Household surveys and the assessment of program effects.
The potential contribution of household surveys to the assessment of the impact of family planning programs is examined. Household surveys, structured interviews at places of residence, with probability samples of the population permit inference to a larger population. The samples may be drawn from national or sub-national populations. Structured interviews permit straightforward transfer of the information obtained from respondents to numerical machine-readable files that can be analyzed by conventional statistical software packages. The prime current examples of the household-survey approach are the surveys in the Demographic and Health Survey (DHS) program, the successor to the World Fertility Survey (WFS) and Contraceptive Prevalence Survey (CPS) programs. Household surveys provide the most important information for the evaluation of the impact of family planning programs; the prevalence of contraception use by method and estimates of the prevalence of behaviors. The surveys in the DHS and the WFS programs have probably not generated prevalence data that might assist family planning program assessment, as opposed to the KAP surveys of the 1960s and the CPS surveys of the 1970s and 1980s. The analysis of WFS, CPS, and DHS data of the past 2 decades might indicate the household survey data are of limited value for research on the causes of changes in contraceptive attitudes and behaviors. So long as the analysis is fundamentally cross-sectional in design, the threats to validity loom large. For the household survey to become a more versatile tool in the assessment of program effects, it is essential that sequences of surveys be linked with each other and with time series of aggregate data on the family planning service environment and on social and economic opportunity structures. Therefore, the quality and quantity of program data that can be appended to household survey data must be improved.
Role of service-based program statistics in assessment of family planning program.
All records maintained as records of provision of services to clients are included in the category of service-based client records. Such information may be kept in registers maintained by the workers or by the service centers and/or in the clinic cards prepared at the clinic for the client. Registers have been mostly preferred in developing countries because limited staff and infrastructure at the service centers do not permit systematic maintenance of the clinic cards. In a family planning program record system, the following types of service-based registers are maintained: household information register, eligible women and children register, family welfare services register, maternal care services register, child care and immunization services register, stock and issue register. The type of information listed in various registers suggests that they have potential use for planning and monitoring the activities and for program assessment. The registers maintained on the basis of services provided by the program workers and the service units have great potential for the program evaluation activities but this potential is not fully harnessed. Actual use of these records is poor. It has led to a vicious cycle; the records are not being maintained well and they are not kept up-to-date because they are not being used, and they are not being used because they are not in a usable form. The service-based program statistics are of great value for monitoring and evaluation of the program and to increase its impact. The challenge is 1) preparing and keeping these records up-to-data; 2) keeping quality of data good, so that indicators developed from them truly reflect the status of the program; and 3) full utilization of the potential of these records.
Working with NGOs: PAHO's approach.
The Pan American Health Organization (PAHO) started collaborating with nongovernmental organizations (NGO) in 1990 because their numbers had multiplied, because the state-supported health care was diminishing with the result of worsening health conditions among vulnerable populations, and because of the growing ability of NGOs to deliver health care. NGOs are community-based organizations with local responses to specific situations led by highly motivated and energetic leaders but with limited funds and technology. In order to be considered as partners in development by donors and governments they must be strong. PAHO supports NGOs and forges links between different NGOs and other social agencies including the public health system. Many NGOs grew angry because they were ostracized by HIV/AIDS control and prevention programs. Some AIDS NGOs were formed by people sidelined because of their sexual orientation, and women's groups and evangelical churches are at variance with such NGOs, both clamoring for limited resources. This circumstance made collaboration between different NGOs difficult and made it difficult to establish a joint front to negotiate with governments. However, the spread of the epidemic and shrinking donor funds have awakened them to the reality of combining forces as the best strategy to change government policy and social attitudes. AIDS NGOs are now seeking partnerships to strengthen their capacity to complement public sector health efforts. PAHO considers strategic planning as the tool for helping NGOs channel their energies into successful actions. This requires management and analytical skills for development planning, programming, and policy dialogue. In October 1992, PAHO held, in Buenos Aires, the first of 3 strategic planning seminars for NGOS working on AIDS in Argentina, with the attendance of 26 NGOs. The second seminar, which was held in Rosario in April 193, was attended by 14 NGOs and 6 governmental organizations, indicative of the need for an AIDS fighting network.
Socio-cultural characteristics and health-seeking behaviour of the Hill Korwas.
A project by the Regional Medical Research Center for Tribals, Jabalpur, in 1991, studied the sociocultural aspects of health care in the Hill Korwa tribe in Surguja district in Madhya Pradesh, covering 170 households. The villages were selected based on distance from the Primary Health Center (PHC) and sub-center. Information was collected by trained female investigators using a schedule supplemented by an in-depth study of antenatal, neonatal, and postnatal care. Regarding health-seeking behavior, 70% of them relied on the Gunia, the tribal doctor, followed by the nurse at the sub-Center (40%), and the PHC (20.8%). About three-fourths of the respondents were aware of the free treatment available at the PHC, but stated that the doctor did not provide services free, while the local Gunia did not have to be paid immediately. Over 63% of the respondents had not used the services of the PHC. Among the PHC visitors, 73% had sought treatment for fever, followed by eczema and scabies (11.5%). Over a 1-month period, about 56% of those who had died, had not been given any treatment, while the Gunia had treated 25.6%. Of a total of 145 eligible females who were interviewed, none reported an abortion. Of the 14 women who were pregnant, only 1 had antenatal care. Common reasons for not visiting the PHC were: not necessary; the fetus may get harmed; and economic problems. Out of 14 pregnant women studied, 5 seemed to know about tetanus toxoid injections and the use of iron tablets during pregnancy. 72% of the deliveries were performed by untrained birth attendants, 23.9% by elderly ladies, and less than 1% by trained dais. A few case studies are also presented about the knowledge and attitudes of pregnant women regarding immunization and family planning. The high rates of illiteracy and poverty were the main causes of the under-utilization of PHC services.
Impact of changes in China's urban mortality on the average life expectancy.
The differences and changes in gender-specific and age-specific mortality during the periods of 1973-1989 were analyzed based on changes in average live expectancy (ALE) and disease-induced mortality among China's urban population during 1973-1989. The data were obtained from the Center of Health Statistics and Information, Ministry of Public Health. During 1973-1980, ALE at birth increased from 69.0 to 70.70 among men and from 70.26 to 73.34 among women. During 1980-1989, ALE at birth grew to 71.77 among men and 75.62 among women. The difference in ALE in birth between men and women increased from 1.26 years in 1973 to 3.85 years in 1989. The increase in ALE during 1973-1989 was caused mainly by the decline of mortality in each age group below the age of 15. During 1980-1989, the drop of mortality in the age groups of 45 and above substantially affected the increase of ALE. The increase of ALE prior to 1980 was caused mainly by the decline of mortality from respiratory (particularly pneumonia among lower age groups) and infectious diseases, and the increase during 1980-1989 was attributed to the drop of mortality caused by cerebrovascular and respiratory diseases (particularly chronic bronchitis among the middle-aged and elderly population). Among women, mortality caused by malignant tumors dropped (e.g., cervical cancer). The decline of mortality caused by cerebrovascular diseases in the 1980s accounted for 36.8% of the increase in ALE among men and women, respectively, during 1980-1989. The increase in mortality among men caused by malignant tumor reduced the increase in their ALE during 1980-1989 by -30.8%, mostly among the population above the age of 45, and among men in particular. The increase in ALE among the urban population will further slow down, mainly because of the decrease in mortality from chronic diseases (cerebrovascular diseases and senile chronic bronchitis) among the middle-aged and elderly population.
The introduction of a market economy in China marked a turning point in the urbanization process in China by the coexistence of two types of populations, one urbanized under the planned economy or state plan (PUSP) and the other urbanized outside the state plan (POSP) or under the market economy. The 1990 census identified three types of mobile populations: 1) those with permanent residence elsewhere but who stay in one city for more than 1 year; 2) those away from their permanent residence for more than 1 year but staying in one city for less than 1 year; and 3) those whose residence is yet to be registered. Two anti-urbanization movements before the economic reform, the relocation of 30 million urban employees in the early 1960s and the resettlement of 40 million youths in rural areas in the mid-1960s, resulted in the drastic increase of the PUSP in the late 1970s and early 1980s as large numbers of these people returned. According to the State Statistical Bureau, 49.8% of the total population was urban in 1988; however, the 1990 census indicated only 26.2%. The inclusion of agricultural population living in suburbs was the reason for the differential. The mobile population can also be regarded as POSP, as the majority come from rural areas. Young people account for a greater proportion of POSP, while most PUSP are industrial or service employees, 30.46% with university and 9.47% with high school education. The reasons for moving to urban areas include 1) joining relatives, 2) study 3) employment and 4) government appropriation of land. The POSP are supported by the state in resettlement. In contrast, the mobile population faces discrimination (fines, eviction) and employment, education, and health care problems. Among the PUSP, the fertility rate was lower than the urban average, as showed by a survey conducted in 74 cities in 1987. The fertility of POSP was higher because some have more children for security, since they are excluded from the benefits accorded to officially registered residents.
In the 1980s, the government reform policy exerted a profound impact on Chinese society and the economy, including the fertility rate. A sample survey of two thousandths of the total population was conducted in mid-1988. Social and economic factors were investigated primarily using the total fertility rate (TFR). The new Marriage Act was adopted in 1988 setting marriage age at 20; previously, early marriage and childbearing before age 18 had occurred often. Early marriage had declined from 47.89% in 1970 to 12.53% in 1979. In rural areas more than half of marriages were early marriages, dropping to 16.90% by 1979 and increasing to 25% in 1987. Consequently, the cumulative fertility rate in the 15-20 age group rose 88% from 1980 to 1988. Mature-age marriage, at age 23 or older, became more common both in urban and rural areas, with a 80.0% and 42.26% rate, respectively, in 1979. However, by 1987 it declined to 66.84% and 20.71%, respectively. The age at first childbearing had grown to 24.45 in 1980 (23.89 in rural areas); however, it was reversed to 23.04 in 1987 (22.56 in rural areas). The cumulative fertility in the 15-24 age group shot up between 1980 and 1987. THe cumulative fertility rate in terms of TFR in this group grew from 35.21% in 1980 to 47.74% in 1987. Single-child cumulative fertility rates in the age groups of 15-19 and 20-24 had declined to below 1 in the late 1970s and 1980, but these were merely postponed childbearing. In 1987 many rural women began to have their second child. Multiple births in rural areas declined from 59.80% in 1970 to 20.86% in 1987, while total number of births increased 41.78% in 1987. In urban areas the TFR was 1.98 after 1974 and declined to 1.24 in 1980 and then rose to 1.36, a little below the planned TFR of 1.25. In rural areas, low per capita income and its irrational distribution favor less educated people, while transformation into the household-based economy requires child labor, factors which have impeded the family planning program.
Technological advances and the transformation of the cost of children.
During the decade of 1980-1990, the total fertility rate (TFR) averaged 3.53 worldwide, 1.91 in developed, and 4.07 in developing countries. During this decade, the gross domestic product (GDP) increased at an annual rate of 2.5% in developed countries and at 2.3% in developing countries, except for sub-Saharan Africa, Latin America, and the Middle East, and North Africa. The relationship of population growth and economic development is characterized by two types of circles: 1) low fertility rate-high technological level, high productivity, high per capita income--low fertility rate, seen mostly in developed countries; and 2) high fertility rate--low technological level, productivity, and per capita income--high fertility rate, in developing countries. China's population policy is considered very successful; however, it has not been able to break out of the high fertility--low income circle. The TFR was 5.44 in the 1940s, 5.7 in the 1950s, 4.01 in the 1970s, 2.45 in the 1980s, and 2.25 in 1989, still above the replacement level of 2.10. The per capita gross national product is calculated at $300-1000 vs. $710 in developing countries. Although the educational status more than doubled since 1964 to 1990, it is still relatively low coupled with low labor productivity. Scientific and technological advances help lower fertility by stimulating the growth of the marginal cost of children and reducing the marginal benefit of children, while changing the reproductive attitude from favoring a greater number of children to favoring a lower number of children. The combination of technological advances and better skilled labor constitutes higher productivity. In 1989, in 9 out of 18 provinces in China, where the educational level was higher than the national average, the TFRs were much lower and per capita income was much higher. Thus, upgrading children's educational level is the key to transformation to a low fertility--high income circle, as well as halting the irrational income distribution whereby highly educated professionals often get paid less than average employees.
How pervasive are sex differentials in childhood nutritional levels in South Asia?
The assumption that there are widespread sex differentials in the household allocation of food in South Asia is examined using primary field data and a critical review of the existing literature. Indirect evidence infers from the well-established sex differential in mortality that there must be corresponding sex differentials in feeding habits, especially in childhood. In the primary data in a paper, North Indian children were found to show marked differences in favor of boys in both mortality and health care, whereas, the case of nutritional levels, girls did somewhat better than boys. Basu, in 1989, concluded that it is not necessary to use household discrimination in the allocation of food to explain sex differentials in child mortality in India. A field study of cultural influences on demographic behavior was conducted among a orth Indian (from eastern Uttar Pradesh) and a South Indian (from Tamil Nadu) group living in the common physical environment of a Delhi slum (Basu, 1992). On the whole, severe malnutrition was greater in the North Indian boys than in the girls, while in the Tamil Nadu case, boys had a slight edge over girls. Where actual discrimination against girls does exist, it is more likely to begin in late childhood or early adolescence as the girl is socialized for the role of ideal wife and mother. The actual evidence strongly suggests that food imbalances are not a major part of the gender inequalities in South Asia. There may be a certain amount of discrimination, but it is far from uniform even in those areas with the largest sex differentials in child survival. The more accurate conclusion would be that not enough is known, and the areas in which women are worst, discriminated against should be identified more precisely for more effective action.
Prevention of sexually transmitted infections: physical and chemical barrier methods.
According to recent estimates, over 75% of the 10-12 million HIV-infected adults worldwide have contracted the virus through heterosexual intercourse. In 1992, heterosexually acquired HIV infection increased to 90% of all HIV infection. In the United States, males who had engaged in sex with other males constituted 57% of acquired immunodeficiency syndrome (AIDS) cases and males who had had sex with injecting drug users represented 23% of adult cases of AIDS at the end of 1993. Barrier contraceptive methods, including the male condom, spermicides the vaginal sponge, the cervical cap, the diaphragm, the female condom, and vaginal contraceptive film, have the potential to reduce the spread of sexually transmitted diseases (STDs). The prolonged irregular bleeding that may occur either with Norplant or Depo-Provera may enhance STD and HIV transmission or acquisition in women. Breakage rates for condoms in clinical studies range from 0.5% to 7%. In vitro data strongly suggest that latex condoms can prevent the transmission of sexually transmitted pathogens. In human studies, condoms have protected men against gonorrhea and Ureaplasma urealyticum infections. On the other hand, gay men have substantially increased their condom use, yet their acquisition of STDs is decreased by only 50%, possibly because of incorrect use. In 1980, the US Food and Drug Administration recognized nonoxynol-9 and octoxynol as safe and effective spermicides A study of the toxic effects of nonoxynol-9 on the female genital tract (150 mg or placebo 4 times a day for 14 days) showed epithelial disruption of the cervix and vagina in 6 (43%) women receiving nonoxynol-9 compared to none of the 5 women receiving placebo. Laboratory tests have demonstrated the activity of nonoxynol-9 against Neisseria gonorrhoea, Trichomonas vaginalis, herpes simplex virus, HIV, and Treponema pallidum, whereas findings regarding Chlamydia trachomatis and Candida spp. have been contradictory. Future research should focus on exploring the fact that HIV is highly sensitive to pH, being infectious at neutral pH and being inactivated at acid pH.
Improving the effectiveness of condom advertising: a research note.
Gender differences in attitudes toward condoms were examined with a protest that measured attitudes toward condoms and attitudes toward using condoms with two three-item scales (good/bad, favorable/unfavorable, positive/negative). A total of 82 students in undergraduate business classes (37 males and 45 females) participated in the pretest. These pretests suggest that both males and females in this study old negative attitudes toward the condom. Subjects for the main study were 286 undergraduate students (131 males, 155 females) at a major western university. They were randomly assigned to treatment groups and asked to complete the booklet containing stimuli and measures The booklet contained 2 distractor print advertisements (for shampoo and toothpaste) along with the condom advertisement, structured so that each ad was followed by several dependent measures. Subjects were told that the researchers were pretesting advertisements for a manufacturer of personal care products. Reliabilities for both the attitude (Cronbach's alpha = 89) toward the ad and attitude toward the brand scale (Cronbach's alpha = .96) were within acceptable ranges. Thus, a two-way analysis of variance was undertaken. As hypothesized, two-sided messages (positive and negative advertising information about the product category) resulted in more positive attitudes toward the advertisement and the brand than did one-sided messages (positive information only about the product category) (p < .01). In addition, subjects who saw the two-sided ad expressed more positive attitudes toward the brand than those who saw the one-sided ad (p < .056). While exposure to the two-sided versus one-sided condom advertisement produced attitudinal differences in terms of the ad and brand, it did not result in a significant difference in purchase intention (p > .40). Neither significant main effect gender differences nor significant gender by sidedness effects were found on any of the 3 dependent measures (p > .24) or higher on each measure for both the main and interaction effects).
Condom use: a self-efficacy model.
Psychological factors, associated, with sexual risk behavior were investigated guided by A. Bandura's (1986) social-cognitive theory. It was examined whether a self-efficacy (SE) model is capable of predicting condom use from expectancies, social influences, peer group comparison, sexual attitudes, perceived risk for HIV infection, and AIDS-related knowledge. A self-report questionnaire was developed to gather information. A final sample of 212 single heterosexual and currently sexually active undergraduate students (103 men and 109 women) completed an anonymous survey. The ethnic composition was 83% Caucasian, 8% African-American, 3% Hispanic and 6% other. The state religious affiliation was 28% Catholic, 37% Jewish. 24% Protestant, and 11% other. The mean age of the respondents was 21.4 years (men = 21.8 years; women = 21.1 years). The subjects reported a mean number of 1.8 sex partners during the past 6 months and a mean number of 5.4 sex partners during the past 3 years. Only 29% of the subjects reported consistently having condoms during the past 6 months. 73% claimed pregnancy prevention and only 17% mentioned fear of AIDS. 80% of the students perceived themselves only slightly at risk for HIV infection. The fit of the model was evaluated with LISREL VII. The variables in the model accounted for 46% of the measurement error variance in condom use and for 53% of the variance in SE. Consistent with social-cognitive theory, condom use was predicted by SE beliefs, but it was also significantly predicted by peer group comparison. SE was predicted by self-comparisons with one's peer group and by outcome expectancies: positive expectancies about condom use (disease and pregnancy prevention) were directly related to Se, whereas negative expectancies (reduction of pleasure) were inversely associated with SE. Consistent with predictions, AIDS knowledge was unrelated to condom use. A positive correlation between AIDS knowledge scores and perceived vulnerability to HIV infection was found, but perceived vulnerability was not a significant predictor of either SE or condom use.
Data collection by survey. Norwegian Family and Fertility Survey: 1988.
As part of the Norwegian Family and Fertility Survey, 1988, the household and migration section aimed at identifying the persons belonging to a household, their sex, age, and their kinship; the domicile of the target person before turning 16; the kind of place in which the person grew up (rural, district village, town); and the month and year permanent departure from the parental home. The cohabitation and marriage section was designed to collect information on whether a respondent was cohabiting without a formal marriage; and on every period a respondent was cohabiting or married. The section on education, labor force activity, and other activities dealt with the married or cohabiting status of spouse or common-law spouse; the registered owner of the dwelling unit; any written agreement in the event of departure or passing away of a respondent or common-law spouse; and any plans of either party for marrying within the next two years. The section on married or cohabiting women or women who have been pregnant started out with inquiring about any sexual activity and the year of first intercourse. The section on attitudes towards children inquired about the two most important reasons for a woman to want or not to want to have a child; the ideal number of children for a family; the reasons why a respondent does not expect to have a child and the possibility of having a child as a single person. The section on attitudes and values in general dealt with the frequency of church attendance in the past 12 months; acceptability or nonacceptability of common-law marriage; satisfaction or dissatisfaction with family life; and female employment while responsible for upkeep of home and care of children. Finally,
Skin vascular reactivity in healthy subjects: influence of hormonal status.
71 healthy volunteers not using any vasoactive medication were selected to investigate the influence of the hormonal status on skin vascular reactivity; 18 males, 18 premenopausal women using oral contraceptives (OC) for 6 or more months (30 mcg ethinyl estradiol and 150 mcg levonorgestrel in 10 females), 17 premenopausal women with regular menstrual cycles, and 18 postmenopausal women (last menstruation 6 or more months before the study). All subjects were at least 18 years of age. Finger skin temperature (FST, in degrees Celsius [C] and laser Doppler flux (LDF, in perfusion units) were measured during heating (45 degrees water bath) and cooling (15 degrees, followed by a subsequent recovery period. Maximal heat-induced vasodilation was significantly higher in women using OC and in premenopausal women when compared with males. Women using OC had the lowest preheating FST (30.5 +or- 1.1 degrees C vs. 32.2 +or- 1.0 degrees C for males, P < 0.01) and reached the highest maximum FST during heating (women using OC, 39.4 +or- 0.3 degrees C vs. males, 39.0 +or- 0.4 degrees C, P <0.05). The percent increase of FST was significantly different between the groups (P < 0.001, 28.9% median in women using OC, 26.3% in premenopausal women, 25.3% in postmenopausal women, and 21.4% in males). During cooling, FST and LDF were significantly higher in males compared with women using OC and premenopausal women, respectively (women using OC, 20.9 +or- 0.7 degrees C, vs. males, 23.2 +or- 2.3 degrees C, P < 0.001). During recovery, FST (males 26.45 +or- 4.4 degrees C, vs. women using OC, 2.0 +or- 2.5 C, P < 0.001) and LDF were significantly higher in males than in women using OC, and LDF was also higher in males than in premenopausal women. Stepwise regression showed a significant influence of the group on the results and not of biological factors (age, amount of subcutaneous fat, hand volume, and body mass index) or hemodynamic parameters (mean arterial blood pressure and heart rate). The observed differences suggest that sex hormones influence finger skin perfusion.
Effects of desogestrel on carbohydrate metabolism.
Progesterone and the synthetic progestins used in oral contraceptives are associated with a dose-dependent impairment of carbohydrate metabolism. Hyperinsulinemia and alterations in glucose metabolism are significant risk factors for the development of cardiovascular disease. However, long-term use of OCs does not appear to increase the risk of cardiovascular disease. In addition, long-term studies do not indicate any trend toward diabetes in long-term users. Desogestrel, a new progestin derived from 19-nortestosterone, is highly selective for progesterone receptors, with little affinity for androgen receptors. Of the four small studies using 150 mcg monophasic desogestrel and 30 mcg ethinyl estradiol (EE) mild increases in blood glucose were shown in one study after 6 months and after 12 months in another. In addition, plasma insulin decreased in two studies, increased in one, and remained unchanged in one. In a large cross-sectional study, users of OCs for at least 3 months were compared with nonusers. All OC formulations were associated with a deterioration in glucose tolerance. The smallest effect on both glucose tolerance and insulin secretion, as indicated by the C-peptide response, was found with the desogestrel-containing monophasic preparations. In a follow-up study, the metabolic basis of insulin disturbances was investigated as a consequence of the use of combination OCs containing levonorgestrel, norethindrone, or desogestrel as well as progestin-only formulations (norethindrone or ethynodiol diacetate). The levonorgestrel-containing combinations had the greatest effect on intravenous glucose tolerance tests, insulin, and C-peptide concentrations, followed by desogestrel and low-dose norethindrone. The new low-dose OCs show slight decreases in glucose tolerance, usually from 10% to 15% increases in glucose and from 10% to 30% increases in insulin curves compared with base-line. Desogestrel has been demonstrated to have generally less pronounced effects on these parameters of carbohydrate metabolism.
The effects on hemostasis of oral contraceptives containing desogestrel.
Epidemiologic research has correlated current low-dose estrogen oral contraceptives with a low risk of myocardial infarction, stroke, and venous thrombosis or thromboembolism. Nevertheless, misgivings still linger about the effects of low-dose oral contraceptives on the cardiovascular system. Changes in the coagulation system have been linked primarily to the estrogen component; however, the progestin may have an influence on the fibrinolytic system. Oral contraceptives (OCs) containing desogestrel, a new progestin, became commercially available in Europe in 1981. Since that time, more than 30 million women have used the monophasic preparation containing 150 mcg of desogestrel and 30 mcg of ethinyl estradiol. During this widespread clinical use, desogestrel-containing OCs have not been associated with an increase in the risk of thromboembolic disorders. A total of 13 studies from different countries involving different ethnic groups were reviewed concerning the effects of OCs containing novel progestins on coagulation and fibrinolytic variables. The observed changes indicate that a new balance has occurred, increases in both procoagulation and profibrinolysis factors and their inhibitors. With the exception of two studies, all studies were comparative versus a variety of low-dose oral contraceptives. None of the studies observed a notable difference between the desogestrel OC and the comparison OC, and no incidental difference between OCs was confirmed in a subsequent study. This lack of a specific progestin effect confirms an earlier theory that any thrombogenic effect of oral contraceptives is caused by the estrogen component. Desogestrel differs from progestins currently in use in its lower relative androgenicity, which eliminates or reduces adverse effects on lipid and carbohydrate metabolism. The use of the desogestrel-containing OC is associated with minimal changes in the coagulation and fibrinolytic systems. A careful medical and family history rather than the selection of a particular OC combination is an effective means of preventing thromboembolic disorders.
HIV, BCG and TB in children: a case control study in Lusaka, Zambia.
As part of a project, a case control study was conducted with the aim of estimating the effectiveness of bacillus Calmette-Guerin (BCG) vaccine, the influence of HIV infection on BCG effectiveness, and the relative risk (estimated from odds radio [OR]) of TB in HIV-positive children at the Department of Pediatrics and Child Heath of the University Teaching Hospital (UTH), Lusaka. A total of 116 TB cases, children of both sexes and ages from 1 month to 14 years, were identified prospectively during January-September 1991. TB infection cases included 108 cases of pulmonary TB, 3 cases of adenitis, 2 cases of pleural effusion, and 1 case each of pericardial effusion, disseminated TB, and TB meningitis. 154 controls (aged 1 month to 14 years) were selected from the UTH and included 69 injury victims, 47 other acute surgical patients, 23 children with acute diarrhea, and 15 with common cold of 1-2 days duration. In all, 71% of cases and 88% of controls had a BCG scar. HIV tests were positive in 38% of case and 13% of control children. The crude risk of TB was close to four times greater in HIV-positive compared to HIV-negative children. The relative risk adjusted for sex was similar to the crude risk, but the risk adjusted for age was higher (OR 6.0). The risk of TB in children aged 1-18 months was five times greater (OR 6.0). Age- and sex-adjusted OR was 6.8. Among children aged over 18 months, the crude OR of TB in HIV-positive individuals was 6.3. THe age- and sex-adjusted OR was larger (8.1). There was no altered risk associated with BCG vaccination in HIV-positive children (OR 1.0). A crude estimate of the effect of vaccination in HIV-negative children was 59% (OR 0.41). The OR was not different from the crude risk after adjusting for sex, birth history, history of children's clinic card, number of persons per room, child's age, and number of siblings.
Patterns of infant weight gain in developing countries.
Data relating to growth in weight were taken from the literature for 23 populations from the developing world. These populations were compared with National Center for Health Statistics (NCHS) standards and with a second reference sample of 212 children from the Stockholm urban area who were mostly initially breastfed. Multiple regression analysis using means for each population was performed on birth weight and subsequent weight increments in relation to weight at 12 months. All possible combinations of any four of the five variables were entered in the regression equation. The variability of poor growth range within the 23 populations was 74-104% of the NCHS mean at birth and 56-96% of the NCHS mean at 12 months. Mean weight of all populations was significantly below the NCHS mean at 12 months (P < 0.001); in 20 of the populations it was below the NCHS 25th percentile and in 11 populations it was below the NCHS 10th percentile. Initially, many monthly increments were higher than in the western populations (range 80-181% of NCHS mean), but by 9 months all increments were below the standards (range 34-100% of NCHS mean). The patterns of weight gain in the NCHS and Swedish samples showed a difference in that a higher birth weight in the Swedish cohort was followed by smaller initial increments but larger subsequent increments (49% of NCHS mean at 0.5 months; 107% at 9 months). Regression analysis showed that birth weight was not significantly related to growth increment over the first 3 months, but was related to weight at 12 months (R = 0.78; P < 0.0001). Multiple regression analysis revealed that growth increments over the periods 0-3 months, 3-6 months, 6-9 months, and 9-12 months were all significantly related to weight at 12 months, but that the increment over 0-3 months had the strongest relationship. The contribution of the other four variables was about equal.
Depot-medroxyprogesterone acetate (DMPA) and cancer: memorandum from a WHO meeting.
Depot-medroxyprogesterone acetate (DMPA) is a highly effective long-acting progestational contraceptive, which is administered by injection. DMPA has been widely used in Thailand and New Zealand. The licensing, acceptability, and prevalence of use have been influenced by concern that DMPA may increase the risk of cancer, in particular cancer of the breast. The results of toxicological tests in animals and epidemiological studies in humans concerning the carcinogenicity of DMPA are reviewed. Animals injected with DMPA were exposed to far greater concentrations of the progestogen than were animals tested with orally administered 19-nortestosterone derivatives. In beagle dogs, a unique response to DMPA led to increased serum growth hormone, which was probably responsible for the tumorigenic effect of DMPA on the mammary gland. However, women taking contraceptive doses of DMPA have no significant elevation of serum growth hormone. Available toxicological data do not seem to indicate that DMPA is different from other progestogens in its tumorigenic potential. Epidemiological studies reassure that use of DMPA does not increase breast cancer risk overall. Elevated risks in the same or similar subgroups were observed in the WHO and New Zealand studies, consistent with an acceleration in detection of pre-existing cancer. The data were not compatible with DMPA as an initiating agent. Research is needed on the biological mechanisms of action of progestogens on the human breast. Findings from studies of DMPA and invasive cervical cancer showed no overall increase in risk of cervical cancer and no association between DMPA and cervical cancer. Data from the WHO study provided evidence that DMPA protects against endometrial cancer and that DMPA use was not associated with either an increased or decreased risk of ovarian cancer. Therefore, restriction of DMPA use as contraceptive on the grounds of risk of neoplasia is not recommended.
Thermoregulatory responses to exercise in relation to the phase of the menstrual cycle were studied in 10 female university students taking oral contraceptives (P) and in 10 females not taking oral contraceptives (NP). P subjects had a mean age of 21.3 years, height of 168 cm, body mass of 62.3 kg, and body surface area of 1.65 sq. m and they had been taking oral contraceptives (OCs) for 1.5-2.0 years. Eight of them used Trikvilar (containing levonorgestrel and ethinyl estradiol, made by Leiras, Finland) to inhibit ovulation. Two subjects used Neo-Gentrol 150/30 (Wyeth International Ltd., USA) containing levonorgestrel 150 mcg and ethinyl estradiol 30 mcg. NP subjects who had never used OCs had a mean age of 22.0 years, height of 167 cm, body mass of 62.3 kg, and body surface area of 1.65 sq. m. Exercise was performed on a cycle ergometer. Each subject was tested for maximal aerobic capacity (VO2max) and for 50% VO2max exercise in the follicular (F) and luteal (L) phases of the menstrual cycle. A quasi-follicular phase (q-F) and a quasi-luteal phase (q-L) of the menstrual cycle were assumed for P subjects. In P subjects, rectal temperature threshold for sweating (Tre,td) was 37.85 degrees Celsius in q-L and 37.60 degrees Celsius in q-F (P < 0.01) and corresponded to a significant difference from Tre at rest. The Tre, mean skin (Tsk), and mean body (Tb) temperatures and heart rate (fc) increased similarly during exercise in q-F and q-L. In NP subject, Tre,td was shorter in L than in F (37.70 vs. 37.47 degrees Celsius P < 0.02), with a significantly greater value from Tre at rest. The gain for sweating for the whole period of sweating (G) was also greater in L than in F. In these women there were a greater temperature threshold and larger gains for sweating in phase L than in phase F. OCs reduced the differences in the gains for sweating, making the thermoregulatory responses to exercise more uniform.
A comment is made on the study of Egan and colleagues concerning the theoretical mechanisms by which pregnancy and oral contraceptive use may influence metastasis and mortality from primary posterior uveal malignant melanoma. Their retrospective study investigating the impact of pregnancy and oral contraceptive use on metastasis and mortality from posterior uveal malignant melanoma found no evidence that pregnancy, oral contraceptive use, or female gender in patients 45 years of age and younger have any clinically important effects on the prognosis for death owing to metastatic disease. A previous report by the commentator indicated that the survival of young women with posterior uveal melanoma in the Wills Eye Hospital series appeared to be better than that of older women and men of all ages, but only when patients were studied by lognormal survival modeling. Younger women who had a poor prognosis of surviving their uveal melanoma tended to have a longer median survival time than did older women and men of any age who had a comparable tumor in terms of its size an intraocular location. However, the cured fraction appeared to be essentially identical in women and men. These findings are in complete agreement with the study of Thorn and co-workers on cutaneous malignant melanoma based on the Swedish National Cancer Registry but contradict the findings of Egan and co-workers. The issue of the impacts of pregnancy and oral contraceptive use on survival in posterior uveal melanoma has not been resolved. However, the current study reassures future pregnant patients with posterior uveal melanoma that there does not appear to be any large, sort-term unfavorable effect of their condition on their prognosis for survival. Additional studies are needed to establish the impacts of pregnancy and oral contraceptive use on a woman's survival prognosis.
Reports from Women and Health Network. Uganda.
The Uganda Health Committee and Subcommittee of the Action for Development (ACFODE) established in 1989 by 3 people has been involved in the following activities: 1) establishing youth discussion groups on sexuality among school youth; 2) seminars on women as providers and promoters of health; 3) politically directed campaigns on women's health problems; and 4) panel discussions and family life education learning. Future projects are targeted for creating awareness among local policy-makers about the poor health status of women and implementing specific activities on the health priority needs of women. There were 10 schools in the Kampala area that were involved in discussion groups in 1989 about the problems of teenage pregnancy and the health risks. A pamphlet entitled "Responsible Parenthood" and another about adolescent boys and girls were published and distributed among school students. In 1990, the subcommittee organized a seminar for 40 policy-makers in government departments and nongovernmental organizations on women as providers and promoters of health. In early 1991, another seminar for members of parliament was organized in order to create awareness about policies and programs that could promote the health status of women. A byproduct of the seminar was the submission by members of a plan of action to ACFODE for their districts. The ACFODE plans to use this information and other resources to implement women's programs in 7 districts. In May 1992, International Day of Action on Women's Health was celebrated by emphasizing concerns about teenage pregnancy. In attendance were students from 13 schools, which were implementing a family life education project, and teachers, professionals, and parents.
Partners: existing health institutions.
AIDSCOM's Resident Advisor to the WHO Caribbean Epidemiology Centre (CAREC) discussed partnerships with existing health institutions. These institutions included Ministries of Health, multilateral agencies (e.g., WHO and UNICEF), family planning associations, universities, international private voluntary organizations, bilateral agencies (e.g., Canadian International Development Agency), and indigenous nongovernmental organizations (NGOs). AIDSCOM helped them develop an appropriate and effective conceptual approach to HIV prevention, which generally meant integrating new HIV prevention skills and concepts into existing programs and activities. AIDSCOM technical assistance addressed issues of accessibility of health services, testing, counseling, policy and confidentiality. Technical assistance included improved planning and management, program design skills, materials development, training in prevention counseling and condom skills, and a model for personal and professional behavior regarding AIDS, sex and risk. A key factor contributing to a successful partnership with CAREC was continuity of AIDSCOM staff contact. AIDSCOM helped CAREC with social marketing and behavioral research. It helped CAREC and its national counterparts to develop a regional KABP protocol for all 19 countries. AIDSCOM helped implement the protocol and strategize how to develop programmatic activities based on the results. The identified activities were training health workers and HIV prevention counselors promoting condom skills, establishing 5 national AIDS hotlines, developing 3 national media campaigns, and developing music, theater, and radio dramas. AIDSCOM and CAREC became partners with local NGOs who had access to hard-to-reach groups. Lessons learned included: technical assistance helps heath projects shift program emphasis from information to behavior change; successful partnership result in innovative programs; and proven effectiveness can be replicated in parallel programs.
Partners: institutions new to health activities.
In almost every country, AIDSCOM encouraged partnerships with organizations that were new to health promotion activities. There were groups needing specific technical expertise in the design or implementation of HIV prevention interventions. They included commercial research and advertising firms and university-based research units. AIDSCOM taught these groups how to design AIDS-related KABP surveys, behavioral analysis, and message testing. Constituent groups were existing groups that were active in areas other than HIV/AIDS or were newly formed groups working primarily in HIV prevention activities. They comprised more than 50% of AIDSCOM's local partnership. They included women's and gay groups, labor unions, professional or business associations, and religious and youth groups. An advantage of working with these groups was that they had existing networks that served hard-to-reach populations who were most in need of services. Constituent groups were people who were oriented toward and knew the jargon of the hard-to-reach groups. They focused on constituent-needs-based interventions and modified interventions so they would be more credible and appropriate. These groups had something other groups often lacked: passion and commitment. They assumed ownership of HIV prevention efforts quickly, which improved the chances that they would be sustainable. They lacked basic organization, management, and technical skills, however. AIDSCOM helped them develop these skills. For example, AIDSCOM helped the Remedios AIDS Foundation in Manila set up an AIDS information center and a hotline. The Foundation continued to operate even after AIDSCOM support ceased. AIDSCOM has provided training on various topics (e.g., basic HIV/AIDS facts and formative research). It often served as a catalyst in partnership formation. Advantages of local partnerships were: they kept AIDSCOM focused on people who make behavioral decisions; they improved the likelihood of effective innovation; and they kept HIV prevention efforts going.
Indonesia: population central to development.
The Indonesian representative to the 50th session of the Economic and Social Commission for Asia and the Pacific (ESCAP) reiterated the issue of population as being central to sustainable development. Indonesia recognizes that quality of life, which can be improved with education, health, skills, productivity, self reliance, and resiliency, has an impact on the process of development. Without quality improvements, large numbers of people become a burden. Population programs must aim to reduce population growth rates simultaneously with enhancing the quality of life. Women's improvement in education, health, and employment opportunities must be accomplished because of women's important role in national development. The goals of sustainable development are to maintain a balance between human needs and desires of the population and available resources and the environment. Sustainable development is necessary for present and future generations. The Fourth Asian and Pacific Population Conference was held in Bali in August 1992, at which time the Bali Declaration was affirmed. At the January 1994 meeting of officials regarding the implementation of the Bali Declaration held in Bangkok, Thailand, the Indonesian representative stressed the importance of the vigorous involvement of the ESCAP secretariat in planning and implementing population programs in the region. Recommendations included in the Bali Declaration are related to the issues being addressed at the International Conference on Population and Development to be held in Cairo in September 1994. The secretariat was also asked by the Indonesian representative to disseminate information on the implementation of the Bali Declaration through regular publications and other appropriate venues. Comprehensive data collection and information systems were needed on the links between population, development, and resources.
Nepal's rapid population growth still a concern.
The Nepal representative of the Economic and Social Commission for Asia and the Pacific (ESCAP) noted at the 194 ESCAP Commission meeting in Beijing that rapid population growth was still a problem: 2.1% per year. The annual average income growth rate was only 3.5% and poverty was widespread. The combination of poverty and rapid population growth were contributing to environmental damage. Sustainable solutions were needed for dealing with all three aforementioned issues. A high priority was already attached to population control programs, because population growth was linked to raising the standard of living and solving environmental problems. Women need to be placed in prominent positions in development efforts and given equality with men. Nepal representatives did attend the preparatory meeting on April 22, 1994, to the International Conference on Population and Development (ICPD) to be held in Cairo in September. The Preparatory Committee will be developing a report for the Conference. Solutions to population issues were seen as instrumental to achieving poverty alleviation and high economic growth.
Pope, head of UNFPA discuss problems.
The Pope, in attempts to influence the United Nations Population Fund (UNFPA) and the International Conference on Population and Development (ICPD), held a meeting at the Vatican with Dr. Sadik, Executive Director of UNFPA and Secretary General of the ICPD. At that time, the Pope strongly criticized population programs that try to impose limits on family size. Of particular concern were programs that try to persuade couples to have 1-2 children. Dr. Sadik commented that the disagreement was really over contraception, and the access to control of one's own fertility. There were also points of agreement. The Vatican had also called a meeting of all ambassadors accredited to the Holy See, which is about 120. The purpose was to explain the Church's position on population and development prior to the ICPD meetings in Cairo during September 5-13, 1994. It is a rare occasion when all ambassadors are summoned to the Vatican for a meeting. Diplomatic sources said that the meeting was a direct attempt to influence the ICPD. It was officially reported that the Pope will address the General Assembly in October. This will be the first time that Pope John Paul II has addressed the assembly since 1979. Archbishop Martino commented that the Pope would be commemorating the Year of the Family and the 50th Anniversary of the UN. The address will be directed to issues about the family.
Guidelines for identifying and implementing health care financing activities.
The Resources for Child Health (REACH) Project was initiated by the U.S. Agency for International development (AID) to provide technical assistance to developing countries in the areas of immunization and health care financing (HCF). The overall goal of AID assistance is to improve health status in developing countries through support of cost-effective interventions directed at the most needy populations--poor mothers and children. Gains are reflected by reductions in infant, child, and maternal mortality and morbidity. Sustaining improvements in health status requires assistance for strengthening the national capacity to manage resources more effectively. AID involvement i health care financing is a central focus of the REACH Project. These Guidelines provide a common framework of analysis for host countries as well as donors and international organizations, active in the field of health care financing in the region. The Guidelines describe the relationships that exist among the four major economic dimensions of the health system: resource mobilization, resource allocation, efficiency, and equity, and the various health care financing initiatives which might be considered to influence each of them.
The impact of CSM on prevalence in the Dominican Republic.
The contraceptive social marketing (CSM) program of Social Marketing for Change (SOMARC) in the Dominican Republic had made the low-priced oral contraceptive Microgynon available to consumers since the third quarter of 1985. Sales had grown significantly, with sale on the order of 16,000 cycles monthly. National contraceptive prevalence was around 50%, but the major goal of the program was to stimulate a significant increase in prevalence, particularly among lower socioeconomic groups. A survey and an analysis of sales and price data of the market for contraceptives addressed these issues and revealed the impact of the Microgynon program on prevalence. A consumer intercept of Microgynon purchasers in a sample of Santo Domingo pharmacies conducted over the period of October through November 1986 clearly indicated the positive impact of the Microgynon CSM program on prevalence. A questionnaire on product purchasing and consumer characteristics was administered at home to a subset of these respondents. 252 respondents participated in the home interview related to their family planning practices, purchasing behaviors, and influences on product choices. This survey found that 34% of Microgynon users were first-time users of any family planning method. An additional 10% had switched to Microgynon from less effective methods (e.g., rhythm, condoms, vaginals). Of those who switched, the largest number switched from Nordette, another low-dose oral contraceptive. Several analyses of sales statistics for the major oral contraceptive products (including Microgynon) confirmed the positive impacts of the Microgynon CSM program on prevalence. The estimate that the program stimulated the expansion of the market at a rate of around 60% of Microgynon sales was not contradicted by the consumer intercept. The consumer intercept reported that when switching did occur from other brands to Microgynon, the largest number switched from Nordette, but Microgynon did not grow at the expense of other brands.
Epidemic model of HIV infection and AIDS in Argentina. Status in 1990 and predictive estimates.
HIV and AIDS are spreading rapidly through Argentina. The authors evaluated the prevalence of HIV infection and AIDS in the country, studied the dynamics of HIV spread, and predicted the future course of the epidemic using an epidemic model. The model was constructed using differential equations to describe the interactions between members of the various groups at risk. The functional form of the solutions was used in a back-calculation procedure using data from cohort studies conducted in the US and France together with data on AIDS cases reported to the National AIDS Program, to determine the time evolution of HIV infection in each of the defined at-risk groups. HIV was introduced to Argentina during the early 1980s among homosexuals and bisexuals. By April 1990, an estimated 34,131 people were infected with HIV; 47.6% homosexual/bisexual men, 39.5% IV drug users, and 11% heterosexual adults. Infection among heterosexual adults is currently in the first and exponential phase of spread, and dominated by transmission from IV drug users and bisexual men. An estimated 107,946 people will be infected by December 1992, and more than 200,000 by the end of 1994, along with more than 12,000 AIDS cases. Heterosexuals will comprise more than 20% of the estimated 107,946 HIV-infected persons by December 1992. Also by December 1992, the authors predict 4130 people will contract AIDS: 1958 among homosexual/bisexuals, 1483 among IV drug users, 449 in heterosexual adults, 153 in children younger than 4 years old, and 87 among hemophiliacs or patients with blood coagulation disorders. A significant proportion of the more than 200,000 HIV-infected persons predicted by the end of 1994 will be heterosexual adults.
The Household, Gender, and Age Project.
The coordinator of the UN Households, Gender, and Age Project (HGA) reported that very little research had been conducted on changes for women within the household unit and at the individual level since 1975. Research was reported as lacking in attention to how macrochanges affected the microlevel, the individual, the household, or the small community. Over the past decades, major changes have been reflected in low fertility and increased aging among people in developed countries, in globalized world markets, and in political decisions in one country having immediate effects on other countries. The HGA project aimed to examine the macro and micro links: the relationships between societal and individual change over time, with attention to the role of women in the development of community and society. Age and gender were considered key concepts shaped by the specific cultures. Household was defined by kinship, economic position or conditions, and other obligations of co-residence. The household was viewed as a production entity. Every country-specific study examined the impact of development on the socioeconomic and cultural features of the household, women's changing labor force participation rates, and the related issues of fertility, sexuality, and family planning. Each country also focused on employment, education, and domestic power structures. Migration was the focus for those countries with significant movements of population. The target audience for the HGA reports comprised national decision makers involved in social and economic development planning and international decision makers. Each country made specific recommendations for action. The methods of analysis included a life course analysis of retrospective and prospective data in age cohorts: longitudinal life history data which may reveal individual and social processes. The main hypothesis was that, of the many rapid changes in the world today, some changes will greatly affect women and will be observable or not so easily evident changes. The main urban analysis was done in Bogota, Colombia; San Martin, Argentina; Petropolis, Brazil; and Santiago, Chile.
Trends in induced abortion during the 12 years since legalization in Norway.
An analysis was conducted on data from 174,595 women, 15-44 years old, who had undergone an induced abortion during January 1979-December 1990 in Norway to determine abortion trends by marital status and age since the 1979 legalization of all abortions up to 12 weeks gestation. The annual number of abortions fell from 14,621 to 13,342 between 1979 and 1982 and gradually increased to 15,460 in 1990. The general abortion rate remained relatively the same during 1979-1990. The age-adjusted abortion rate had a significantly increasing trend. Yet when the general abortion rate was adjusted for age and marital status, it fell with time. The general abortion rate fell by 12% among married women, however, it did not change among unmarried women. Unmarried women had higher abortion rates for all age groups except 15-19 years than married women. During 1979-1980, the difference in the abortion rates for unmarried and married women was 11 abortions/1000 women, by 1988-1990, the difference had grown to 13 abortions/1000. A hospital committee had to approve abortions performed beyond 12 weeks. Later-gestational-age abortions were less common during the last three years than during the first three years (2.4 vs. 3.1/1000). They fell among unmarried women, while they increased among married women. Among married women, there was a significant increase in pregnancy terminations beyond 18 weeks (0.1% in 1979-1980 to 0.75% in 1988-1990; X2 = 97.2; p < 0.0001). They were more likely to have these later stage terminations than unmarried women.
Abortion services under national health insurance: the examples of England and France.
The US can anticipate possible problems and benefits of different financing mechanisms as it moves to providing national health insurance coverage. England, Wales, and France have a national health service with a policy mandating abortion services. Examination of these systems shows that bureaucratic health care structures do not assure that all women have access to abortion services, however. Ideological, budgetary, and bureaucratic resistance operates at many public hospitals and public sector services. Abortion services always are a target for spending cuts when there is limited health care funding. In the US, the strong anti-abortion faction is likely to pressure health maintenance organizations and other managed care systems to limit access to abortion services. In the UK and France, independent, private health facilities fill the gaps in the public system and thus provide women universal access to abortion services. These facilities are at least as necessary in the US as they are in the UK and France. UK's National Health Service process of abortion referral delays abortions. In the UK and France, women tend to view public facilities as lacking confidentiality, so they automatically go to private providers. Other problems with obtaining a referral by a primary care provider include an extra health care visit, that the provider may not make or may delay the referral, and the woman's desire not to discuss the pregnancy with the regular provider. Bureaucratic and legal barriers in France force many women to seek and physicians to perform illegal abortions. Barriers in France are a one-week waiting period, required counseling by a social worker, and a required overnight stay in the hospital. These barriers must be avoided in the US to prevent illegal abortions.
Comparative contraceptive efficacy of the female condom and other barrier methods.
The research design for clinical trials of the female condom did not include randomization with another contraceptive method, so no one can definitely determine its contraceptive efficacy. Less formal comparisons with studies of other barrier methods reveal that the contraceptive efficacy of the female condom during typical use is not different from that of other vaginal barrier methods among US women. When researchers standardize probabilities of failure by parity and age, the diaphragm may be more effective than the female condom, the sponge, and the cervical cap during typical use. Yet, during perfect use, the contraceptive efficacy of the female condom is the same as that of the diaphragm, at least that of the cervical cap, and greater than that of the vaginal sponge. The clinical trial of the female condom did not include women with low coital frequency, included chemically confirmed pregnancies even when they were not clinically confirmed, and lost a much smaller percentage of the sample to follow-up than other clinical trials. Thus, one would expect the female condom to have higher failure rates than the other barrier methods, even if the contraceptive efficacies of the barrier methods matched. It is impossible to conduct statistical comparisons of the contraceptive efficacies of the female condom and the male condom because no carefully controlled clinical trials of the male condom have been conducted. The contraceptive efficacy of the female condom is probably similar to that of the male condom without a spermicidal lubricant, even though a superficial comparison with published probabilities of failure suggests otherwise. Extrapolations from results on contraceptive efficacy suggest that the female condom has the potential of reducing the annual risk of HIV infection by more than 90% among women having intercourse two times a week with an HIV-infected male.
[Recent demographic trends in Turkey]
Coverage of Turkey's vital registration system remains incomplete, and it cannot yet be used to measure annual population changes. Data and demographic indices based on the 1990 census and the 1989 National Demographic Survey are the most recent available. Turkey's population in 1990 was 56 million. The proportion urban increased to 59% from 49.2% in 1980. Nearly 35% of the population was under 15 years old, and the median age was 21.6 for males and 22.3 for females. The average age at first marriage in 1989 was 24.8 for men and 21.8 for women. Mortality has been in continuous decline. The crude death rate dropped from 16.4/1000 in 1960-65 to slightly under 8 in 1989. Life expectancy at birth was 63.3 for men and 66 for women. The infant mortality rate declined from 166 in 1965-70 to 85 in 1989. Rural or urban residence and maternal educational level were the most significant determinants of infant mortality differentials. Turkey's total fertility rate declined from 6.2 in 1960 to 4.3 in 1978 and 3.4 in 1988-89. The crude birth rate declined from around 40/1000 in 1968 to under 28/1000 in 1989. Fertility began to decline in the last third of the nineteenth century in Istanbul and other large cities of the Ottoman Empire. Istanbul's total fertility rate was a relatively low 3.9 even before World War I. Turkey adopted a policy to slow demographic growth in the mid 1960s, and family planning activities were supported by nongovernmental organizations. The direct impact of these policies on demographic behavior appears to have been somewhat limited, and the use of traditional methods of birth limitation remains widespread. Abortion was legalized in 1983 and is available at public hospitals. The proportion of married women aged 15-49 who use contraception increased from 38% in 1973 to 63% in 1988. Regional differentials in demographic indices are significant in Turkey, with the Anatolian East and Southeast lagging behind other regions in fertility and mortality decline, contraceptive usage, and other indicators. Turkey thus appears to be divided into a region in which the demographic transition is well advanced and one where it is proceeding more slowly.
This work analyzes the model of procreation described by Delaney for Turkish peasants in rural Anatolia, and provides ethnographic evidence to document existence of such a model elsewhere in Europe and the Mediterranean. A model of procreation is a symbolic system embodying a series of interrelated notions about procreation. The definition of each particular element implies taking into account the entire model. Models of procreation are simultaneously conceptual, explaining reality, and moral, explaining proper behavior. The recommended methodology involves analyzing the relationship between the procreative model and the concepts of gender, marriage, and family. Delaney described a monogenetic model of procreation observed in Anatolia in which men are considered to plant the seed while women are regarded as a kind of field which nourishes what has been planted. Delaney states that the "field" is a space enclosed and protected by the proprietor, who must be assured that the seed is his. Evidence from Portugal, Spain, Italy, and Greece is advanced to support the suggestion that such a model of procreation is more adequate for explaining concepts of man/woman, marriage, procreation, family, unmarriedness, concepts of honor and shame, and concepts of evil eye and witchcraft than are the commonly used analytical categories of sex and sexuality. Among one group of Portuguese fishermen, the definition of a man depends entirely on marriage and fatherhood. Females are considered women at menarche because they are eligible for maternity, but their status becomes more ambiguous at menopause. Marriage, procreation, and family are conceptualized in this procreative model as stages of a single process, which culminates in formation of a family.
[Genealogy and historical demography]
Historical demographers and genealogists work with the same parish registers and records of vital events, and they use the same procedures for linking data to gain insights into past occurrences. Despite these common elements, cooperation between the two worlds remains limited. Genealogists are primarily interested in families, and they are able to trace instances of geographic and social mobility. Historical demographers work exclusively within communities or small groups of communities, which they come to know exhaustively, but their focus never moves beyond the community. The major problem in trying to generalize from the work of genealogists is lack of representativeness. Virtually all genealogists are most interested in tracing their own families, and virtually all are of similar middle class background. Families of modest means are underrepresented. In addition, because genealogists work in an ascending direction, they underrepresent individuals dying too young for marriage and parenthood. Their work does not allow estimates of fertility and sterility because sterile couples leave no genealogical trace. Genealogical studies that work in the descending direction face the obstacle of loss to observation through migration. Although migration in the absence of accurate population registers renders genealogy almost useless for the analysis of demographic events, the addition of genealogical techniques could contribute to historical demography by helping to alleviate the narrowness of the field of observation. The conclusions of most community monographs rest essentially on the families that are most sedentary and whose data are most complete, but whether such sedentary families are truly representative is a topic of debate. Another potential contribution of genealogy is in the linking of records for related families. At present, unions rather than families are the analytical unit in historical demography. Linking of families resulting from remarriage or of the families of parents and their children would greatly increase the scope of questions that could be addressed.
Demographic data pertaining to women and children are very scarce from the Ottoman Empire. Fiscal records usually mentioned only males aged 15-75. Few parish registers or other records allowing statistical study of demographic events are available. Research on Bulgarian peasant society strongly suggests, however, that the rites, beliefs, customs, and practices of all kinds in observation of the stages of life are capable of revealing demographic phenomena. Maternal and infant mortality profoundly affected traditional society. The census of 1887 showed fertility to be very high, but mortality through the age of 20 was also very high. The resulting age pyramid had a broad base which rapidly narrowed. An impressive mass of beliefs and customs were intended to safeguard the health and life of mothers and infants. The stipulations concerning mothers lasted until the fortieth postpartum day, while those involving the infant were prolonged until the first birthday. Beliefs about malevolent forces menacing the parturient women, secrecy about the place of birth, widespread knowledge of herbal remedies in case of postnatal complications, protective amulets, and prohibitions to be respected by the pregnant women were shared by both Muslim and Catholic women.
[Trends in prenuptial conceptions as an indicator of cultural change]
The BALSAC population register containing data on reconstituted families in the rural Saguenay region of Quebec between 1842 and 1971 was the basis for an analysis of prenuptial conceptions. The proportion of conceptions occurring prenuptially was considered an indicator of how seriously young people respected the official norms of the Catholic Church prohibiting procreation before marriage. Combined with other indicators in a larger study, this evidence of religious morality is expected to shed light on the general process of cultural change in the region over time. The analysis considered 49,331 first marriages and 2953 prenuptial conceptions indicated by birth within seven months of marriage. The proportion of prenuptial conceptions never exceeded 9% during the entire period, attesting to strict compliance with Catholic doctrine. The low level of illegitimate births confirmed the result. The proportion of prenuptial conceptions began to rise slightly but progressively beginning in 1922-31. Its highest point of 9.0% was reached at the end of the study period in 1962-71. The proportion of prenuptial conceptions as a dependent variable was not influenced by significant social or spatial factors such as distance, the size and structure of the family of origin, geographic mobility, or the age or birth order of the mother. Of the dozen independent variables analyzed, only literacy and occupation were found to be correlated to the proportion of prenuptial conceptions. But the limited correlation suggests that the entire regional culture shared a deeply rooted disapproval of prenuptial conception and birth. It has even been suggested that a French Canadian illegitimacy pattern may exist, at least in rural Quebec.
The definition of the demographic transition rests on macrodemographic indicators which have been well studied. The "microdemographic" implications of the transition are much more concrete for the individuals and families experiencing them, but have received little study. For example, the number of families with many children has shrunk, but the lengthening of life has increased the number of persons who have great grandchildren or living great grandparents. With reference to the family tree, the demographic transition replaced horizontal families with many siblings and cousins with vertical trees in which three or four generations coexist. Statistical documentation is lacking, probably because of the difficulty of describing the change and the multidisciplinary nature of the phenomenon. But recently, a meeting of the International Association of French Speaking Demographers on "Households, Families, Kinships, and Solidarity in the Mediterranean Populations" heard several communications concerning this type of "statistical anthropology", with comparisons in time and space for populations with different kinship systems. A simulation study of women living in families with one, two, three, or four generations projected an increase in the number of 50-year-old women with one or more grandchildren and at least one living parent from 24.7% of those born in 1920 to 42.1% of those born in 1950. The number of women at age 50 with no children or parents surviving declined from 9.7% of those born in 1920 to 3.6% of those born in 1950. The number of women at age 50 with no children has increased, but the number with surviving parents has increased much more. Another topic at the meeting was marriage between cousins, which is quite common among Muslim populations of the Mediterranean. The question of whether migrants from the Maghreb countries continue to prefer to marry cousins after they have migrated north cannot be easily answered with available data. The anthropological study of this question could shed light on the future in Europe of this preference for endogamy which is so contrary to European matrimonial tradition.
[Families in Curitiba (Brazil) in the eighteenth century: a look at fertility]
Studies of Brazil's eighteenth century population remain rare because of the scarcity and mediocre quality of available sources. This work assesses registration in Brazilian parishes, describes difficulties in reconstituting families with available records, and provides indirect fertility estimates for the free population of the small south Brazilian town of Curitiba in the eighteenth century. The registers theoretically included all individuals but the considerable population of slaves were identified by first name only, and only a part of the Indian population was included. The average interval between birth and baptism was 16 to 19 days, and it is likely that some infants dying before baptism were never registered. The data were judged to be of lower quality than comparable French data, but adequate for a careful analysis of fertility using the method developed by Louis Henry. The large numbers of slaves and of illegitimate and abandoned infants not identified as belonging to any family limited the cope of the study. 2631 family records were established, of which 871 corresponding to stable families were retained for the fertility study. 3392 births accounting for 51% of those reported in the family records corresponded to the 871 files. Completed family sizes were found to exceed ten children for women married before age 20 and 8.5 for those married between 20 and 24 years. The average age at last birth was 39.0 years for all women and 40.8 years excluding women who had their last child before age 30. A nonnegligible proportion of couples became sterile before the woman turned 30.
[A retrospective study: population policy in Romania, 1945-1989]
Examination of Romanian demographic history under the Communists suggests that perceived aberrations in demographic policy were a reflection of inherent features of Communist rule itself. Romania began its demographic transition in the late nineteenth century and was in a phase of renewed fertility decline after the postwar rebound when in 1957 abortion was decriminalized. The motives for decriminalization remain an object of speculation, but the author asserts that social change and not the abortion legislation was responsible for most of the fertility decline. Legislation restricting abortion was enacted in 1966, one year after Ceausescu's rise to power. Unlike the 1957 liberalization, the restrictive measures were preceded by an intense media campaign and accompanied by an incessant barrage of pronatalist propaganda. Contraception was not prohibited, but was simply not available for the majority. The maternal mortality rate including deaths from abortion complications increased from 8.51/10,000 live births in 1965 to 10.55 in 1969 and 16.94 in 1989. Romania's fertility fluctuated widely under the different measures. The total fertility rate declined from 2.9 in 1956 to 1.9 in 1966 and rose to 3.7 in 1967, to decline anew to 2.4 in 1973. The number of births doubled between 1966 and 1967, but immediately began to decline again. The Romanian age pyramid has two cohorts, those of 1967 and 1968, that are twice as large as the preceding cohorts and over 100,000 persons larger than the following cohorts. The measures enacted after 1966 constitute a true population policy, whose goal of increasing fertility was to be sought through a system of programs including prohibiting abortion, withholding contraceptives, limiting divorce, and persuasion through propaganda. Family allowances and the taxation system were ineffective but had a pronatalist character.
[Historical demography and social history]
Historical demography and social history, two disciplines that would appear to be highly complementary, have in reality not sufficiently influenced each other. Most monographs based on parish records have attempted some social analysis, but it has amounted to indicating differences without explaining them. Most parish monographs have neglected to identify the components of demographic growth and the differential reproduction of social groups. In the past ten years, new topics of research for historical demographers have appeared at the margins of a social history that is enlarging its interest in cultural aspects. Demographers have become less assured of the explanatory value of economic conditions since the work of the Princeton group on fertility decline in Europe put greater emphasis on cultural and political explanations. Following the work of Ron Lesthaeghe, it became as important to consider ideological factors such as religiosity and institutional factors such as the family mode of production or rules of property transfer, as it was to examine social and economic disparities. Macrodemographic studies do not allow innovative forces at the margins of social groups to be grasped or integrated into interpretive models. They measure changes after they have occurred but are incapable of explaining how a system is transformed. Microanalysis may do a better job if some means can be found of focusing on the individual behavior of forerunners that will eventually influence the group. Existing indices are obtained by aggregating individual data to produce averages which obscure diversity, the behavior of specific groups, and the innovative capacity of variations. Analysis of changes in demographic systems will require a complete fusion of demographic, economic, sociocultural and political history.
Levonorgestrel (LNG) has been recently introduced on the Danish market. In addition to being a contraceptive method, the LNG-releasing IUD also constitutes a therapeutic principle for idiopathic menorrhagia. The LNG-releasing IUD consists of a T-shaped plastic rod in which the vertical leg is surrounded by a cylinder that functions as a hormone reservoir and allows the release of LNG at a rate of 20 mcg/24 hours. The released hormone exerts in part a local atrophying effect on the endometrium and in part a slightly suppressing effect on the ovarian function. The preventive effect of this IUD is greater than that of the well-known copper IUD, and the risk of infection in connection with its use is significantly less. In contrast to the copper IUD, the LNG-releasing IUD reduces the amount and length of bleeding during menstruation, and only 20% of users experience amenorrhea. In Sweden and Finland LNG-releasing IUDs were compared in randomized studies to copper-T IUDs. LNG-releasing IUDs had a significantly lower Pearl index (0.1-0.6 vs. 3.3-6.7). In a multicenter study 937 women were randomized to Nova-T IUDs and 1821 women to LNG IUDs. Among LNG-releasing IUD users unwanted pregnancy occurred in 5 cases, equivalent to 0.5 per 100, and among Nova-T users 35 pregnancies occurred, corresponding to 5.9 per 100. In a Danish study with 1697 Nova-T IUD users the rate of pregnancy was even greater than 3.7/100 after 6 years of observation. In a 1994 Swedish study the rate (per 100 women) of expulsion during 5 years was 5.8 LNG and 6.7 Nova; bleeding problems 13.7 and 20.9 (p = 0.01), respectively; amenorrhea 6.0 and 0 (p = 0.001), respectively; hormonal side effects 12.1 and 2.0 (p = 0.001), respectively; and infection 0.8 and 2.2 (p = 0.01), respectively. The LNG-releasing IUD seems to be a new therapeutic method for menorrhagia. It is not yet clear whether this treatment principle can also be used for women with metrorrhagia.
[Population reproduction in Serbia and Slovenia]
The populations of Serbia (without the provinces of Voivodine and Kosovo) and of Slovenia were in 1991 in the midst of demographic transition, with fertility and mortality at very low levels. The fertility levels were high in these regions before the transition started (before 1880). Meanwhile, the fertility rate declined to a level of 35/1000 in Slovenia and 40/1000 in Serbia. At the same time, fertility was low in Slovenia in comparison to the populations of western and central Europe because of relatively late marriages (average age at marriage among women is 26-28 years), the high level of singles (among women up to 20% never married), and migration. In contrast, in Serbia marriages occurred at a young age in order to adequately maintain the household and to expand agricultural areas. The slow reduction of fertility has preceded the reduction of mortality. In Slovenia fertility declined slowly and gradually in parallel with mortality. In Serbia fertility started to decline later and faster, while natural growth stayed at a high level longer. The average annual population growth rate during the period of 1931-48 was 9.3/1000 in Serbia vs. 2.3/1000 in Slovenia. In Serbia the net reproduction rate has been low in the last 3 decades, whereas the simple reproduction of the population has not been assured in Slovenia since 1981. Until 1955 Slovenia was characterized by outmigration and Serbia by immigration. The population of Serbia increased from 1.9 million in 1880 to 5.7 in 1981, while that of Slovenia increased from 1.2 million only to 1.9 million during the same period. The differential fertility, the problems of abortions and contraception were analyzed using moment and cohort analyses in 1976. Socioeconomic factors (industrialization with urbanization), the increase of living standards, the dissolution of patriarchal life, the change of women's status, the expansion of education, the reduction of infant and child mortality, more effective contraception, and pronatalist religious views have influenced the family size.
[Presidential Decree No. 28/90 of 10 September 1990]
In Mozambique the state is committed to the protection and assistance of children, old people, and those with physical, sensorial, and mental deficiencies as well as to their education and social rehabilitation. Therefore, the president of the republic decrees that in order to achieve these objectives the state secretary of social affairs should achieve these essential functions: 1) to organize assistance programs for infants and promote social units with the task of setting down pedagogic norms for infant and child care establishments; to assist orphans, abandoned children, and those without family care; to conduct research on children in hardship situations; to plan educational programs in the community addressing child care and the role of adults in it; and to promote the implementation of the law of adoption and guardianship. 2) With regard to the elderly, the secretary should plan assistance actions for those without family support and subsistence, or in need for their integration into the community; promote socially useful tasks for the physical and mental health of the elderly; establish contacts with their families where the elderly are in old age centers with a view to reunite them; and organize, equip, and regulate a network of social units to assist them. 3) Regarding assistance to the physically and mentally handicapped, the secretary should organize actions to protect, assist, educate, and reintegrate them into the community and create centers for their care; promote socially useful tasks for them; establish contacts with their families whenever they live in centers in order to attempt to integrate them into their families; educate the population about the need to integrate such individuals into the family and the community; and organize and regulate a network of social units for them. Further points are spelled out concerning social and community action and programs, hospitals and the health sector as well as education and international cooperation.
[Neuropathological findings in acquired immunodeficiency syndrome (AIDS): review of 138 cases]
In order to determine the incidence of diseases that could affect the central nervous system (CNS) in AIDS cases a retrospective study was performed by means of studying the autopsies of 138 AIDS patients (only 9 females) who had died between January 1985 and December 1990 at the Hospital de Clinicas de Porto Alegre, Brazil. The brains were evaluated macroscopically and microscopically via hematoxylin-eosin staining and, if necessary, by special staining techniques such as PAS, Grocott, Giemsa, and Ziehl-Nielsen. In 81 cases (59%) there was some kind of CNS involvement. Opportunistic infections were responsible for 49 deaths (35%). The main lesions found were cerebral toxoplasmosis in 29 cases (21%). Stage 1 of toxoplasmosis (5 cases) was characterized by a necrotizing abscess with ill-defined boundaries. Stage 2 (10 cases) represented an abscess with a halo of macrophages and lymphocytes surrounding the area of necrosis. The chronic abscess of Stage 3 (14 cases) had microglial nodules and rare encysted and isolated toxoplasmas. Furthermore, cryptococcosis was detected in 17 cases (12%), tuberculosis in 2 cases (1%) as well as candidiasis in 1 case (0.7%). The cryptococcal lesion was characterized by the formation of intraparenchymatous cysts that contained numerous fungi easily identified by HE or Grocott tests. In addition to these there were 15 cases (10%) of vascular lesions: 12 cases of hemorrhage, 2 cases of atherosclerosis, and 1 case of venous thrombosis. Also, 8 cases (6%) of gliosis, and 7 cases (5%) suggestive of encephalopathy caused by HIV, 6 cases (4%) of cortical atrophy, 3 cases of neoplasia (2%) with 2 lymphomas and 1 ependymoma, and 1 case (0.7%) of bacterial meningitis. The CNS is one of the major target organs of AIDS and cerebral toxoplasmosis is the principal form of disease of the CNS in AIDS patients. This study confirms the findings of other authors and indicates the necessity of using such techniques as computerized tomography and/or magnetic resonance for the early detection of lesions of the CNS.
[Hormonal contraception: what's really new?]
In 1992 on the Portuguese contraceptive market 3 new oral contraceptives (OCs) were introduced, namely 2 triphasic OCs with gestodene and 1 monophasic OC with 20 mg of ethinyl estradiol and 150 mg of desogestrel. The promotional drive has created much confusion in medical circles, among nurses, and in the general population. Therefore, it is important to clarify whether all new pills are better and whether those satisfied with old pills should take new one just because they are new. It must be underscored that low-dose OCs (monophasic or triphasic) are effective in the control of the menstrual cycle with notable metabolic safety. The question is whether there are advantages of taking these OCs for those who have not taken them because of contraindications. The answer is no, because a woman who could not take OCs previously on account of known contraindications (obesity, heavy smoking), may not take the recently introduced OCs either. It is unfortunate that the literature of OCs with 20 mg of EE did not refer to the classical contraindications. It was recorded that OCs with 20 mg of EE have been used in the US (with other progestagens) for over 15 years with the negative side effect of spotting. The side effects should not be confused with contraindications, as some women may experience side effects with a certain OC while they may have nothing with another. Similarly, the metabolism of a certain hormone changes from person to person: a particular woman may experience side effects with a monophasic OC, while she could do well with a triphasic OC. At this juncture, the appearance of triphasic OCs like gestodene represents a real scientific advancement because it imitates the hormonal level that exists in the natural menstrual cycle, and has significantly reduced the incidence of side effects attributed to monophasic OCs lacking hormonal fluctuation.
[Decree-Law No. 24/89/M of 3 April 1989, Labor Relations in Macau]
The labor relations juridical regime in the territory of Macau was approved by the Decree No. 101/84/M of August 25, 1989, and after this regime has been in force for one year, the government and the associations of workers and employees will be obliged to evaluate it. Regarding women's rights in the workplace, the government of Macau declares the law as valid for the territory as follows: women's right to work means no discrimination based on sex whether married or not, while temporary measures to correct inequalities and to protect motherhood as of social value are not considered discriminatory. Prohibited work implies genetic risks. During pregnancy and up to 3 months after childbirth women shall not perform tasks that are not advised for their condition. Equal salary is ensured to workers for work of equal value. Pregnant women who have been employed over 1 year have the right of 35 days of maternity leave with guaranteed reinstatement without loss of salary. 30 days shall be allotted immediately after delivery and the remaining 5 before or after delivery. In case of an illness originating in pregnancy or from delivery that lasts beyond the maternity leave, the worker has the right to be absent without loss of employment or salary. The paid maternity leave is assured only up to 3 deliveries for each worker, and the employee can demand proof of pregnancy. A worker shall not be dismissed without just cause during pregnancy and during the 3 months after childbirth.
The regulation and entry into force of the Decree no. 2/90/M of January 31, 1990, remaining in effect in the territory of Macau, is presented, and simultaneously the Legislative Certificate No. 1 796 of July 5, 1969 and the Decrees no. 21/83/M and 28/89/M of April 9 and May are revoked. The articles of the law cover various aspects of travel, including: area of the law's application; definition of native status; entry and departure from the territory; documents; formalities related to documents; authorization of entry; special situations; permanent residence and its extension; refusal of entry; nonresident workers; authorization of residence status; evaluation of application; payment of tax; types of residence status (temporary for 1 year and permanent for those living in the Territory for 7 years), their renewal, and cancellation; determination of residence status of Chinese citizens coming from China; authorization of return to Macau of residents temporarily living abroad; fees for granting residence status; penalties and fines for exceeding the limits of permanent stay (failure to file an application for permanent residence, expired residence status, failure to report the change of residence, and failure of those coming from China to report to the public security authority). The receipts from fees and fines shall enrich the coffers of the public treasury.
[Act No. 7/90 of 1990, Constitution of the Democratic Republic of Sao Tome and Principe. Excerpts]
The revised constitution of the Democratic Republic of Sao Tome and Principe was passed on August 22, 1990. Major points of this political constitution are listed in Part I: definition of national identity, citizenship, national territory, unitary state, democratic state, justice and legality, mixed economy, fundamental objectives of the state, national defense, international relations, and national symbols. Part II: fundamental rights and social order, the principle of equality, citizens staying in foreign countries, foreigners in S. Tome, personal rights, family, marriage, and children. The rights to culture, enterprise, movement and emigration, peaceful demonstration, assembly, and association. Citizens shall not be extradited or expelled from the national territory neither for political motives nor for crimes. The right to work is granted to all, and the state ensures equal opportunity irrespective of sex. Social security is a guaranteed right to all citizens in illness and disability, in old age, widowhood, and orphanhood. It is incumbent on the state to promote public health, the objective of which is the physical and mental well-being of the population in accord with the national health system. The family as the fundamental element of society is entitled to protection by the state. In particular, the state must promote the social and economic independence of families; promote the creation of a national network of maternal-child assistance; and cooperate with the parents in the education of children. The youth, especially young workers, enjoy special protection of their economic, social, and cultural rights. Elderly persons have the right to live in family settings and to adequate economic security. Education is recognized as the right of all citizens as forming human beings and promoting their active participation in the community. The state promotes the elimination of illiteracy and promotes education in accord with a national educational system. The state ensures basic, compulsory education free of charge.
[Act No. 48/90 of 24 August 1990, The Basic Health Law]
The Assembly of the Republic of Portugal decrees pursuant to the Constitution the following Law No. 48/90 of August 24, 1990, on the fundamentals of health. The protection of health constitutes an individual and community right, which comes to realization by means of joint responsibilities of citizens, society, and the state. The state promotes and guarantees the access of all citizens to available health care. The national health policy is concerned with promotion of health, prevention of disease, special attention to major risk groups such as children, adolescents, pregnant women, the elderly, the handicapped, and drug addicts. The national health service is characterized by universality for the population, equality of access to users, and regional and decentralized organization. The beneficiaries are all Portuguese citizens and nationals of the European Economic Community as well as foreigners residing in Portugal. The organization of the national health service, regional administration, subregional coordinator of health, advising commissions of health, continuous evaluation based on statistical data, codes for professionals of the national health service, physicians, financing, moderate rates, benefits, and the administration of hospitals and health centers are detailed. Particular initiatives of health comprise: assistance to the private sector, particular institutions in solidarity with health goals, the licensing and regulation of for-profit private health organizations, and health professionals in a liberal regime.
Toxoplasmic encephalitis (TE) is among the most common neurologic afflictions, and it is the most prevalent cause of intracerebral mass lesions in AIDS patients. In a retrospective study the files of 516 patients (44 females) were reviewed to determine TE prevalence, serology, the sensitivity and specificity of the computed tomography (CT) brain scan, clinical findings and serology for making the diagnosis. The patients had been hospitalized with AIDS at the Hospital de Clinical de Porto Alegre, RS, Brazil, between May 1985 and December 1991. In 125 cases autopsies were also studied. The brain slices were evaluated macroscopically and microscopically via hematoxylin-eosin staining and, if necessary, by special staining techniques such as PAS, Grocott, Giemsa, and Ziehl-Nielsen. The presumptive diagnosis of TE prevalence was 31% (66) in 209 patients who underwent CT, or 13% when the whole sample of 516 patients was considered. Blood serology and cerebrospinal (CSF) serology to toxoplasma were positive in 65% (225) of 343 patients and 49% (83) of 169 patients examined, respectively. TE was also definitively confirmed in 27 of 125 patients, a prevalence of 22%. CT scan had 65% of sensitivity and 82% of specificity. Immunofluorescence (IF) demonstrated TE positivity in the serum of 225 (65%) of 343 patients. Sensitivity and specificity of IF in blood serology was 95% and 30%, respectively. IF indicated TE positivity in CSF in 83 (49%) of 169 patients examined. The CSF serology had 77% sensitivity and 56% specificity. The 3 clinical findings associated with major frequency of TE were: 1) fever above 37.5 degrees Celsius (sensitivity of 92%, specificity of 56%), 2) neurological focal signs (sensitivity of 59%, specificity of 82%), and 3) headache (sensitivity of 41%, specificity of 69%). The high sensitivity of serology (95%) and high specificity of CT scan (82%) may be useful in the diagnosis of TE whenever CT presents alterations compatible with TE.
[Sex behavior, STD / AIDS and drug use among Brazilian army conscripts]
A questionnaire on sexual behavior, sexually transmitted diseases (STDs), AIDS, and illicit drug use was submitted to 388 conscripts from the 20th regiment of armored cavalry in the city of Campo Grande, MS, Brazil. The mean age was 18.5 years; 62.63% had completed the 8th grade of elementary school; and 94.85% were unmarried. They had obtained information about sex from TV, radio, and newspapers (33.51%), teachers (27.58%), friends (24.23%), relatives (8.76%) and others (5.93%). The frequency of sexual intercourse per month was less than 1 for 35.82%, 1-4 for 35.57%, 5-8 for 12.89%, 9 or more for 6.19%, and none for 9.54%. The number of sexual partners in the preceding year was 1-2 for 46.65%, 3-4 for 22.16%, 5-6 for 9.02%, 7 or more for 8.76%, and none for 9.28%. The type(s) of sexual intercourse were vaginal for 35.57%; oral-vaginal-anal for 25.77%; anal-vaginal for 14.43%; oral-vaginal for 12.63%; oral for 1.29%; anal-oral for 1.03%; and anal for 0.77%. The rate of homosexual relationship in the previous 2 years amounted to 14.69%: because of money (46.2%), coercion (6.0%), enjoyment (1.6%), and other reasons (46.2%). The use of condoms amounted to 51.29% and previous STDs to 11.60% (N=46). Only 31% turned to physicians for treatment. 97.94% wanted to avoid AIDS, but they were ignorant about prevention and considered the following to bring risk of transmission: mosquitos (121), kiss on the mouth (103), drinking from the cup of another person (69), and donating blood (64). 23.20% of the conscripts used illegal drugs: marijuana came first, followed by lolo, glue and cocaine, frequently in combination with other drugs. High risk sex behavior, the high incidence of STDs and drug use, and ignorance about AIDS point to the necessity of an effective national public health program.
The capital of Mato Grosso state, Cuiaba, has a high rate of HIV infection (50/100,000 inhabitants in mid-1992). 78 AIDS cases of Group IV required admission into the University Hospital Julio Muller (UFMT) from 1988 until June 30, 1992. This caseload corresponded to 40% of the 195 cases of AIDS reported in the state during this period. There were 16 women (20.5%) among the cases, a male-female ratio of 3.87:1, while in Brazil the ratio was 6.61:1 (p < 0.05). This regional difference was also confirmed when analyzing the reporting of AIDS up to June 1992, when 37 female cases were revealed among the 195 notified (male-female ratio of 4.27:1, p <0.05). This difference could be explained by the large percentage of high-risk behavior for HIV infection or IV drug use (35 of 78 patients or 45%). 57.7% of patients had been infected within the state. In the northern area of the state urban centers with more than 50,000 inhabitants, such as Peixoto de Azevedo, 1 woman out of 100 was infected. Among prostitutes in the city of Pontes e Lacerda 2 women were infected out of 60 women examined. In this area the intensive migration flow favors the alarming spread of the epidemic which is very difficult to control. With respect to clinical symptoms and opportunistic infections, there were 25 cases (32%) of tuberculosis among 78 patients, while the national rate was 20.8% (p<0.05). In other words, when only the cases were considered in 1991 and 1992, the prevalence of TB was 39%, indicating an association with AIDS. Myocardial infarction was found in 3 individuals, in 1 of them Toxoplasma gondii infected cardiac fibers. Although endemic tropical diseases did not influence the caseload, malaria caused by Plasmodium falciparum was diagnosed in 3 patients, and 2 of them were approaching death. A larger sample could confirm trends, such as the high number of women with TB, and that the majority of patients were infected in the less populated center of the state.
[Users' perspective on the Norplant contraceptive method]
The objective was to present the experiences and opinions of women who chose Norplant as their contraceptive method. The women were selected in family planning clinics at 3 institutes: the Federal University of Parana in Curitiba, the State University of Campinas, Sao Paulo, and the Assis Chateaubriand Maternity School in Fortaleza, Ceara. A total of 280 women were interviewed by means of a pretested structured questionnaire in their own homes by trained interviewers during May and November, 1985. 46.4% had pain in the arm after insertion, and 1/3 said the arm was swollen. Ecchymosis was claimed by 85% of women at clinic B, 57% at clinic C, and only 35% at clinic A, a significant difference. Burning was the most frequently mentioned (40.3%) local symptom during use, followed by itching of the arm or the hand (25.4%). 49.6% of women said that the implants were hardly visible. One-third of the women who had reported menstrual cramps, diarrhea, headache, and nervousness said these symptoms diminished with the use of Norplant, but 24.3% said that the headache increased. More than half of the women had amenorrhea for 2 or more months, or menstruated, had bleeding and/or spotting for 10 or more days in a month. However, 26.9% of these women disliked the occurrence of amenorrhea, and 42.1% disliked prolonged bleeding. Weight gain was reported by 42.9% vs. weight loss by 30.5%, breast size increase by 9.3% vs. decrease by 2.5%, and the decrease of libido by 22% vs. the increase of libido by 17%. 58.8% said that the bleeding interfered with their sex life. On the other hand, 24.4% reported that they had sex while having bleeding. The great majority of users (77.2%) considered their experience with Norplant good or very good, and 80.6% said that they would recommend it to other women.
[Sex-sin, illness-punishment: on AIDS among us]
The anthropology department of the University of Pernambuco, Brazil, conducted a study involving 23 students of both sexes in the city of Recife. The objective was to identify changes in sex behavior since the advent of AIDS, behavior to reduce the risk of AIDS, and to learn about the thinking of young people about AIDS. The subjects associated AIDS with homosexuality and prostitution. Homosexuality was alluded to as something dangerous and dirty. They considered themselves safe in sexual relations, without taking preventive actions, when with persons of their social group whom they knew. They had also conservative values in relation to sexuality per se, and thought that AIDs was a punishment. The study indicated that it is possible to comprehend sexuality among this age group, which knowledge assists prevention efforts.
[On the clandestine epidemic: intravenous drug use in the transmission of AIDS]
The Graduate Social Science Studies Program of the Pontifical Catholic University of Sao Paulo, Brazil, under funding by the National Council of Scientific and Technological Development, surveyed 30 adult intravenous drug users of both sexes in the city and its suburbs to determine their knowledge of AIDS, the impact of the disease on networks of psychotropic substance consumers, use rituals, different sociocultural contexts, and communal use of needles and syringes in order to modify the risk of HIV transmission. No serological tests were carried out. The project is in the phase of systematization of collected data by processing questionnaires and life histories. To this end, 2 types of drug user networks were observed with different levels of education and socioeconomic conditions. At the moment the complexity of the data did not allow the presentation of any definite conclusions or discoveries. Nevertheless, preliminary findings did indicate that communal use of syringes was quite frequent before the appearance of AIDS, but networks of users began to hear conversations about the disease in their groups around 1986. There was also evidence that AIDS has had an impact on behavior; to prevent transmission, some cocaine injectors have stopped injecting.
[Caring for the AIDS patient: a current nursing problem in Sao Paulo]
The University of Sao Paulo School of Nursing surveyed 19 students in their last year at the school, 10 practicing nurses in a governmental hospital, and 20 AIDS patients in the hospital to ascertain their thinking about AIDS, because caring for AIDS patients is an existing problem in nursing in Sao Paulo. The students and the practicing nurses evinced various uncertainties about AIDS, while the majority of the patients perceived the terminal nature of their disease, but preferred not to admit it to themselves and others. Nursing must keep abreast of scientific advances with respect to the syndrome and it must establish effective control measures.
Marketing vasectomy in Mexico.
Recently vasectomy has been successfully promoted in Mexico by social marketing techniques. Mass media campaigns have used posters, radio, TV, and newspapers followed by promotion in factories and maternity wards to overcome the barrier of machismo. In the year before the program only 12 vasectomies had been performed in the city of Leon, Central Mexico, which had been chosen as a testing ground, but in the 3rd year of the program there were 322. The social marketing project was a joint effort between Profam, a nongovernmental organization that promotes family planning, and the London-based Marie Stopes organization, which provided technical assistance and funds from the British Overseas Development Administration. Profam carried out most of the vasectomies, but government institutions and private doctors were also involved. Profam will now develop a nationwide network of vasectomy service centers supported by a national promotional effort, and it will train doctors in smaller cities. Community and church reaction in Leon was assessed at the start, and initially the media showed some reluctance to talk openly about vasectomy in advertisements. Outdoor advertising was mentioned by 2/3 of acceptors as their primary source of knowledge about vasectomy, while the fewest of those interviewed named radio as their first contact with the method. Handing out information to women who had just given birth also worked well. Luis de Macorra, the president of Mercadotecnia Social Aplicada, said the project proved that it is important to screen and counsel clients properly beforehand, to give them accurate pre- and post-operative instructions, and to check sperm counts after the vasectomy. The quality of the medical services, including using the latest surgical techniques, was a key factor in the success of the scheme.
Role of traditional birth attendants in maternal care services -- a rural study.
In India various programs have been launched to provide primary health care to women and children, particularly in the rural areas. However, the impact of these programs has not been significant. Though there is a provision of a trained dai (traditional birth attendant) in every village in the national program, most of the deliveries in rural areas are still conducted at home by untrained dais. This study was undertaken to find out about the decision of pregnant women in rural areas as regards the place of delivery and the nature of assistance received at delivery. Four villages in the Jawan Block, District of Aligarh, were randomly selected. All the villages were covered by the Integrated Child Development Services Scheme (ICDS). A total of 212 pregnant women were registered and each of them was contacted to inquire about the type of assistance received at delivery. 96.7% of the women were Hindus; 93.0% were illiterate and 68.5% were poor; 33.5% were high caste, 30.2% were low caste, and 30.2% were scheduled caste. Out of 212 deliveries, 205 (96.6%) were conducted at home. Assistance received at delivery (N = 212) was as follows: untrained dais (traditional birth attendants) 190 (89.6%); trained dais 0 (0.0%); prenatal care assistants 11 (5.2%); doctors 9 (4.2%); and relatives 2 (1.0%). The utilization of existing prenatal care services was meager, as the majority of pregnant women were illiterate and poor. As many as 205 (96.6%) deliveries were done at home. The finding that 89.6% deliveries were conducted by untrained dais assumes considerable significance in light of the fact that these villages of Jawan Block were among one of the first 3 ICDS blocks in Uttar Pradesh. This shows that there is still a wide gap between provision and utilization of maternal care services. Since most of the deliveries are conducted at home by untrained traditional birth attendants, the people must be educated to utilize the services of trained personnel.
Decrease in uterine rupture in Conakry, Guinea by improvements in transfer management.
In January 1988, a collaborative program was established between the teaching hospitals of Donka and Ignace Deen and the 7 peripheral units in Conakry, Guinea, with the purpose of reducing the number of uterine ruptures. The Conakry model contained: a common prenatal prevention program, a common transfer record, a medical report, screening of high-risk pregnancies at the central unit, an experienced pediatrician at peripheral units, monthly meetings to discuss indications for transfer, and fortnightly training programs on obstetric emergencies. After 6 months a modest and steady decline was noted in the total number of births in the region and in the hospital beginning with 2 years preceding the study, but the percentage of deliveries at the hospital remained constant. In contrast, the rate of uterine ruptures decreased markedly from 0.20% in 1986 to 0.12% during the study period of January-June 1988. A total of 11,790 births were registered in the region of Conakry during the study period. Of these, 3781 occurred at the 2 hospitals of Conakry. Transfers accounted for 220 of the hospital deliveries (5.82%). During the same period in 1987, there had been 184 transfers (4.42%) of 4161 hospital deliveries. Of the 14 patients with uterine ruptures during the study period, 6 were transfers from peripheral units, while only 5.82% of all hospital deliveries were transfers. On the other hand, these 6 cases represented only 2.72% of the total 220 transfers to the hospitals. The incidence of uterine rupture among transfers was high, compared to the hospital rate of 0.37% and the rate in the region of 0.12%. Death occurred in 3 of 14 cases of rupture, and all to transferred patients. Perinatal mortality amounted to 11 of 14 patients with uterine ruptures. No child survived in a transferred mother. Perinatal mortality rates did not improve, but maternal mortality dropped from 28% in 1987 to 21.4% during the study period. The incidence of uterine ruptures may be lowered by integration, consultation, and feed-back between the 2 levels of medical care.
Antenatal records of 241 consecutive patients who attended the antenatal clinic at least twice and who had given birth in Pelonomi Hospital from 31 August 1988 were reviewed. Patient records were documented: maternal gravidity, age and blood pressure measurements, fetal gestational age at birth, weight and perinatal outcome. The perinatal period extended from 28 weeks gestational age until 7 days neonatally. All patients had at least 1 ultrasound examination, which was taken into account in determining the gestational age. All blood pressure recordings were taken in the right arm. Hypertension was defined as a diastolic blood pressure of 90 mmHg or more on at least 1 occasion. Korotkoff sound IV was used as the diastolic blood pressure and sound I as the systolic blood pressure. For analysis the hypertensive patients were divided into the early hypertensive group (1st elevated recording before 32 weeks) and a late hypertensive group (1st elevated recording at or after 32 weeks gestational age). The 241 patients were all Black females with a mean age of 25.17 years and a mean parity of 1.07. 140 patients (58%) were classified as normotensive, 34 (14%) as early hypertensive, and 67 (28%) as late hypertensive. The gestational age at birth was lower in the early hypertensive group (34.62 weeks) compared to the normal and late hypertensive groups (38.79 and 38.8 weeks) (p = 0.0465). The early hypertensive group had a significantly higher prevalence of intrauterine death (p = 0.00027) and perinatal mortality (p = 0.0006). Only 1 of 7 neonates born before 28 weeks survived. Of the 34 patients in the early hypertensive group, 17 (50%) had been admitted to the obstetrical high risk unit. Since significantly more fetal losses occurred before delivery in this group, it is concluded that these patients were managed too conservatively. Single blood pressure of 90 mmHg or more before 32 weeks of gestational age is a severe risk for perinatal loss in this African population.
Coital rates and sex ratios in the South Pacific.
A number of anthropologists have recently cited the papers of William H. James to support questionable hypotheses. Their argument is based on 2 premises: 1) sex ratio (proportion male at birth) is positively related to parental coital rate at the time of conception, and 2) in their independent sets of Micronesian data, there was no evidence of a decline in sex ratio with parental age or parity. Underwood infers that her data constitute a serious challenge to the assumed universality of at least certain aspects of Euramerican patterns of marital sexual behavior. Accordingly, she hypothesizes a Micronesian pattern of marital sexuality in which coital rates do not decline appreciably with duration of marriage. If coital rate is a determinant of sex ratio, then it must be a weak one. This conclusion follows from the facts that though coital rates roughly halve across the 1st year of marriage, yet the concomitant decline in sex ratio of conceptions (in the 1st and 12th months of marriage) is only from about 0.522 to about 0.513. It is clear that the decline in sex ratio with maternal age (or with paternal age, birth order, or duration of marriage) in large human populations is very small indeed. For instance, there were 21 million births in England and Wales 1938-68. The sex ratio of those born to married women 20-24 and 40-44 years were 0.5152 +or- 0.0002, and 0.5129 +or- .0006, respectively. Standard power analysis suggests that to stand 8 chances in 10 of detecting a difference of this magnitude in 2 equal-sized samples at the 0.05 level (one-way), the samples would each have to number more than 500,000. So the failure of Brewis and of Underwood to detect such an effect in their comparatively minute samples can scarcely be regarded as grounds for the inference that the effect does not exist in Micronesia.
Sex ratios at birth in Micronesia: reply to James.
In response to comments of William H. James on the authors' articles, it is stated that Micronesian populations are now and have been in the past characteristically highly masculinized at birth (i.e., secondary sex ratios [SSR] of over 108-110). It is fascinating to examine how this finding may reflect microevolutionary change in this island setting. Aspects of reproductive behavior in Micronesia were examined for clues to proximate/remote mechanisms that may promote this pattern of male versus female births. One of the most singular defining features of the reproductive pattern of these groups is high coital rates, maintained against age and marriage duration. It is argued that SSR patterns in Micronesia are a corollary of the unique biobehavioral reproductive features of these island groups, which includes high coital rates. Professor James' concerns relate to 2 considerations: 1) the statistical aspect of results from small scale populations, and 2) the veracity and reliability of results from ethnographic research. Methodologies employed by modern ethnographers entail extensive and intensive cross-checking, multiple verification, and repeated re-evaluation of information collected from a large number of independent sources. In the Butaritari case, conclusions are drawn from several very different but consistent lines of evidence that show coital rates are maintained with age and marriage duration in this group: ethnographic data showing the marriage relationship maintains a highly sexualized environment, demographic data showing no effective reduction in fertility through the first 2 decades of marriage. In the case of the sex ratios, almost all births in these populations over the last century have been covered, and sample sizes in the thousands are available. These are acceptable for use of chi-square and sufficient to make inferences about variations in sex ratios by age group as they relate to coital activity.
What does "health futures" mean to WHO and the world?
"Health futures" is defined as a set of tools that can help explore probable, plausible, possible, and preferable futures for guiding actions whereby potential health threats could be anticipated. The World Health Organization (WHO) is promoting national futures studies for health planning and development as confirmed at the World Health Assembly in 1990. WHO began scanning the field of health futures and learning about the methods used for trend assessment and forecasting. An international consultation on health futures was convened in July 1993 and attended by 38 experts. The consultation proposed follow-up activities sharing studies and methods through international publications; establishing electronic communication to this end; developing a handbook on health futures; and cataloguing experts, institutions, and training opportunities in health futures. A variety of people presented a wide range of studies on the purposes of health futures studies, methodologies, and funding; there were 5 scenarios for health care in the United States (continued growth/high technology, hard times/governmental leadership, buyer's market, a new civilization, healing and health care). The consultation focused on 6 themes, including assessing health technology. An extensive study undertaken in the Netherlands between 1985 and 1988 identified emerging health technology: neurosciences, the use of lasers in treating ischemic heart disease, biotechnology, new vaccines, genetic testing, computer-assisted medical imaging, and home care technologies. Health resources projection was also described for China using simulation models for 3 estimates of demand for hospital beds and doctors between 1990 and 2010. Also presented was Statistics Canada's new population-health model (POHEM), which is based on an individual life-cycle theory of health. A well-institutionalized modeling system by the US Bureau of Health Professions was introduced, showing the physician-supply model for forecasting purposes in the debate over health care reform. Artificial neural networking was introduced for predicting hospital length-of-stay.
Demand increases for mandatory Norplant sentences.
Darlene Johnson, a 28-year-old unwed welfare mother from Visalia, California, was found guilty in January 1991 of beating 2 of her 4 children with a belt and an electric cord while she was pregnant with her 5th child. In addition to a 1-year sentence in a county jail she was ordered to receive the Norplant contraceptive implant or spend 4 years in federal prison. She agreed to the procedure, however, a few days later she changed her mind, and with the help of the American Civil Liberties Union she appealed the decision, arguing that the court was depriving her of a fundamental right and providing a frightening prospect for the country. The case is the most prominent in the controversy about how to prevent low-income teenagers, "crack" cocaine smokers, convicted criminals, and welfare mothers from having children. Legislation was introduced in Kansas providing free Norplant to women on welfare and a $500 cash incentive. In Kansas the cost of treating a baby born to a crack-addicted mother costs about $48,000 in the 1st year, and the annual cost of caring for cocaine-exposed babies amounts to $500 million. Critics charge that forcing contraception on women turns the government into caretakers of women's bodies. However, the rising number of crack babies, child abuse cases, and skyrocketing welfare numbers have convinced politicians and the public about the suitability of this approach. In May 1991 a Los Angeles Times poll showed that 46% of respondents strongly approved of making Norplant mandatory for drug-abusing women. In Denver, Planned Parenthood of the Rocky Mountains has been using $50,000 in private donations to provide free Norplant to teenage girls from drug rehabilitation centers. In Seattle, where 50 disabled crack babies were cared for in 1990, 3 housewives formed a group to lobby for mandatory Norplant for drug-addicted mothers. If the California court ruling is upheld, Norplant debates are expected to continue as more states enact mandatory birth control.
In 1993 political, social, and economic events in India also affected child health. India experienced a crisis in the balance of payment and devaluation of the rupee, and its population has reached an all time high of 843.9 million persons. On the other hand, market-oriented policies, the national literacy drive, and 30% of legislative seats set aside for women are major steps forward. Although 40% of the population are children, they cannot voice their views and concerns. Major campaigns are needed to ensure the healthy development of children and to eradicate poverty that overwhelms them most. The Indian Academy of Pediatrics (IAP) is in the forefront of child health, nutrition, immunization, education, child labor, and child protection. IAP is instrumental in giving guidelines and recommendations on national policies. IAP's library network is being upgraded to have computerized interfacing with US resources. General practitioners are provided continuing education to update their skills in child health care. Pediatrics is now also recognized by the Ministry of Health as an independent discipline at the undergraduate level. Nagpur University accorded this status to pediatrics first in 1979. The achievements of the state of Kerala bear out the positive outcomes of giving priority to the educations of girls with respect to lower infant mortality, improved social conditions, and smaller families. Maternal and child health and family planning are key determinants of the health and well-being of children, and they also help reduce mortality and fertility rates. Therefore, neonatal units should be upgraded to a higher level at medical colleges, district hospitals, and primary health care centers. At the instigation of IAP, the states of Haryana and Punjab have enacted 6 months of maternity leave for working mothers to promote breastfeeding. The threat of the spread of AIDS requires mass sex education to prevent the eradication of progress achieved in child survival.
On the slow lane. Family planning campaign now catches on in Nigeria.
Nigeria's 3-year effort to slow down population growth seems to be paying off, according to a 1991 demographic survey that shows the total fertility rate has fallen to 6 children per woman. The country's first population policy was inaugurated on February 4, 1988, and based on voluntary fertility regulation. The hope is to reduce the proportion of women who marry before the age of 18 by 80% by the year 2000; and to reduce population growth from 3.4% to 2.5% by 1995 and to 2.0% by 2000. The soaring population growth has hampered improvements in the standard of living. Nigeria will reach a population of 165 million by 2000 and 280 million by 2015 at the present rate of growth. The population policy would also impact maternal and infant morbidity and mortality because pregnancies under 18 and over 35, less than 2 years apart, and after the 4th birth account for the highest risks. The 1990 demographic survey indicates that only 3.8% of every 1 million Nigerians were using modern contraceptives, while over 50% of women 15-49 years old wanted to delay or stop childbearing. Critics of the policy charged that it would encourage men to marry several women, and called for male obligations as well. Africa has 420 million people with an average GNP of $400 and the world's highest population growth rate of 3.3%. The Nigerian government and religious leaders need to cooperate to disseminate information and educate the public about the dangers of uncontrolled population growth. Some suggest that the policy will be popularly accepted if population is de-emphasized as a basis for economic planning and allocation of resources. Moreover, family planning is becoming increasingly accepted.
Vaccine contraceptives are in the early stages of 2 clinical trials, but despite their potential advantages they do not offer protection against HIV and sexually transmitted diseases. The Women's Global Network for Reproductive Rights called for a stop to this research on grounds that the contraceptives: 1) have a higher abuse potential than existing methods, 2) have many potential health risks, 3) present no advantages in terms of efficacy, safety, or protection against sexually transmitted diseases, and 4) science-led research may distort contraceptive priorities. Anti-fertility vaccines do not cause hormonal disturbances, do not require specialized insertion or self discipline, and are reversible. Fertility regulating vaccines are feasible for men, satisfying the demand that men should also take responsibility for fertility control. If there can be an effective male vaccine developed few women would object to it, since women want safe, reliable, and easy methods of contraception. Concerns include the lack of disease protection and that countries striving to achieve rapid fertility reduction may carry out trials or introduce the anti-fertility vaccines without giving clients proper information about advantages and potential side-effects. New technologies can be invented relatively easily but using them requires wisdom and goodwill. Those responsible for formulating policies to control the rapid growth of population in the developing world may not always possess such qualities.
Immunocontraceptives, contraceptive vaccines, and fertility regulating vaccines (FRV) are terms applied to a new method of birth control utilizing an immune response for short-term prevention of pregnancy. Immunocontraception has generated controversy between women's health advocates and the scientists who developed it. Women's health advocates demand the halting of all FRV development. Some researchers and policy makers, however, insist that FRVs are absolutely safe, effective, and necessary to control global population growth. Other more moderate protagonists believe that carefully designed and tested FRVs could expand women's choices of safe and reversible contraceptives. Societal expectations, religious restrictions, socioeconomic status, and educational level all influence acceptance of any contraceptive method. There is a need for more rather than fewer methods. Women's health advocates propose the development of barrier methods rather than vaccines in their concern about the AIDS pandemic. Such methods could prevent sexually transmitted diseases as well as pregnancy. However, they require acceptance by men. FRVs also pose the potential of coercive use in population control. Another concern is the potential for destructive autoimmune responses, however, clinical trials can resolve this issue. Several contraceptive vaccines are being developed: those that act on the sperm and egg are the least promising, vaccines against gonadotropin-releasing hormone and follicle-stimulating hormone are proposed for use in men, but they would require the administration of testosterone to restore libido. Immunocontraceptives acting on human chorionic gonadotropin (hCG) are the best developed and most promising. Two vaccines react also with luteinizing hormone, but the long-term risk is unacceptable. Only the anti-hCG FRV developed by the World Health Organization meets safety requirements expected by the international community.
Anti-fertility vaccines have the prospect of expanding contraceptive choices, but their introduction holds the potential for abuse. It is crucial to decide whether such potential abuse justifies on ethical ground the halting of research and development. The right to voluntary informed consent to research and treatment is vital in this respect. Coercion of research subjects or of women visiting family planning clinics has been well documented. Disincentives and even material incentives can stifle rational choice. Potential abusers include: researchers, individual health care providers, family planning clinics or programs, and governmental agencies. Implants such as Norplant are doubly open to abuse given coerced insertion and refusal to remove them. Vaccines do not have to be removed, and their efficacy naturally wears off, therefore they are less subject to abuse. The reversibility of anti-fertility vaccines still has to be ensured to preclude abuse. Contraceptives administered without a woman's consent violate the woman's autonomy. Prospects for abuse in conducting research on a new contraceptive also exist, especially in delivering services because of deficient quality and ethical procedures. The remedy is to improve the conditions, or, failing that, an anti-fertility vaccine should not be introduced in those places. Scientists are expected to train personnel associated with research, and if abuses can not be prevented, research should stop. Unfortunately, governments may fund researchers even if safeguards are inadequate. Service providers, governmental agencies, and nongovernmental organizations are required to improve the consent process and follow-up once the fertility regulation method has been proved safe and effective. Anti-fertility vaccines may have the potential for abuse, but a favorable benefit-risk ratio mandates the ethic of providing those benefits to women while combating abuse.
The Center for Development and Population Activities (CEDPA) carried out a rapid assessment of nongovernmental organizations (NGOs) engaged in maternal health and family planning in Bangladesh, India, Indonesia, Pakistan, and the Philippines with a view to identify benefits and barriers to stronger partnerships between NGOs and governments. A questionnaire pretested at the July 1991 management training program of CEDPA held in Washington was sent to key CEDPA alumnae in each of the 5 countries who forwarded them to directors of up to 10 NGOs currently delivering maternal health and family planning services in their country. Of the 50 questionnaires distributed 40 were returned. Indonesia had the highest number of long established NGOs: half of them have worked in family planning and maternal health for over 35 years. On the average each organization has been involved in health care for 20 years. The annual budgets of these organizations averaged $550,000; Bangladesh ranked highest with $950,000, and Pakistan with $78,000 in 1990. The NGOs had reached more than 14.3 million people in 1990. The NGOs were also a source of empowerment and employment for women. NGOs in their self-evaluations considered their community-based approach their greatest strength, enabling them to reach beneficiaries at the grassroots level. They offered quality services via trained staff and viewed themselves as less bureaucratic than government services. Lack of resources (inadequate funds, lack of materials, transportation, and medicines) and of technical skills were their major weakness. All 40 NGOs had developed multiple working relationships with their governments. On the average, NGOs were linked to 15 various government entities. Only 50% of NGOs were currently receiving financial support from their governments. Almost 70% of NGOs had been evaluated by their governments, and the benefits of collaboration included greater access to government networks and international donors. Barriers to collaboration included bureaucracy, delays in financial support and providing commodities.
Post-marketing surveillance of Norplant: current status and preliminary observations.
The Post-Marketing Surveillance of Norplant involves 8 countries (Bangladesh, Chile, China, Colombia, Egypt, Indonesia, Sri Lanka, and Thailand) and 3 international agencies (Family Health International, Population Council, and World Health Organization). The pilot phase was initiated in 1987 and the main phase in 1989. By January 1991 about 1/4 of the planned 80,000 women years of follow-up experience had been accumulated, and a total of 13,038 subjects recruited had been reported to the coordinating center in Geneva in addition to another 3000 recruited in Indonesia and Egypt. Among these there were 6559 Norplant acceptors and 6479 controls, of whom 5105 had an IUD inserted and 1374 were sterilization acceptors. The study required a follow-up at 6 month intervals for 5 years. A total of 12,579 women did not change their contraceptive method, and over 11,000 woman years of experience had been reported by January 1991. During the study 3492 significant health problems occurred at a rate of 30.6 per 100 years, which was 50% higher in Norplant users (37.7 per 100 years) than in the controls. A total of 131 (3.8%) major health related events were reported, of which 77 and 51, respectively, occurred in Norplant and IUD acceptors, mostly in Chile and China. Among 18 cases of infectious diseases, the most common events included 8 cases of viral hepatitis. 9 cases of neoplasms, and 21 cases of cholelithiasis or acute cholecystitis also occurred. A multivariate log-linear model indicted the rate ratio of the occurrence of these events associated with current use of a hormonal contraceptive method as 1.1 (0.4-2.8). There were 130 pregnancies, of which 70 occurred in women who had discontinued, giving a Pearl rate of 64.8 per 100 years, and only 3 pregnancies in Norplant users, 2 of them via device failure (0.05 per 100 years). 80% of the 51 pregnancies that occurred in IUD users (rate of 1.21 per 100 years) was reported from China, a total of 42 cases. A pregnancy rate of 7.8 per 100 years was observed among users of other methods (spermicide, barrier, or natural methods).