; 2) the configuration of clinic services (services available, services added recently, comprehensiveness, and changing client needs); 3) the uniqueness of the services offered (client race/ethnicity characteristics, income levels, and access to services); 4) payment structures and other financial issues, such as free or subsidized care, medicaid eligibility, Title X funding, budget changes, responses to funding constraints over the past 5 years, and factors affecting these responses; 5) staffing, administrative, and regulatory issues, such as the characteristics of the clinic managers, the work context, and recruiting and retention; 6) the working conditions and perspectives of direct care workers, including their characteristics, in-service training, HIV-related training, specific tasks, what services are needed but not available, birth control methods desired and used, outreach, and job conditions; and 7) managers' perceptions of policy options in delivering FP services, including top priorities, new contraceptive methods, and health care reform proposals. The final section presents conclusions and implications in regard to clients, financial issues, staffing, services, and the future of FP. Specific information on the methodology of this study is included in the appendix.
Chile: reaping the rewards of investments in quality.
During the first 2 years of a quality assurance program/Ministry of Health collaboration in Chile, training, organization, and planning were emphasized. During the third year, a significant number of small teams were achieving quality improvements at the local level. Currently, 50 projects on different aspects of maternal and child health care are in various stages of completion, covering between 1 and 10 health centers each. In Santiago, health center staff improved breast feeding support and achieved 60% exclusive breast feeding at 4 months (33% at 6 months) as well as an improvement in health professionals' knowledge from 4.25 to 6.43 on a scale of 1 to 7. A regional effort undertaken by a group of midwives improved the collection, dissemination, and analysis of information about the incidence of low birth weight infants so that this information could provide the high-quality data necessary to influence planning and programming decisions. In Santiago, which has the highest rate of adolescent pregnancies in Chile, a midwives group improved the way in which information on prenatal care was given to these young women during their prenatal orientation. By including all of the relevant information on one card, the midwives improved significantly the likelihood that the adolescents would make and keep the necessary appointments and that they would have important information at their fingertips. The teens all saved the cards as keepsakes of their first pregnancies. Also in Santiago, a team of physicians assessed the quality of care in treating acute respiratory infections. They found that over 80% of providers did not have time to record the necessary information which would insure appropriate care as the patient moved through the health system. An initial effort to improve this situation was only partially successful, so the physicians are developing a more detailed plan. In the final example, a physician evaluated the quality of record-keeping across 7 specialties in his hospital and found it lacking. The initial response to the findings was not positive, but as providers received more training in quality evaluation and improvement, attitudes changed. The hospital formed a medical records committee to develop ways to improve record-keeping and, thus, patient care. This indicates that a move from evaluation to improvement requires broad-based awareness of the merits of quality control.
Women's action for health development.
In Indonesia, the importance of the role of women in economic activity and community development has been recognized by the government through the establishment of the State Ministry for Women's Affairs. Women-centered community development projects include training housewives to produce handicrafts for sale; developing integrated health posts in communities to address questions of water supply, sewage, and garbage disposal; and a special effort to eliminate illiteracy with reading materials geared to improving public health. Communities are encouraged to finance their own health care, and all proposed changes are firmly rooted in religious and cultural norms. Wives of members of Indonesia's state health insurance scheme have collaborated with the insurers to develop a program of health promotion and disease prevention. In the villages, the tradition of mutual aid has been used to develop a health insurance scheme. One pilot prepaid community health program initiated in 1987 in Kerambitan Subdistrict, Bali Province, has a target population of 30,000 people and provides access to public and private facilities. A second project was started in 1988 in Candiroto Subdistrict, Central Java Province, with 49,000 potential members. A third, in Jakarta, benefits home handicraft workers and small-scale traders and food manufacturers. Thus, women, working individually, in small groups, or through nongovernmental organizations are playing a vital role in the development of health care in Indonesia.
This study explored whether current contraceptive use in Peru is affected by the family planning (FP) service environment where the a woman resides. Service-delivery data from the 1992 Situation Analysis Survey (known by its Spanish name with the acronym EDIS) were linked by cluster number to behavioral and demographic data from the 1991-92 Demographic and Health Survey (DHS) individual survey in Peru to produce a woman-level file with individual, household, and cluster variables. The EDIS is a new type of survey of family planning (FP) service delivery points which involves an inventory of facilities, exit interviews with staff and clients, and observations of client/provider interactions. The EDIS provided the "supply" variables. For this analysis, DHS data were used for women who were married or in a consensual union (a weighted sample of 7841 women). These data supplied the dependent variable, the current use of contraceptives, as well as a set of variables controlling for factors believed to affect a women's decision to control her fertility (demand variables). Analysis of these data revealed that, net of personal and household characteristics, a significant, although small, effect of service quality on contraceptive use does exist. Availability of services had no effect, but since quality is conditional on having services available, the 2 variables are highly correlated and difficult to distinguish statistically. As expected, quality of care is less important than standard socioeconomic variables in explaining differences in contraceptive use. It was noted that an upper limit exists on the percentage of variation that can be explained by variables measured at the cluster level, as is quality of care. This point must be remembered to avoid undervaluing services when evaluating their impact on reproductive behavior. Finally, it was predicted that contraceptive prevalence would increase 5% if all women lived in a cluster with the highest quality of care.
State of the world 1995. A Worldwatch Institute report on progress toward a sustainable society.
This edition of "State of the World" opens with a chapter on nature's limits which is concerned with the carrying capacity of the planet. The imminent limits, the economic effects of these limits, the ways in which unsustainability feeds instability, and the "China factor" are all considered. Chapter 2 concentrates on protecting oceanic fisheries and jobs and discusses the roots of overfishing, the sheer number of fishers, issues of food and fairness, the fact that aquaculture is no panacea, overreacting to overcapacity, fencing the oceans, and promoting fishers and healthy fisheries. The third chapter is devoted to a discussion on sustaining mountain peoples and environments. Chapter 4 covers harnessing solar and wind power and the possibility of using this as a replacement for fossil fuels to supply our energy needs. The fifth chapter considers creating a sustainable market economy. Chapter 6 discusses making better buildings through the use of appropriate materials, appropriate designs, and recycling. The machines that we use to enhance life are also discussed in this chapter. Chapter 7 pays special attention to China, an individual country focus which recognizes that the demands of China's 1.2 billion people could alter many global supply/demand balances and have extreme economic repercussions. The eighth chapter covers migration, refugees, urbanization, and poverty. Chapter 9 considers the economic factors associated with disarmament. The tenth and final chapter deals with forging a new global partnership to protect the global environment, meet human needs, revamp international institutions, involve people, and, ultimately, secure the future.
Hormonal contraception. Current status and future perspectives.
Hormonal contraception was pioneered by Gregory Pincus in the 1950s. Today, hormonal contraception is accepted as having a highly favorable benefit/risk profile. There is, however, a need for the development of new contraceptive methods to broaden the range of choices and enhance motivation and compliance in users. With the staggering rate of increase in the world's population, the number of contraceptive users in developing countries is expected to increase from 381 million in 1990 to 567 million in the year 2000. This will require substantial supplies of inexpensive contraceptives and the development of new and improved methods. The use of contraceptives is an asset to women's health, which can be jeopardized by the risks of pregnancy, as well as to the psychological and social well-being of mother and child. Oral contraceptives also have noncontraceptive health benefits such as protecting against endometrial cancer, uterine fibroids, menorrhagia, benign breast disease, anemia, ovarian cancer, functional ovarian cysts, dysmenorrhea, ectopic pregnancy, salpingitis, and bone loss. The new low-dose formulations are considered to be very safe for most healthy, nonsmoking women of reproductive age. Therefore, current research efforts are focused on new delivery methods, such as vaginal rings, rather than on the development of new hormonally active steroids. Nonoral contraceptive methods which avoid first-pass effects on the liver are being developed or improved. These include implants, vaginal rings, vaginally applied pills, and progestogen-containing IUDs. Contraceptive research is also focusing on immunologic interference with the hypothalamic-pituitary-gonadal axis in both men and women. This may spawn as yet unforseen methods of molecular modulation of sperm-ovum interactions which would result in the inhibition