This document contains the Latvian Citizenship Law of 1991 which details who may and may not claim Latvian citizenship. Distinctions are made between those who lived in Latvia prior to June 17, 1940, and those who entered during the occupation period which began on that date. Individuals who were citizens of Latvia prior to the occupation and their descendants who are residing in other nations may register for Latvian naturalization at any time, but they must renounce any other citizenship. Those residing in Latvia must register for citizenship certification prior to July 1, 1992. Other citizenship requirements include mastering the spoken Latvian language, holding permanent residence in Latvia for at least 16 years, and knowing the main provisions of the Latvian Constitution. Citizenship will not be granted to individuals who fought against Latvian independence; have been imprisoned for a premeditated crime; served in the USSR Armed Forces; have been convicted in court for crimes committed against humanity (including war crimes); have been convicted in court for propagating the ideas of chauvinism, fascism, communism, totalitarianism, class dictatorship, or racial differences, are registered drug offenders, or live without a visible means of support.
Act of 16 October 1991, concerning employment and unemployment. [Excerpts].
This document contains several chapters of Poland's Act of October 1991 defining the role of the State in regulating employment as well as in counteracting unemployment and diminishing its effects. Chapter 1 sets out general provisions and definitions. Chapter 3 covers the employment placement and vocational guidance services to be carried out by the State as well as reimbursements to employers for hiring previously unemployed persons. Chapter 6 details allowances to be made for persons accepting employment outside of their place of residence. The seventh chapter makes provisions for the employment of Polish citizens abroad by foreign employers and the employment of foreigners in Poland. Chapter 8 establishes a compulsory Labor Fund which will collect contributions to cover unemployment benefits and allowances.
Children (Relationship and Legal Position) Act 1991 [1 November 1991].
In 1991, Cyprus enacted a statute dealing with the legal rights of children in relation to inheritance and proof of paternity. The statute holds that a child born during a marriage or within 302 days of the dissolution of a marriage is the child of the husband in that marriage unless the mother remarried during the 302 days, in which case the new husband is presumed to be the father of the child unless it is proved otherwise. The legitimacy of a child born in marriage can only be attacked in court if it can be proved that the mother did not conceive the child from her husband. The only people allowed to bring such action are the husband of the mother, the parents of the husband if he has died, the child, and the mother and first husband. There is a statute of limitations on such actions brought by a husband or a dead husband's parents. A child born out-of-wedlock may be recognized as legitimate if his parents marry at any time after his birth (even after his death). A child born out-of-wedlock may be recognized by a father (if the mother is living, her consent is required). If the father is dead, the paternal grandparents may recognize a child. Recognition always confers retrospective rights to the time of a child's birth.
Declaration of Human and Civil Rights and Freedoms, [22 November 1991].
In 1991, the USSR issued this Declaration of Civil Rights and Freedom to bring its legislation in line with the standards generally recognized by the international community. This document acknowledges the supremacy of recognized international human rights norms to national laws and protects the legal equality of everyone, specifically men and women. The exercise of rights should not infringe on any other's rights, and the use of rights to forcibly change the constitutional system, engender hatred, or propagate violence or war is prohibited. Specified rights include the right to citizenship, the right to life (measures will taken to seek the total abolition of the death penalty), the right to appeal an arrest, and the right to a private life and confidential communications. The right to accommodation is laid out as is the inviolability of accommodation. Freedom of movement is assured as is freedom of thought and expression, freedom of information, and freedom of conscience. Provision is made to excuse a citizen from military service if such service violates his conscience. National affiliation and the right to use a native language are protected. Other rights include the right to assembly, to association, to appeals, to ownership, to engage in entrepreneurial activity, to work, and to decent working conditions. Additional entitlements include social security, skilled medical aid, and education. Those accused or convicted of crimes also have specified rights. In the event of a state of emergency, temporary restrictions may be imposed on rights and freedoms.
Lithuanian Republic Law: "On Lithuanian Republic Citizenship" [5 December 1991].
This document contains the 1991 Law on Lithuanian Republic Citizenship. The first section covers general principles such as who can claim citizenship, what document (a passport) confirms Lithuanian citizenship, the legal status of citizens, the preservation of Lithuanian citizenship upon marriage or the dissolution of marriage, and the preservation of Lithuanian citizenship among citizens who reside outside of the country. Section 2 deals with the acquisition of citizenship, including the means of acquisition, the citizenship of children of citizens, stateless individuals, the citizenship of children whose parents are unknown, conditions for acceptance to citizenship, the oath of allegiance, and the awarding of citizenship to persons who have served the state. Section 3 describes the maintenance of the right to citizenship as well as the restoration, loss, and return of citizenship. The fourth section sets conditions governing the citizenship of children when the citizenship of their parents changes. Section 5 gives the procedure for resolving citizenship disputes, and the final section acknowledges the applicability of international treaties.
[Resolution No.] 46/100. Improvement of the status of women in the Secretariat, 16 December 1991.
On December 16, 1991, the UN General Assembly adopted a resolution to improve the status of women in the Secretariat. The resolution notes that the UN failed to achieve a goal of 30% participation by women in posts subject to geographical distribution by 1990 and recalls the goals for 1995 of a 35% overall participation by women in posts subject to geographic distribution and of 25% participation of women in posts at the D-1 level and above. The resolution then urges the Secretary-General to afford greater priority to the recruitment and promotion of women and to increase the number of women employed in the Secretariat from developing countries and other countries from which women are poorly represented. Member States are encouraged to engage in activities (such as nominations, recruitment, and creating rosters) which support these efforts. The Secretary-General is requested to assign a senior-level official to implement the action program for the improvement of the status of women in the Secretariat and to submit the results of a comprehensive study of the barriers to the advancement of women as well as details of the action program to the General Assembly. A progress report for 1991-95 is to be made to the Commission on the Status of Women.
On December 19, 1991, the UN General Assembly adopted a resolution on women, the environment, population, and sustainable development. The resolution requests that the Commission on the Status of Women make relevant parts of the report of its 36th session (in 1992) available to the Preparatory Committee for the UN Conference on Environment and Development. In addition, UN agencies are asked to strengthen their data collection and capacity-building efforts in the field of women, environment, population, and sustainable development. UN agencies are urged to integrate women as active participants at all levels in the planning and implementation of programs for sustainable development. Finally, the Secretary-General is asked to report on the role of women in the environment and sustainable development at the 48th session of the General Assembly.
Passports Act, 1991 [24 December 1991].
Saint Lucia's Passports Act of 1991 directs the Minister for Home Affairs to issue a passport upon the application of any person who proves that he is a citizen of Saint Lucia. Passports can be withdrawn or cancelled on the grounds of national security or if the holder has been convicted of an offense involving drug trafficking or if the Minister has reasonable grounds to believe that the holder is involved in drug trafficking. No one over the age of 16 years can enter Saint Lucia without a valid passport or other document establishing his nationality and identity and augmented by a photograph. The Act also sets out the penalties for persons guilty of an offense against this Act.
Spouses Property Relations Act 1991 [30 December 1991].
This document summarizes major provisions of the 1991 Spouses Property Relations Act of Cyprus. After defining the terms used, the Act holds that the obligation for maintenance is mutual and that when marriage cohabitation ceases, either spouse may apply to the court for maintenance. Maintenance can vary according to circumstances such as a spouses age, health, and ability to work; whether a spouse has the care of an underage child or a child with a disability; and whether the spouse is in need of training (limited to three years). Other factors affecting maintenance include the duration of the marriage, if the applicant was responsible in a serious way for the dissolution of the marriage, or if the applicant's need for maintenance has been brought about by the applicant's own volition. The amount of maintenance will reflect need and lifestyle, and a maintenance order may be of a temporary nature. The Act also contains provisions which allow a spouse to file a claim for a portion of an increase in assets to which said spouse has contributed. Maintenance amounts will also reflect such factors as the behavior of both spouses during the marriage and dissolution of the marriage. This Act applies to cases filed after January 1, 1991.
France. Crack-down on clandestine employment.
In response to the growing concern of the French people about immigration, the National Assembly passed a bill on December 12, 1991, to provide for stronger measures against clandestine employment and the illegal entry and residence of foreigners. Despite the fact that the French public has been convinced since 1988 that foreigners pose a threat to employment, clandestine employment grew by 7% in 1991. The new Act requires an employer to register a new employee immediately and to issue a certificate of employment. Employers now share joint responsibility for clandestine employment with the workers and will be held jointly liable for the payment of taxes, charges, etc. Clients of prime contractors who hire subcontractors also have obligations to insure that clandestine employment is not occurring. The Act provides harsher penalties for clandestine employment than those which previously existed, including the barring of foreigners from France (with some exceptions) for a period of five years. Since the clandestine employment market involves between 300,000 and 1 million workers, it may be impossible to implement this Act to any great effect.
This UN Resolution on prevention and control of AIDS was adopted on December 20, 1991. The resolution notes that the World Health Organization (WHO) predicts that 30-40 million individuals (90% in developing countries) will be infected with HIV by the year 2000 and that the epidemic will have produced 10-15 million AIDS orphans by that time. The UN expresses concern that the epidemic is increasing rapidly in urban areas and developing countries. The UN recognizes that the epidemic demands a multisectoral response and that discriminatory measures against people with AIDS not only force the epidemic underground where it is more difficult to combat but also infringe upon the human rights of the victims. The resolution stresses the need to promote safer sex behavior and to detect and treat other sexually transmitted diseases as early as possible. It also notes the importance of supplying young people in particular with sex and health education and counseling. All means of transmission should be targeted, including IV drug use and unsafe medical practices, and the status of women should be improved so they can protect themselves from unsafe sex. It is also important that scientific technologies and pharmaceuticals be made available quickly and affordably. The resolution urges Member States to give the AIDS pandemic top priority; to continue to develop national AIDS programs; to develop information, education, and counseling services; to adopt a multisectoral response to the socioeconomic consequences of AIDS; to encourage private sector, community group, and nongovernmental organization involvement; and to protect the human rights of infected individuals. The scientific community is asked to continue research into means of prevention and therapy. The WHO is asked to strengthen information exchange among Member States and to help countries develop plans to deal with the socioeconomic consequences of AIDS to women and children in particular. The Secretary-General is asked to use the capacities of the UN system to plan multisectoral activities and to earmark funds for requested assistance. The information capacity of the UN should be used to intensify public information activities. A report on the implementation of this resolution is to be made to the 47th session of the General Assembly.
On April 3, 1990, Belgium changed its abortion law by amending four sections and repealing one section of its Penal Code of 1867. The law provides that any person who induces an abortion may be fined and imprisoned unless 1) the termination occurs before the 12th week of pregnancy; 2) the termination is performed by a physician in a care establishment, and the pregnant woman is given information and counseling about her legal benefits and rights and alternatives to abortion; 3) the woman is informed of the risks associated with abortion; and 4) the physician is convinced that the woman is determined to end the pregnancy. The earliest time in which the procedure can be performed is six days after the first of the legally prescribed consultations. The woman's informed consent must be given in writing. If a pregnancy has progressed beyond 12 weeks, an abortion can only be performed if the pregnancy jeopardizes the health of the woman or if the child would be afflicted with an incurable pathological condition. The opinion of a second physician is required in such cases. After an abortion, a qualified staff member of the care establishment must provide the woman with information on contraception. No one is obliged to assist in an abortion, but a physician must inform a pregnant woman of his unwillingness to perform the abortion during her first visit.
Is lack of self-esteem a major determinant of teenage pregnancy in the Bahamas?
This study opens with an examination of the magnitude of the problem of adolescent pregnancy which considers the changing pattern of teenage pregnancy worldwide as well as adolescent pregnancy in the Caribbean, provides a rationale for the present study in the Bahamas, and reviews the risks and consequences of teenage pregnancy to maternal health (including psychosocial risks, repeat pregnancies, abortions, and sexually transmitted diseases) as well as to infant health (including congenital abnormalities). The objectives of the present study in the Bahamas were 1) to determine the socioeconomic status of pregnant teenagers, their parents, and the putative father; 2) to describe the preparation of the girls for puberty and menarche; 3) to identify their knowledge about reproduction and contraception; and 4) to make recommendations for action based on the study findings. The study methodology is discussed in terms of the methods available for studying teenage pregnancy, the selection of study indicators, the design of the questionnaire, the choice of the population sample, and data analysis. Characteristics of the study population are presented as are limitations of the study. The results of the interviews with 91 currently pregnant teenagers and 24 teenage mothers conducted during July 28-September 5, 1986, reveal that 1) the teenagers themselves were probably unexpected and unwanted babies and, therefore, lack self-esteem; 2) many of the teenagers came from single-parent families where the mothers worked, the fathers reneged on their responsibilities, and the kinship system was an ineffective social control system; 3) the teenagers had sexual relations with older men for "love"; 4) their sex education came from ill-informed friends and older sisters; 5) information about contraception was limited and inaccurate; 6) early childbearing, while not generating approval, had no sanctions; and 7) the cycle is likely to be repeated. Recommended actions include using existing groups to improve self-esteem, increasing knowledge, educating men and boys about their responsibilities, providing early access to contraception, and researching informal sources for reaching adolescents with information, education, and services.
Understanding adolescents. An IPPF report on young people's sexual and reproductive health needs.
This International Planned Parenthood Report was published in preparation for the 1994 International Conference on Population and Development. The report examines the extent of adolescent sexual behavior, pregnancy, childbearing, and abortion as well as the incidence of sexually transmitted disease (STD) among young people. The lack of sex education is shown to be a contributing factor to these problems, and the rights of adolescents to family planning services are reiterated. The risks and consequences of unknowledgeable adolescent sexual intercourse include early childbearing, unwanted pregnancies, STDs, and sexual exploitation and abuse. Regional perspectives are given for Africa and the Middle East, sub-Saharan Africa, Asia, Latin American and the Caribbean, and industrialized countries. The success in reducing the incidence of unwanted pregnancies, abortion among teenagers, and STD transmission experienced by the Netherlands is described. This section is also enlivened with actual case histories from around the world. The report then turns to policy and program implications arising from adolescent sexuality issues. The provision of information, counseling, and services as well as the involvement of adolescents in programs are targeted as successful initiatives. The provision of contraception for adolescents is then covered, and charts illustrate the unmet need and current contraceptive use in sub-Saharan Africa, North Africa, Asia, Latin America and (separately) in industrialized countries. The successful and constantly evolving program developed by MEXFAM, the IPPF affiliate in Mexico, is then described. The report ends by providing a list of additional reading.
This report summarizes the international conference "Effective Nutrition Communication for Behavior Change," which was held in Paris, France, in 1991 to 1) illustrate mechanisms for achieving nutritional behavior change, 2) develop strategies for changing nutrition behavior in various target groups, and 3) empower teams from developing countries to launch successful nutrition communication programs. The conference included a keynote address "From Nutrition Education to Social Marketing," the presentation and discussion of case studies from eight developing countries and presentations from 12 developing country teams and donor agencies. The case studies presented 1) a model for building partnerships between broadcasters and health professionals in Africa, 2) experience with nutrition behavior change in Egypt, 3) changing dietary behavior through social marketing in Thailand, 4) a national breast-feeding program in Brazil, 5) nutrition interventions achieved in Peru and Nigeria through the cooperation of nutritionists and communicators, 6) highlights of a rural integrated nutritional communication program in Mail, 7) the Philippine experience with social marketing, and 8) the impact of social marketing on megadose vitamin A capsule consumption rates in Central Java. The general discussion led to the uncovering of the following key principles of success: developing a comprehensive and systematic approach to the program, eliciting the support of policy-makers and the health care community, and using a multimedia approach. The case studies incorporated considerations of price, product, promotion, and place in their social marketing models. The necessary of adding a fifth "p," for process became evident, for it is the process used to identify and develop price, product, promotion, and place that is most essential. The decision-making process is also the only aspect of a social marketing program which is guaranteed to be transferrable to another setting.
The Bangladesh Family Planning and Health Services Project (388-0071): evaluation report.
In April 1995, the USAID-funded Bangladesh Family Planning (FP) and Health Services Project (August 31, 1987, through August 30, 1997) was evaluated to assess progress to date and to generate recommendations for the final two years. In general, the project has met or exceeded the following goals for 1997: 1) decreasing the total fertility rate of 4.6 in 1991 to 3.8 (3.4 was achieved in 1993-94); 2) reducing the infant mortality rate of 118 in 1991 to 107 (87 was achieved in the early 1990s); 3) increasing the contraceptive prevalence rate of 40% in 1991 to 50% (44.6 was reached in 1993-94); 4) increasing acceptors from 9.9 million in 1991 to 14.5 million (the initial framework contained an error, and the baseline rate actually was 7.8 million in 1991; 12.1 million are expected for 1997); and 5) increasing immunization of urban women and children from 25% in 1988 to 85%. Other project impacts were a drop of 26% in under-5 mortality and achievement of a maternal mortality rate of 5.5/1000. This report describes the project organization (as too complex), the four components of the project structure (assistance to the public sector, the social marketing company, nongovernmental organizations, and support services), and includes 12 recommendations of ways to take advantage of significant socioeconomic changes, strengthen service quality, stimulate the use of longterm methods, and create a more manageable structure for the follow-on period. The overall assessment is that the project has been a major factor in the expansion of population and health services and has demonstrated how USAID can stimulate the growth of a national program.
A random survey was conducted using the campus voice mail system among 550 students of Princeton University to determine their knowledge of and attitudes about postcoital contraception (which has been available at the university health center for more than 15 years). The survey elicited a response rate of 82% and included demographic information in the data collected. The results showed that 95% (>98% of the undergraduates) of the sample knew about emergency oral contraception (EOC), but 52% of the respondents could not distinguish EOC from RU-486, only 38% knew that the correct time of use was within 72 hours, only 26% knew that EOC was a regimen which used a large dose of combined oral contraceptives, and 25% knew that the effectiveness of EOC is 75%. 54% of the students believed that EOC is associated with unpleasant side effects, and 7% thought there would be serious side effects (this attitude was significantly related to nonendorsement). Only 12% of the students correctly identified the fertile period in the menstrual cycle and understood the timing factors associated with EOC. 80% of the students approved of EOC, and 91% approved in cases of rape. Those who identified themselves as Democrats were significantly more likely to approve, and those who were highly religious were significantly less likely. Ethical concerns were cited by 32% of the respondents, and 57% had health concerns. 84% felt that EOC was readily accessible, but only 43% knew it was available throughout the week. 30% of the students had experience with a situation in which more information about EOC would have been helpful. Regression analysis of these findings revealed that approval was higher among students who knew the ingredients and side effects of EOC, knew of a situation where it would have been helpful, were not religious, and/or were Democrats. Ethical concerns were associated with health concerns, strong religious feeling, Republican affiliation, and a lack of knowledge about ingredients.
Family planning outreach and credit programs in rural Bangladesh.
A 1992 study in rural Bangladesh examined the effects of the Grameen Bank program (which provides credit for women's self-employment schemes) and of home visits by family planning (FP) workers on reproductive norms. Data were gathered through two random samples of women who had been members of the Grameen Bank or the Bangladesh Rural Advancement Committee for at least 18 months. These data were compared with 1) eligible nonmembers from Grameen Bank villages and 2) eligible nonmembers from nonserved villages. Specific hypotheses tested were that 1) FP home visits are positively related to contraceptive use, 2) membership in credit organizations or residence in credit-available villages increases contraceptive use, 3) women's physical mobility increases contraceptive use, and 4) the greater propensity of credit program members to use contraception is not entirely explained by increased mobility. It was found that women living in Grameen Bank villages are 16% more likely to use contraception than women in villages without a program (this is highly significant upon Chi-square analysis). When other variables were controlled in regression analysis, the significant effect of the presence of the Grameen Bank was not explained by the FP home visits, but home visits had strong independent effects (raising contraceptive use rates 21% and 30% among the comparison group and the nonmember credit-village group, respectively) along with age, relative wealth, and presence of a surviving son. A significant difference was also found to be caused by mobility, with 60% of the more mobile using contraception compared with 46% of the less mobile. When "relative mobility" is added to the regression, Grameen Bank membership is still significant; significance disappears for nonparticipants living in a credit-available village. These results indicate that programs which decrease women's isolation and dependence upon men can influence fertility. The presence of a Grameen Bank in a village in combination with a FP outreach program can have a dramatically positive impact on contraceptive usage as reproductive norms change. The study also revealed that fear of side effects and potential health problems associated with contraceptive usage remains a major obstacle to fertility control. Women need increased economic opportunities, improved access to health care, and improved contraceptive quality.
A prospective study of 221 healthy women planning to become pregnant examined the timing of sexual intercourse in relation to ovulation to determine whether time factors influence the probability of conception, the pregnancy outcome, or the sex of the baby. Using urine analysis, the dates of ovulation were determined in 625 cycles. 192 pregnancies were indicated by increased levels of human chorionic gonadotropin, and 129 ended in live births. In every cycle in which pregnancy occurred, intercourse occurred at least once during the six consecutive days that ended with the day of ovulation. None of the 31 cycles in which no intercourse took place during this time span resulted in conception. The proportion of pregnancies ranged from 0.08 with intercourse on the first of these six days to 0.36 with intercourse on the day of ovulation. The probability of a live birth for any given cycle is 0.25 with daily intercourse, 0.22 with intercourse every other day, and 0.10 with weekly intercourse. No lower fertility (due to depletion of the number of quality of sperm) was found with higher frequency intercourse. Analysis of age of sperm versus survival of the pregnancy revealed that only 6% of the conceptions could be firmly attributed to sperm which was three or more days old, but a similar pattern was found in relation to intercourse/ovulation timing in pregnancies which ended in fetal loss or live births. Timing of intercourse in relations to ovulation had no influence on the sex of the baby. These findings suggest that the fertile period lasts about six days and ends upon ovulation and that sperm retain their fertilization ability in the female reproductive tract for about five days.
Funding initiated to help scientists research AIDS. International (Africa).
A fund was initiated in November 1995 by several African states, developed countries, and international agencies to promote research in AIDS in Africa. In establishing the fund, experts cited the importance of conducting research on the continent which is home to 11 of the 15 million AIDS patients. In addition to setting up training laboratories, the fund will provide training fellowships and prizes for research papers. Specific topics which will receive attention include the variety in prevalence rates from one country to another, ways to make the blood supply safe (300,000 people are infected through infusions in Africa each year), the use of traditional medicine to cure the opportunistic infections associated with AIDS, and the socioeconomic factors associated with the disease.
The willingness to pay for medical care: evidence from two developing countries.
This book considers issues surrounding payment for health care in developing countries. The first chapter introduces the work. Chapter 2 illustrates the importance of health care to the development process and the functions of health production. This chapter also considers the main arguments used to justify government intervention in the health care sector in developing and industrialized countries; categorizes medical care as curative, patient-related preventive, and non-patient-related preventive; and discusses the role of price in the health care market. In the third chapter, case studies from the Ivory Coast and Peru are used to show that charging user fees for medical care is a desirable and feasible alternative to government financing. The larger picture of health and health care in West Africa and Latin America is also examined. Chapter 4 presents options in health care financing and describes the welfare analysis of health care demand. Chapter 5 uses evidence from the literature to create a behavioral model of the demand for health care and the resulting empirical specifications. Empirical results for rural Ivory Coast and rural Peru are presented in the sixth chapter, and their implications for policy are demonstrated in Chapter 7 through simulations of the consequences of various pricing policies. The final chapter contains suggestions for future research and for policy implementation. This chapter contains suggestions for governments to introduce user fees while still protecting the poor from adverse effects. The four most important empirical findings of the study are that 1) the demand for medical care is price sensitive, 2) the poor are more price sensitive than the rich, 3) care for children is more price elastic than care for adults, and 4) if the price of one provider increases, patients are more likely to turn to another provider than to self-care.
Certainty and agnosticism about lethal injection in late abortion.
This article was written in support of a claim forwarded by Joan Callahan that fetal intracardiac potassium chloride injection (KCl injection) should be offered to women undergoing second-trimester abortion. Callahan provides three positive arguments for use of the technique: maternal safety, the short-term interests of fetuses, and the longterm interests of fetuses who survive the abortion. The author of this article notes that the fact that KCl injection is currently the safest procedure for the mother is argument enough in favor of offering the procedure. Even physicians who object to the procedure are obligated to inform their patients about it and should be encouraged to help their patients locate a physician willing to perform KCl injection. Callahan's argument about fetal pain is sound but unnecessary as long as KCl injection remains the safest procedure for the mother. The argument about preventing longterm suffering for fetuses who survive late abortion is the weakest because it is impossible to determine whether the fetuses would be better off dead or alive. Hospitals can resolve some of the dilemmas which are associated with KCl injection by having a well thought out and clearly communicated policy about resuscitation of an aborted fetus. Callahan argues that the policy should be a blanket "do not resuscitate." The author is less sure that a blanket policy in either direction would be correct. Since it is impossible to know in advance what is best for the child, other factors must determine whether one policy is preferable to another. These include legal considerations such as the Americans with Disabilities Act which prohibits discrimination against disabled individuals in hospitals.
Introduction: principles for meeting increased demand.
The demand for family planning is expected to increase from 192 million users in 1990 to 286 million in 2000. The USAID has identified five principles on which family planning services must be based to meet this increasing demand. These principles, which apply to all family planning services, including natural family planning (NFP), are that service delivery must 1) emphasize quality of care; 2) expand to serve larger populations in more cost-effective ways; 3) evolve to accommodate a diverse, younger population and improved method mix; 4) include cooperation by all sectors, i.e., government, private voluntary organizations, and for-profit groups; and 5) be sustainable. The papers in this session address how NFP service delivery programs can follow these principles to improve the quality and availability of services and contribute to efforts to meet increasing demand. They will focus on the importance of the following factors: a clear understanding of the service delivery organization's goals and objectives in light of the organization's purpose and the needs of the community it serves; mechanisms to ensure quality of care, including measurable standards and supportive supervision; an information system that can be used for a variety of purposes; and a system of responsible financial management that ensures continuity of the program as well as efficient, effective service delivery. (full text)
At what stage is NFP service delivery?
An initial reaction of the participants was that modern natural family planning (NFP) as a "product" or "theory" has been accepted as valid, but that the delivery of the "product" has not been well developed or very well established. Some believed that NFP had not even yet reached a demonstration phase or, at most, was only at the very beginning of a demonstration phase. The following indications of this stage of development were stated as follows: there is still very little public knowledge about modern NFP, and when there is knowledge or use of NFP, it is still associated with the traditional calendar method; new groups of acceptors need to be identified, particularly those who have never known that NFP is an effective method; NFP needs to be included in recognized, national family planning programs; and NFP should demonstrate and prove that it is cost-effective and that it is beneficial to family planning. The session also included a discussion on ways to modify behavior to make periodic abstinence more acceptable. (full text)
The missing link: why NFP is still "the best-kept secret".
The importance of continuing to bring scientific data to the attention of the medical community was stressed. Information on topics such as natural family planning (NFP) effectiveness and the documentation of dissatisfied and successful users of NFP was emphasized. It was also recommended that medical professionals be utilized in selected roles, such as consultants, to stimulate their interest and respect for the natural methods. The need for patience and perseverance in seeking support for NFP, not only from the medical profession but from the clergy and various religious groups, was discussed as well. It was suggested that positive words be used to describe NFP such as "scientific" and "modern" family planning with "No side effects." Ideas about marketing NFP through existing women's organizations and infertility intervention programs were explored, along with a plan to initiate fertility awareness programs in schools. The final recommendations were to target resources in the community, presenting NFP as a positive option. It was noted that NFP does not profit by attempting to discredit other family planning methods. (full text)
Various forms of financial support for NFP teachers.
Creative ways to compensate natural family planning (NFP) teachers need to be developed. Because each program has its unique circumstances, there are many different strategies to be explored: the recovery of costs through client revenues; investigation into third-party reimbursement; financial support from the Catholic church and other organizations; and the bartering of services. In programs without funds to offer teachers, alternative means of compensating enterprising NFP teachers need to be established. Examples include continuing education opportunities, articles about NFP teachers in client newsletters, and providing social functions that enable the teachers to interact with one another. (full text)
Providing NFP counseling within a family planning clinic.
It is necessary to have the support of the clinic staff and an atmosphere of respect and tolerance for the beliefs and practices of all clients, staff, and administrators. Such an atmosphere of respect includes the recognition that natural family planning (NFP) is a viable alternative to other family planning methods, as well as the acknowledgement that there is no one family planning method that is good for everyone. The presentation of all method options should include, therefore, the advantages and disadvantages of each of the methods. Others believed that NFP instructors should teach only NFP and that it should be taught in a private area. The NFP instructor could work on a part-time basis and be available to provide services to more than one clinic. It was recognized that NFP needs more publicity and positive support in general from organizations, including the Catholic church. (full text)
Making periodic abstinence more acceptable to NFP users.
The participants felt that the term "periodic abstinence" was negative and should not be used. It was suggested that the focus be on new dimensions of the relationship, including "outercourse." For example, couples can lack the ability to love fully and comfortably when the sexual aspects of marriage are overemphasized, rather than the emotional aspects, particularly feelings of love and tenderness. Periodic abstinence should not be identified with puritanism or the withholding of love, but rather with a period to rediscover, refuel, and revitalize the love of the couple. Periodic abstinence can be used positively to challenge a couple's customary patterns of relating by removing the focus on sexual intercourse. This can be seen as an opportunity for the couple to increase their awareness of and sensitivity to each other from which feelings of love and tenderness grow deeper. This approach should be taught early in the relationship, as part of the relationship, rather than attempting to change established behavior and attitude patterns at a later stage in the relationship. Therefore, periodic abstinence and alternative expressions of affection should be a natural part of children's education and development. (full text)
The fertility awareness method: extent of use, potential, and research needs.
Little research has been done on the fertility awareness method (FAM) in developed countries and even less in developing countries. Some of the questions addressed in this discussion included: Is FAM of sufficient promise and interest to be a concern? Is more information required on its acceptability, effectiveness, and continuation rates? The research literature was briefly reviewed and new studies mentioned. When comparing "pure" natural family planning (NFP)--that is, the use of abstinence during the fertile period--with mixed methods--such as the use of barriers during the fertile period--the results have generally found that the mixed method has slightly higher pregnancy rates. Mixed use may be underreported because the users may be embarrassed or afraid to mention barrier use. Not everyone liked the term "fertility awareness method." There was also disagreement about whether FAM should be standardized and whether users should be taught how to use condoms correctly. Some felt it was cumbersome to use two methods and that people using barriers might become lax in their monitoring of the fertile period and their fertility signs. It was suggested that Contraceptive Technology (journal) describe FAM in the next updated issue. The following research questions and priorities were proposed: Who is using FAM and why? What is the use effectiveness of FAM by user characteristics (education, religion, duration of use, quality of education)? What reasons are given when people do not use the method successfully? Does fertility awareness education improve condom use? How do NFP and FAM compare when studied prospectively? (full text)
Natural family planning (NFP) services are provided through an increasing variety of public- and private-sector programs, including community-based programs, ministries of health, family planning programs, religion-based programs, and others. To improve the availability of NFP services and increase the options for family planning clients in the 1990s, NFP programs must continue to be offered through a variety of channels. The purpose of this session is to identify the gaps in current NFP service delivery and to summarize recommended strategies to expand NFP programs. The presentations in this session cover topics that include the development of national NFP programs in the US and Kenya, how NFP programs have expanded through the health sector in three developing countries and through education centers in the Ivory Coast, NFP services provided through multimethod family planning programs and nontraditional approaches, and new opportunities for NFP service delivery. Discussion focuses on how to expand NFP into a variety of service delivery programs; other settings appropriate for NFP expansion also are proposed. (full text)
The right not to know HIV-test results [letter]
Temmerman and colleagues report 5.9% of HIV-positive women being chased out of the house, beaten by their partner, or committing suicide. The situation was worse than this, since 13 of 66 (19.7%) who told their partners were subjected to such treatment. Most women who chose not to tell their partners (73%) may have included those with most reason to fear violence, Temmerman and co-workers relied only on spontaneous reports from women, so the true violence rate might have been higher. It is hardly surprising that so many women chose not to disclose their status. It is surprising that such effects have not been systematically documented in the past, although several workers have referred to the issue in passing. In a study of discordant Zairean couples Kamenega and colleagues reported that culturally-sensitive counseling of couples (rather than individuals) had "prevented several separations, episodes of intrafamilial violence and eventual divorce." North and Rothernberg reported anecdotally in the US two women who were shot and many others who were injured or abandoned after revealing to their partners that they were infected with HIV. Among seropositive heterosexual women in our clinics in London, concerns about possible partner violence have been frequently voiced. Violence against women associated with partner notification is, of course, part of wider difficulties resulting from power imbalances between men and women in most societies. Such difficulties are not restricted to women. Brown and co-workers reported that 3 of 120 UK gay men had experienced violence as a result of telling others about their status. Temmerman and colleagues conclude that their findings are grounds for women not being forced to know their status. They are also grounds for counselors playing a much more direct part in helping patients to tell partners rather than merely exhorting the patient to do so, and for providing much more extensive support to couples after a positive test result. At the very least studies in this area need to monitor the extent of this problem more directly than hitherto. (full text)
Cambodia. Programmatic approach to IEC on reproductive health.
Various UNFPA-funded population programs are now in place in six provinces and the capital and some more are in the pipeline. The ones currently being implemented include projects on maternal and child health and birth spacing, national population census, improvement of family health of displaced persons, and socio-economic research. Those in the pipeline are population education in the school system, gender and population issues, and population and environment. All the programs mentioned have implications for information, education and communication (IEC). To implement these programs effectively, UNFPA and the government realized the need for IEC support. To provide a coherent, integrated and holistic approach to the provision of IEC support to all the UNFPA-funded population activities, a programmatic approach to IEC was developed with the assistance of CST adviser on population communication, Mr. Francisco Roque. The IEC program will basically support the government policy of providing voluntary birth spacing services as a means to promote better maternal and child health through IECM activities; and to provide adequate information to selected target groups required to bring about desired behavioral changes in responsible reproductive decision-making and lifestyle. The target groups to be reached include: service providers and health workers, policymakers and administrators, women of reproductive age, men, and the adolescents aged 15-19 as well as teachers and trainers. The IEC interventions hope to create awareness of the benefits of birth spacing, introduce population concepts in curricula and appropriate health/teaching materials in selected medical schools and secondary schools, reduce misconceptions, provide proper counseling, and sustain government's interest and commitment to the population program. (full text)
Cambodia. MOE to introduce population education in three subjects.
Cambodia is currently undertaking reforms of its educational system both in structure and substance. Under these reforms, the Ministry of Education (MOE) is revising its curricula and textbooks in selective subjects. The government and UNFPA saw a timely opportunity to introduce population education concepts into three subjects, geography, home science, and moral education and civics from grades 7 to 12. To pave the way for this activity, the UNFPA and the government discussed the development of a pilot project that will concentrate first on the training of small numbers of professional educators and development of a first draft of curricula and textbooks including teacher's guides which could be tried out in this pilot stage and reproduced during the second phase. The project document has been prepared with the assistance of CST adviser on population education, Mr. Ansar Ali Khan, based in CST Bangkok, and is now under review. (full text)
Maldives. Package on population education for special interest groups developed.
The Population Education Program of the Non-Formal Education Center has developed a package of Population Education for Special Interest Groups comprising a learning package and fieldworker's guide. The learning package is especially developed for teaching population education for out-of-school populations. Special interest groups in Maldives include newly married couples, adolescents, and working youth. Produced under the guidance of UNESCO, Bangkok, the package contains 36 different materials such as posters, charts, leaflets, booklets, stories, and illustrated booklets which may be taught in 36 to 45 periods. The materials deal with eight themes, namely, family size and family welfare, population and resources, delayed marriage and parenthood, responsible parenthood, population-related values and beliefs, women in development, AIDS/STD, and respect for old people. Accompanying the learning package is the fieldworker's guide used to teach the package. It contains individual guides for each of the 36 learning materials. The guide gives the titles of the materials, format, objectives of the materials, messages, target groups, and an overview of the content of each learning materials. The methodologies used for teaching the learning materials include role playing, group discussion, questioning, brainstorming, survey, creative writing, problem-solving and evaluation. The package will be used by fieldworkers to conduct island-based population education courses. (full text)
Nepal. Teacher educators trained.
As part of its teacher training program series on population education, the Population Education Unit of the Tribhuvan University organized a one-week training course on population education from 5-11 July 1994. Attended by 20 teacher educators who are involved in teaching population education in their respective campuses, the training provided opportunities for upgrading the participants' knowledge, and changing their attitudes and behavior with regard to population concepts. It also developed their skills in more effective methodologies for teaching population education in their campuses. The Faculty of Education, through its Population Education Unit, has been introducing population education in its teacher training program under the UNFPA-funded country program. This is done through incorporating population education contents into different subject areas such as health education, geography and economics in the curriculum of Proficiency Certificate Level, Bachelor Level and Master Degree. In addition, it has been offering population education as major subject at the Proficiency Certificate Level in Mahendra Ratna Campus. Thirteen resource persons from Tribhuvan University, Curriculum Development Center of the University and UNFPA Field Office and Country Support Team, Kathmandu, provided lectures on the following topics: population education in Asia and the Pacific, population situation in Nepal, demography and population dynamics, population theories, curriculum development in population education, teaching methods, human sexuality, STDs and AIDS, population education program, research, and population policy. (full text)
Descriptor terms related to 37 articles dealing with the oral question of abortion and taken from a printed database specializing in Catholic applied ethics were scanned for clusters with respect to the Anglo-American or European origin of the articles. To identify types within the data Configural Frequency Analysis was used. Application indicated a dominant interest in the process of ethical decision-making in Anglo-American Catholic bioethics. The assumption that European Catholic bioethicists discuss the morality of abortion primarily in terms of an anthropological debate focused on the moral status of prenatal life could not be validated statistically. (author's)
A Muslim perspective on female circumcision [editorial]
Western observers are unable to understand why women would want to practice clitoridectomy, just as they are perplexed at the vocal, if mostly inarticulate, rejection by many Muslims of the Cairo conference. The battle lines which get drawn have on one side public health professionals, development organizations, and feminists, and on the other side conservative and "fundamentalist" Muslims who, if they are heard at all, sound impossibly antediluvian. Many Muslims, including myself, are uncomfortable with both sides. What is needed is an alternative to this polarization. The alternative I propose is the Islamic legal discourse, which might best be described as the discursive arena in which issues of societal importance get worked out. That positive change can come about from within--using the Islamic discourse--is possible because Islamic discursive systems are broad and nuanced enough to accommodate a wide variety of medical and public health endeavors. Meaningful social change and improved public health could come about by stimulating and recovering the many Islamic sunnah (exemplary) practices which are so conducive to physical and material well-being. By dealing change through existing, and proven, traditional formats, Muslims would be able to effect valuable and meaningful change in their communities. Muslim communities should not become dependent on and indentured to Western agencies and their own nation-states to solve the problems they face, including the tragic consequences of widely practiced infibulation and clitoridectomy; instead we need to apply our own traditional practices and to support an indigenous Islamic legal discourse. (author's)
Barrier methods of contraception.
Although a recent Cavalieri d'Oro et al. article correctly concludes that while barrier methods reduce the risk of gonorrhea and HIV, they may be less consistent for other diseases, the review does not include the female condom, the newest method of barrier contraception. Laboratory tests have shown polyurethane, the material of which the new condom is manufactured, to be impermeable to HIV and cytomegalovirus. Similar permeability studies using bacteriophages smaller than hepatitis and HIV show the membrane to be a complete barrier. As such, one may expect polyurethane to be the raw material from which male condoms will be made in the future. One clinical study assessed the prevention of reinfection with Trichomonas vaginalis among 104 women who had sexual intercourse with infected male partners. No woman who used the female condom during every act of sexual intercourse became infected. 14% of nonusers and 14% of inconsistent users were, however, reinfected. A study by Soper et al. found use of the female condom to not be associated with genital trauma. Leeper and Conrardy subjected the female condom and the male condom to the standard ASTM water leak test to find a 0.6% incidence of leakage from pinholes and tears for the female condom compared to 3.5% with the male condom. The risk of semen leakage during actual use as identified by acid phosphatase was 2.7% with the female condom and 8.1% with the male condom. Perfect users of the female condom may expect a 2.6% probability of failure over six months' use. Perfect use, however, reduces the annual risk of acquiring HIV by more than 90% among women who have sexual intercourse twice weekly with an infected male.
Onapristone (ZK 98.299): a potential antiprogestin for endometrial contraception.
Antiprogestin drugs such as RU 486 (mifepristone), ZK 98.299 (onapristone), and HRP 2000 block progesterone action at the receptor level. They bind to progesterone and glucocorticoid receptors, which leads to an antagonistic instead of an agonistic response. Treatment with these antiprogestins, depending upon the dose, retards endometrial development and impairs gonadotropin release, thereby blocking ovulation. The hypothalamus, pituitary, and endometrium, however, differ in their sensitivity to the antiprogestins, with the endometrium being sensitive to doses which do not seem to affect ovulation. The authors report on their study of the effects of onapristone upon the fertility; menstrual cycle length; duration of menses; serum estradiol, progesterone, and cortisol concentrations; and endometrial morphologic features in adult bonnet monkeys for four-seven consecutive cycles. The study was undertaken to assess the feasibility of using onapristone as a contraceptive agent and to determine its mechanism of action. Onapristone was dissolved in benzyl benzoate and then diluted in castor oil (1:10, vol/vol). 0.5 ml of the vehicle was used to administer each dose subcutaneously. Five monkeys were treated subcutaneously with the vehicle, four monkeys each with 2.5 mg of onapristone, and five each with 5 mg of onapristone. The study found low-dose onapristone treatment throughout the menstrual cycle to prevent pregnancy without disturbing the menstrual cycle and ovulation in the majority of cycles. Anovulation and luteal insufficiency did, however, occur in some animals during prolonged treatment. The contraceptive effect in the ovulatory cycles seems mainly related to the retardation of endometrial development resulting in the inhibition of endometrial receptivity. The authors find it likely that a dose or treatment regimen of onapristone which will inhibit endometrial receptivity and prevent implantation without affecting the menstrual cycle even on prolonged treatment could be identified.
Risk and vulnerability reduction in the HIV / AIDS pandemic.
An estimated 13.2 million men, 10 million women, and 2.7 million children worldwide have been infected with HIV since the beginning of the pandemic, and more than 10,000 people daily acquire HIV infection. 67% and 19% of these infections have occurred in sub-Saharan Africa and Southeast Asia, respectively. Even though the annual number of new HIV infections appears to have reached a plateau in Western Europe and the Caribbean and may be approaching one in sub-Saharan Africa, and the rise of new infection seems to be on the decline in North America, Oceania, and the southeastern Mediterranean, the HIV/AIDS pandemic has not been controlled anywhere in the world and its major impact has yet to come. Prevention activities undertaken by individuals, communities, nations, and international bodies have shown that the spread of HIV can be effectively reduced. Public health interventions against HIV/AIDS emphasize risk reduction strategies through the provision of HIV/AIDS-related information about safe behavior and the promotion of prevention methods. Exclusive reliance upon risk reduction strategies, however, fails to address the contextual issues in which the pandemic is rooted. In order to significantly affect the pandemic, short-term risk reduction interventions must be expanded considerably, adapted to local needs, and replicated worldwide. An expanded response to the pandemic also calls for medium- and long-term risk reduction interventions, including the linking of HIV/AIDS prevention, care, and support work with other actions in the health and social sector, and the remodeling of services to respond more effectively to growing needs. Until recently, such interventions have been neglected or misconstrued as the process of spreading thinly and irresponsibly HIV/AIDS actions within health and social programs. The sustainability and eventual success of HIV prevention will depend upon the capacity of health systems to integrate HIV/AIDS-related activities with other initiatives, while retaining the ability to track the epidemic and account for what is done about it. The influence of contextual factors on vulnerability to HIV/AIDS is discussed.
Impact of health education during pregnancy on behavior and utilization of health resources.
Health education during pregnancy may improve pregnancy outcome. The authors investigated whether reinforcing pregnant women's social network and emotional support, improving knowledge about pregnancy and delivery, and reinforcing adequate health services use could improve pregnancy outcome. The randomized, controlled trial was conducted between January 1989 and March 1991 in Rosario, Argentina; Pelotas, Brazil; Havana, Cuba; and Mexico City, Mexico among pregnant women at risk. The control group was comprised of 1120 pregnant women at risk who received routine prenatal care. 1115 others received a home intervention of four-six visits providing psychosocial support and education about health-related habits, alarm signs, hospital facilities, anti-smoking and anti-alcohol programs, and a reinforcement of adequate health services utilization for the pregnant woman and a support person. The distribution of risk factors and demographic, obstetric, and psychologic characteristics at baseline was similar in both groups. Women in the intervention group showed a statistically significant better knowledge of seven of the nine alarm signs considered and of two of the three labor-onset signs required. No differences between groups were, however, observed with regard to improvement on diet, cigarette and alcohol consumption, maternal physical strain, lactation at forty days postpartum, and health facility use. The intervention therefore failed to show any benefit upon perinatal outcome, health-related behavior, or health facility use.
Editorial: beyond population statistics [editorial]
If the size of the world's population continues to increase at its present rate of growth, it will not be long before their will be neither sufficient resources nor space on the planet. It will be increasingly necessary to ration scarce resources as we move forward into the 21st century. In the meantime, the public health community has the responsibility to see what moral and humane steps can be taken. Morrow and Bryant have suggested a modified triage approach toward a social strategy for health and population policy in which they assign a standard for judgement in the rationing of health resources in an index to reach those most in need. The index, through an economic analysis of illness and the burden of disability, suggests what is needed and what can be accomplished. It is one of few efforts taking into consideration local expectations and is not based exclusively upon the donors' analysis and decisions. More needs to be done in conjunction with larger issues, such as the application of a burden-of-disease index to the wealthy countries, more prudent management of resources there, and the protection of the global environment.
Health policy approaches to measuring and valuing human life: conceptual and ethical issues.
In order to achieve the most cost-effective and equitable use of health resources, health care decision makers need better ways to define disease burdens and guide resource allocations. Resource allocation decisions in sectors other than health are based upon benefits obtained per dollar expended. During the last two decades, composite indicators which combine losses due to disability and premature mortality have been developed as a measure of disease burden and as an outcome indicator for health status in economic analyses. With the increasing use of these indicators, it is timely to examine potential conceptual and ethical issues related to the measuring and valuing of human life. The authors review the healthy life approach of the Ghana Health Assessment Team, the quality-adjusted life year approach, and the World Development Report disability-adjusted life year approach. The review covers conceptual and ethical issues generic to the use of composite indicators for measuring and valuing life, highlights issues specific to the methods used in the World Development Report, and provides suggestions to refine the approach for developing tools to assist in more rational resource allocation decisions. Further refinement of the tools is needed to incorporate national and local values into weighting, elaborate methods for disaggregating calculations to assess local disease patterns and intervention packages, and develop guidelines for estimating the marginal effects and costs of interventions. It is of the utmost importance that equity be ensured during the attempt to achieve reasonable efficiency.
Abortions in rural Idaho: physicians' attitudes and practices.
94% of nonmetropolitan counties in the US have no legal medical provider willing to provide abortion services. This means that even though a woman's right to undergo a first-trimester abortion is protected by the US constitution, abortions are virtually unavailable in rural America. The considerable distances that most rural women must travel to find a provider willing to perform abortions effectively deny access to the medical procedure in many cases. All family physicians, obstetrician-gynecologists, and general surgeons practicing in rural Idaho in 1994 were surveyed to gain insight into why rural physicians are unwilling to provide abortions. Idaho is a conservative state with the second lowest abortion rate in the country. Rural physicians were defined as allopathic and osteopathic physicians working in nonmetropolitan counties and in communities of fewer than 20,000 people. A survey was sent to each of the 251 physicians identified as eligible for the study; 138 responded. 86% were family physicians, 91% male, and in practice for a mean period of fifteen years. Less than 4% of the respondents performed abortions. Most rural Idaho women seeking an abortion must therefore travel long distances for the procedure, with the average travel distance to the nearest abortion provider being 85 miles. The doctors reported having chosen to not provide abortion services because of both their own moral objections and local community opposition to the procedure. Younger, residency-trained physicians were more likely to have personal moral objections than their older colleagues. 26% of the respondents did, however, indicate interest in using RU-486 for abortions when it becomes available. This intention to use RU-486 suggests that the development of acceptable medical abortifacients may improve access to abortion even in very conservative rural areas.
Subdermal levonorgestrel implants: three years' experience in Cairo, Egypt.
Findings are reported from a three-year, advanced phase III clinical trial assessing the efficacy, safety, and acceptability of levonorgestrel implanted subdermally as a long-acting, low-dose, progestin-only contraceptive method for women. The prospective, observational study was conducted through the family planning clinic of Ain Shams University Hospital in Cairo, Egypt. There was a 0.98% net three-year cumulative pregnancy rate among the 350 women in the study. Menstrual disturbances, present in 25% of women during the third year, were the major side effects and ranged from amenorrhea to menorrhagia. The disturbances resulted in 28 removals, 19 due to amenorrhea. Medical complications, including headaches, hypertension, and non-insulin dependent diabetes; desire for pregnancy; and complications at the insertion site were the principal reasons for another 57 implant removals. No gynecologic or breast lesions have developed, and weight changes were not noted. The continuation rate after three years was 65.5%.
Vitamin A deficiency in the South Pacific.
Vitamin A deficiency is a major cause of morbidity, mortality, and blindness among children in many developing countries. Until recently, however, data have been lacking on the magnitude of the problem in the South Pacific region. Five cross-sectional surveys for vitamin A deficiency were conducted during 1989-1992 in the Republic of Kiribati, Tuvalu, the Republic of Vanuatu, Solomon Islands, and the Cook Islands, covering 10,673 children aged 6-72 months. The prevalence of xerophthalmia was 14.76% in the Republic of Kiribati, 1.55% in Solomon Islands, 0.59% in the Cook Islands, 0.28% in Tuvalu, and 0.11% in the Republic of Vanuatu. Bitot's spots were the most common clinical findings followed by nightblindness. Xerophthalmia was more common among boys and tended to occur in older preschool children.
Hearing loss: a possible consequence of malaria.
More than 200 million people worldwide contract malaria from mosquito bites. In sub-Saharan Africa, 100 million clinical cases of malaria are reported every year, resulting in almost one million deaths. Malaria has been implicated in the causation of deafness in several studies in the West Africa subregion. This paper examines the association between malaria and deafness, and considers which factors may be involved in the causation of deafness. Although age, immunity, the type of malaria parasite, fever, complications of malaria, and complications resulting from the drug treatment of malaria may contribute to the development of deafness in malaria, the actual mechanism of causation is not clearly understood. Deafness in malaria is associated with P. falciparum parasitic infection. The author is certain that the high fever in malaria, leading to febrile convulsions and cerebral involvement, can result in deafness. Further investigation is needed to determine whether the presence of untreated malaria parasites in the blood causes deafness.
The HIV / AIDS epidemic in Thailand: addressing the impact on children.
Within the space of a decade, the level of HIV infection in Thailand has grown to epidemic proportions. With regard to children, 16,000 had been born with HIV by the end of 1994, while tens of thousands of child prostitutes and street children are at risk of infection. By the year 2000, more than one million Thai children will have at least one HIV-infected parent. Many of these children will therefore become either orphans or abandoned by their infected parents. The magnitude of these problems over the course of the lives of HIV-affected children depends heavily upon actions taken now. This paper summarizes the joint report of the Thai Red Cross Society and the East-West Center's Program on Population on the impact of HIV on children in Thailand. The current situation, projected impacts, and policy recommendations are described. No other country has had as complete a monitoring system or as early a warning of the problems ahead. Some recommended approaches are familiar and simply need to be strengthened and expanded to the regional or national level, while others require field testing. The authors stress the need for shared commitment, ideas, resources, and efforts of all sectors of society to plan for the future needs of children affected by HIV, to protect them from infection, and to provide them with the social and economic support, medical treatment, and legal protection they need.
Fistula -- a disaster for teenage mothers.
Obstetric fistula is one of the most severe childbirth-related complications. The small size and physical weakness of many young pregnant girls makes it extremely difficult for them to give birth to a child. Delivery is therefore often prolonged. During childbirth, girls' perineum often tears, leaving holes between the bladder and/or the rectum and the vagina. The young mothers from then on lose control over their bladder and bowels, are unable to bear more children, and find sexual intercourse painful. Such fistula are common in Somalia, Ethiopia, most Sahelian countries, Zambia, and Zimbabwe, but particularly so in Niger. 23,000 girls and women in Niger have the condition, or 1% of all women of child-bearing age. Obstetric fistula can, however, be cured by a simple operation. France recently announced a $400,000 aid project to help teenage girls in Niger with fistula and to discourage parents, village elders, and women's groups from marrying girls at too young ages. Doctors in Niger will be trained to surgically repair fistula, cured women will be helped to reintegrate into society, local health workers will be trained to recognize the early signs of fistula, and female genital mutilation will be discouraged because of its role in increasing the likelihood of fistula development.
High society lacks knowledge of epidemic. Focus: South Africa.
The attitudes, prejudices, and knowledge of 1500 leaders of South Africa's politics, academia, agriculture, military, bureaucracy, business, media, and churches were assessed through a mail survey between July and September 1994. AIDS is a major public health issue in South Africa and one of the most hotly-debated political problems. The survey found that these opinion leaders have a surprisingly low level of knowledge about HIV and AIDS, which may explain the relatively low position of AIDS issues in public policy. Overall, opinion leaders with right-wing affiliations are intolerant toward people with AIDS, it is commonly felt that people with AIDS should be treated in public hospitals, opinion leaders believe that the entry of illegal aliens is making the AIDS problem worse, it is widely considered that the state cannot afford to fund medical research on AIDS at the cost of primary health care services, it is widely felt that regular AIDS tests for all South Africans should not be compulsory, and most opinion leaders believe that employees who test HIV-positive should inform their employers. The author posits that this level of ignorance of the full implications and dimensions of HIV/AIDS may cause institutions to fail to adapt to the growing crisis.
After more than a decade of AIDS, prevention programmes begin to prove their worth.
The first reports of AIDS, then an unidentified new disease, surfaced in the US in 1981. HIV was identified as the causal agent in 1983, and a diagnostic test for the presence of HIV antibodies was developed shortly thereafter. The investment of millions of research dollars since then has yet, however, to lead to a cure or vaccine against HIV/AIDS. Millions of people have been infected over the past decade with HIV, many have died due to AIDS, and many continue to be infected daily. HIV and AIDS are truly global in scope, but they will not annihilate entire populations as predicted during the 1980s. On the one hand, it has been demonstrated that the appropriate prevention and control measures can contain the spread of HIV. On the other, we now know that the prevalence of HIV infection will peak at different levels depending upon the country. Extensive blood screening, the prevention and control of sexually transmitted diseases, and education interventions designed to bring about changes in sex and related risk reduction behaviors have helped to control HIV in selected populations and countries around the world. Examples of such success are noted in Thailand and Zimbabwe. Although AIDS has become a major cause of death among young adults, people are coping with their loss. Cost-effective ways to help these affected individuals, families, and communities adapt to HIV/AIDS are needed. Finally, efforts aimed at stopping the epidemic must continue, with attention also given to understanding and changing the conditions which allowed HIV to spread.
Improved STD treatment: a message of hope. Special report: Tanzania.
The overwhelming majority of adult HIV infections in Africa are acquired through heterosexual sexual intercourse. Many studies, however, report a close association between HIV and long-standing sexually transmitted diseases (STD) such as syphilis, gonorrhea, and chancre. It may be that these latter STDs enhance the transmission of HIV by causing breaks in the skin or by increasing the number of HIV-infected inflammatory cells in the genital tract. STDs are common in many parts of Africa, but appropriate treatment services tend to be poor or nonexistent. It may be assumed that were STDs promptly and appropriately treated, a decline in the incidence of HIV transmission may result. A HIV/STD intervention program in Mwanza region, Tanzania, was established to determine whether improved services for STD treatment would reduce the incidence of HIV infection, and if so, by how much. Twelve rural communities were selected in different parts of the region. Six were randomly chosen to receive the intervention at the beginning of the study, while the remaining six received it at the end. Designed to be effective and affordable, the program was integrated into the Tanzanian primary health care system. Existing health care staff were trained to diagnose and treat STDs using the syndromic approach recommended by the World Health Organization, and supplied with effective drugs. Regular supervisory visits were made to the health units to check drug supplies and to make sure that the staff was treating STDs correctly. Moreover, the project campaign visited the intervention villages regularly to publicize the improved services and to motivate villagers to come for treatment of STDs without delay. In the six communities with improved STD services, there were 48 new HIV infections, giving an incidence rate over two years of 1.2%. In the six other communities, there were 82 new cases for an incidence of 1.9%. Allowing for other important risk factors, the investigators estimate that the intervention reduced the incidence of HIV by 42%. This study has therefore shown that an affordable and replicable program can have a substantial effect upon the spread of HIV. Policy implications are discussed.
South Africa steps up fight against HIV and AIDS.
As of the end of 1993, 4.3% of the population in South Africa was infected with HIV. The proportion of infected individuals in the country grew to 7.6% by the end of 1994. Estimates based upon department of health statistics indicate that one million people may have been infected with HIV in South Africa by the end of 1994. In South Africa's most populous region, Guateng, which contains Johannesburg, Pretoria, the Witwatersrand, and Vaal Triangle, 6.4% of the population is estimated to be infected with HIV. KwaZulu-Natal is the worst-affected province with 14.4% of the population affected. An estimated 6.5% of teenagers are infected with HIV, 8.9% of 20-24 year olds, 9.6% of 25-29 year olds, and 6.4% of 30-34 year olds. The belief among some men that having sex with a virgin will rid them of HIV is cause for concern. Money has been set aside by South African health authorities for HIV/AIDS prevention and education campaigns, with almost two million condoms already imported for free distribution at clinics. A publicity campaign using celebrities is planned as well as propaganda films on state television and a possible play targeted to urban and rural youth.
Talking about a revolution. The politics of population.
5.7 billion people currently inhabit the Earth, but 100 million individuals are added each year. As population size increased over the past fifty years, there has been a range of political thinking, strategies, and policies to address the issue of and need for population stabilization. Governments have pursued either pro-natalist or anti-natalist policies depending upon their individual perceptions of what should be the ideal rate of domestic population growth. Women have been the primary targets of population policies, strategies, and programs. Women, however, have had only limited roles in making policy, with men holding the reins of power over whether and when women bear children. Much was changed at the 1994 International Conference on Population and Development (ICPD). For the first time, population stabilization went beyond family planning and was considered in the context of sustainable development. The 180 countries' representatives realized that only through the empowerment of women can economic development and population stabilization be realized, and worked out a plan to stabilize population. The author reviews some of the history of the population debate since the early 1960s, the role of nongovernmental organizations, and the program of action resulting from the 1994 ICPD.
Contraceptive methods and the risk of Chlamydia trachomatis infection in young women.
Chlamydia trachomatis infection is among the most prevalent of sexually transmitted diseases in young women in the US. Approximately 2.6 million women are estimated to be infected annually in the country. The authors investigated the relation between contraceptive methods and cervical Chlamydia trachomatis infection in a population-based sample of 1779 nonpregnant women aged 15-34 years attending two primary care clinics at Group Health Cooperative of Puget Sound between January 1988 and June 1989. 3.8% of the women were infected with C. trachomatis. Cervical chlamydial infection occurred more often in women younger than age 25 years, of black race, low income level, single marital status, in nulliparous women, women having douched during the preceding year, and those having two or more sexual partners in the preceding year. Overall, the risk of cervical C. trachomatis infection among barrier method users was lower than among all other women. Condoms, diaphragms, cervical caps, spermicidal sponges, foam, and vaginal spermicidal suppositories are barrier contraceptives. The greatest protective effect among barrier method users was found in women aged 25 years or older. Overall, there was no association between the use of oral contraceptives and chlamydial infection. These findings therefore suggest that present patterns of use of barrier methods differ by age and afford only selective protection against cervical infection with C. trachomatis.
Natural infections by Vibrio cholerae 01 are known to confer substantial protection against recurrent infections in populations where cholera is endemic. This suggests that it may one day be possible to develop a highly effective oral vaccine against cholera. It is, however, curious that cholera continues to occur into adulthood in populations which have endemic cholera. This phenomenon could be the result of an inability among some individuals in endemic populations to mount suitable immune responses to natural infections. If such immune hyporesponsiveness is truly at work, it may be an important barrier against the development and use of an effective oral cholera vaccine. The authors evaluated whether deficient immune responses to natural infection were associated with the risk of vaccine failure among recipients of killed oral cholera vaccines in a field trial in Bangladesh during 1985. Their findings support the hypothesis that immune hyporesponsiveness, even after the vigorous stimulus of natural infection, may have limited the protection conferred by the vaccines studied in the trial.
Follow-up bias develops in epidemiologic cohort studies when the incidence rate among individuals who do and do not return for follow-up differ. The authors estimated the rates of HIV incidence in India using a new method which accounts for follow-up bias. This new method combines data on the prevalence of p24 antigenemia among all individuals initially screened together with the longitudinal follow-up data on the subset of patients who return for follow-up. The current annual rate of HIV incidence among patients attending sexually transmitted disease clinics in Pune, India, was found to be 18.6%. The study found that follow-up bias can lead to significant underestimation in HIV incidence rates, perhaps by as much as 60%. These incidence estimates, together with findings from other HIV seroprevalence studies, suggest that the HIV epidemic in India is growing rapidly.
Stopping female genital mutilation. An update.
There is widespread consensus among many individuals, countries, and organizations that female genital mutilation (FGM) is a human rights abuse. France, Britain, Sweden, and Switzerland have passed legislation forbidding medical personnel from performing FGM, eighteen African countries have made official statements against FGM, and FGM was an issue in the 1993 World Health Assembly, the 1993 World Human Rights Conference, and the 1994 International Conference on Population and Development. True change, however, depends upon a transformation in the informal economic, social, and political structures which perpetuate women's dependency upon marriage and men. The Research Action Information Network for the Bodily Integrity of Women (RAINBOW) and the Development Law and Policy Unit of the Columbia University School of Public Health introduced the Global Action Against FGM (GAAFGM) Project in June 1994. The project is designed to integrate action against FGM into existing health and human rights programs and to pool available resources against FGM. GAAFGM has also coordinated an interagency working group comprised of international agencies, in-country grassroots organizations, and women's groups, which met for the first time in November 1994. The project should provide considerable information and leadership on the issue. On another front, participants in the most recent preparatory meeting for the upcoming Beijing Conference noted the existence of a strong recognition that FGM is a problem upon which the international community should act. The author notes recent litigation brought by the Egyptian Organization for Human Rights against the grand sheik of Al-Azhar University for issuing a fatwa declaring female circumcision an Islamic duty. In addition, a Ghanaian may be granted refugee status in Canada on the basis of her efforts to avoid mutilation if deported to her country of origin.
What the U.S. Constitution says. The law and abortion.
The US Supreme Court in its January 22, 1973, decision on Roe v. Wade abolished virtually all abortion restrictions previously imposed at the state level in states across the country. That decision marked the beginning of an ongoing national debate on a woman's right to choose to have an abortion. Some Americans think that abortion should be permitted at some stages of fetal development and in certain circumstances, while others strongly oppose abortion under any circumstances. Americans enjoy certain fundamental liberties which are protected by the US Constitution. The right to abortion is not one of these freedoms. The Bill of Rights balances individual rights and majority rule by allowing the majority to pass legislation through its elected representatives. The decision in Roe v. Wade is an example of such legislation passed by pro-choice Supreme Court judges. As such, the author stresses that a conservative Supreme Court could one day enact legislation denying women in the US the right to abortion on demand. It is clear that many states will pass legislation regulating abortion if the Roe v. Wade decision is ever overturned. Pro-choice supporters therefore want US President Bill Clinton to select pro-choice judges for the Supreme Court.
Malawi uses games to educate the young.
Recent figures suggest that Malawi has the highest rates of HIV infection in the world, with at least 12% of the sexually active population estimated to be HIV-seropositive. In urban areas, 30% of women attending antenatal clinics are infected with HIV. By March 1995, more than 37,000 AIDS cases had been reported. Adolescents and children about to enter adolescence in Malawi are at particular risk of contracting HIV. Attempting to avoid exposure to HIV, many men have spurned mature female prostitutes in favor of young girls. In exchange for school fees and other gifts, girls as young as eight years old have sexual intercourse with mature Malawian men. These men are often infected with HIV. It therefore follows that five out of six youngsters with HIV in Malawi are female. Since their female peers are involved with older men, boys are increasingly having sex with the older women rejected by mature men. Studies suggest that 55% of school pupils have experienced sexual intercourse, 76% of whom first had sex when they were younger than age 15. "AIDS Challenge" is a board game developed for distribution to all secondary schools in Malawi with the purpose of educating students about AIDS. It is played on a modified snakes-and-ladders board, using a pack of 100 cards, each with some true or false statements about AIDS. 36 boys and 35 girls aged 13-20 years from a government secondary school participated in the first trial. Four weeks of playing the game had a significant effect upon pupils' knowledge of HIV. While some of the statements on the cards are specific to Malawi, the game can easily be adapted for use in other African countries. The game is available from UNICEF Malawi at Box 30375, Capital City, Lilongwe 3, Malawi.
Viewing the human cost at Leopard Hill.
Recent data on Zambia indicate that the AIDS epidemic may have peaked in urban areas. The epidemic nonetheless continues to exact an enormous level of human suffering for both those who are infected with HIV and their friends and families. Leopard Hill cemetery is the main burial ground for the city of Lusaka. The author on a recent visit to the city found the site to be rapidly filling up and busy all the time, even Saturdays and Sundays. The intelligentsia and youth of Lusaka are being decimated. While grave plots are free, buying coffins, hiring transport, and covering other incidental expenses must drain the resources of most families. All government ministries are, however, involved in the AIDS control program, and the program's staff is dynamic and imaginative in its response. The country also is trying to accommodate the needs of a growing population of orphans.
The impact of HIV: a closely-guarded secret.
More than ten million people in sub-Saharan Africa, almost 3% of the subcontinent's population, are infected with HIV. Some countries in the South of the subcontinent report prevalence rates of 9%. Many industries have hired analysts and forecasters to help guide them through the epidemic, while police and armed forces have conducted detailed investigations into the impact of HIV. Intelligence agencies routinely hire consultants to analyze and forecast the impact of HIV in selected regions. The results of these studies and forecasts, however, are closely guarded. The many studies on the health care costs of AIDS concur that the HIV/AIDS epidemic is expensive in economic terms. There are virtually no published studies on how the African epidemic of HIV will affect the supply, demand, and quality of healthcare. The demand for care has received the greatest attention. The authors discuss how the AIDS epidemic in sub-Saharan Africa may affect health care personnel.
Prospects for global health: lessons from tuberculosis.
Preventable diseases continue to afflict billions of people worldwide in both rich and poor countries. With regard to tuberculosis (TB), much has been learned over the past century about Mycobacterium tuberculosis, the responsible infectious agent, and its medical treatment and cure. TB is, however, an old disease currently making a resurgence at the global level. An estimated one third of the world's population is infected with M. tuberculosis and HIV infection is increasing the proportion of those in whom infection will progress to TB disease. HIV and M. tuberculosis infections co-exist most extensively in the poorest parts of the world. TB control programs are inadequate, the degree of multidrug resistance is growing, and infections are increasingly transmitted freely across international borders. The combination of these factors suggests that scientific progress and humanitarian aid to developing countries may not be enough to avert the potential tragedy of untreatable TB. The author discusses the history of TB, the present situation, and the future.
Subdermal contraceptive implants.
Subdermal contraceptive implants deliver progestin from polymer capsules or rods placed under the skin. Diffusing slowly from the polymer containers at a stable rate, the hormone provides contraception for 1-5 years, with the period of protection conferred dependent upon the specific progestin and type of polymer employed. Once inserted, the device allows a woman to have sexual intercourse over a certain period of time without any significant risk of becoming pregnant. Protection is ensured with a low drug dosage and no estrogen, and fertility is readily reversible once the implants are removed. The levonorgestrel implant Norplant R is the only subdermal contraceptive implant system approved for distribution. Annual pregnancy rates using Norplant are extremely low. Menstrual problems are the main reason why women discontinue using Norplant. Research is ongoing to reduce the number of implanted units and to introduce other progestins which may minimize side effects. Norplant-2 was designed to release the same dose of progestin from only two covered rods. Nestorone, 3-Keto-desogestrel, and Uniplant are single implants under development which are expected to be effective for 1-2 years. Completed phase II clinical trials with Nestorone found no pregnancies in 1570 woman-months of use, although bleeding irregularities occurred in 20-30% of women. A multicenter study is ongoing with a newly-designed 3-keto-desogestrel implant named Implanon, as well as another multicenter study with Uniplant, an implant which releases nomegestrol acetate with a one-year duration of action.
Transdermal application of steroid hormones for contraception.
The transdermal delivery of steroids (TD) is gaining ground in hormone replacement therapy during menopause. This approach to treatment, however, has only recently been envisaged for contraception. Delivered in the appropriate solvent, both estrogens and progestins can penetrate the skin. Approximately 10% of any total dose applied topically is actually absorbed systemically. Currently available TD systems (TDS) are either of the reservoir type or of the matrix dispersion type in which the drug is dispersed into a polymer matrix. Estradiol is the most appropriate steroid for TD and can be combined with progestins to ensure a contraceptive effect. The use of potent progestins allows effective plasma levels to be reached with low doses through application over a small area of skin. TDS changed weekly and delivering both estradiol and levonorgestrel at daily dosages of 38.4 and 28.8 mcg per 10 sq. cm daily, respectively, was found to suppress ovulation. ST 1435, a synthetic progestin derived from 19-norprogesterone, has also been shown to penetrate the skin when suspended in acetylated lanolin or dissolved in a hydroalcoholic gel and to suppress ovulation at a dose of 2 mg per day in a small number of cycles. TD systems should be perfectly adhesive, well-tolerated locally, and nearly 100% effective.
Childhood diarrhea and malnutrition in Pakistan, Part II: Treatment and management.
Diarrhea and malnutrition are the leading causes of morbidity and mortality among children younger than age 5 years in developing countries. The prevention and management of diarrhea and malnutrition are frequently affected by local customs and vary from country to country. This paper reviews the treatment and management of diarrhea and malnutrition in Pakistan. Discussion of the management of diarrhea is divided into sections on rehydration, oral rehydration solution, the use of antibiotics and antidiarrheals, and the administration of foods and diet. The management of both moderate and severe protein-energy malnutrition is considered. Most mild cases of diarrhea can be managed on an outpatient basis. The authors note that physicians in Pakistan often treat children with diarrhea who are not severely dehydrated with expensive medications and intravenous fluids which lead to serious complications. Children who do, however, show clinical signs of severe dehydration require intravenous fluids and should be admitted to a hospital.
International Union against the Venereal Diseases and the Treponematoses: an overview.
Founded in Paris in 1923, the International Union Against the Venereal Diseases and the Treponematoses (IUVDT) is the oldest international organization focusing upon the control of sexually transmitted diseases (STD). The union was founded to coordinate activities on both medical and social aspects of the control of venereal diseases. The principal aims of the IUVDT are to coordinate and assist in disseminating information about STDs; to stimulate research into the scientific, medical, and sociological aspects of STDs; to compile information on trends of incidence of STDs worldwide; to organize meetings and conferences and to participate with other national and international organizations to study problems related to the understanding and control of STDs; to provide information and materials for health education about STDs; and to maintain a comprehensive list of all organization members. The 36th General Assembly of the IUVDT will be combined with the IUVDT World STD/AIDS Congress and the 9th IUVDT South East Asian and Western Pacific Regional Conference in Singapore during March 19-23, 1995.
Responsibility and irresponsibility: young women and family planning.
Until the 1930s, the medical profession deemed the issue of birth control to be unworthy of its attention. Clerics, politicians, and social commentators avoided any direct association with the promotion of family planning, even if they privately supported its use, while practitioners of family planning were equally reserved. The history of medical opposition to the free provision of contraception regardless of marital status and age is well-documented. Seven doctors and seven nurses, all White females in their mid-twenties to mid-fifties, employed at six inner city family planning clinics in Northwest England were interviewed in an open, structured conversation framework. The interviews were conducted outside of clinic hours in either the clinic or respondents' homes. The research was undertaken to assess the extent to which the value-free appearance of professional practice masks underlying professional ambivalence about the desirability and efficacy of such practice, especially with regard to young single women. The author describes how these women handle the issue of age when providing contraception to young service users.
How teen pregnancy has become a political football.
More than half of all high school students are having sexual intercourse and approximately one million teenagers become pregnant each year. Teens are therefore responsible for 12% of all births in the US, a rate higher than in any other developed country. High rates of teen pregnancy are not new to the US. Indeed, birthrates among teens were actually higher during the mid-1950s than they are today. More of those teens, however, married and even the income of a non-high school graduate could support a family. Rates of teen pregnancy in the US declined quite steadily during most of the 1980s, but they have increased in recent years. This increase comes at a time when poverty, sex, sexual and reproductive freedom, abortion, the breakup of the traditional family, and welfare reform are hot button issues in the US. To satisfy their need for scapegoats, politicians have seized upon the largely disenfranchised and impoverished population of pregnant teens as an easy target. These politicians are exploiting the issue of teen pregnancy to sidestep difficult decisions and advance their own agendas. Teen pregnancy, closely associated with poverty and sexual control, plays well into the welfare reform debate. Fifteen states have or are considering proposals to limit the amount of money welfare mothers receive and the length of time they are eligible to receive it. It is expected that teens will be discouraged from having babies if welfare support is harder to get. Numerous empirical studies, however, have found that girls and women are generally not motivated by welfare payments when they decide to have babies. Giving women real life options to pregnancy and motherhood is the fastest way to reduce the number of children women have. Moreover, instead of punishing teens for becoming pregnant, politicians should fight against sexual predators, violence and incest at home, and merchandizing which capitalizes upon sex.
Population growth threatens nutritional status of up to one billion people. Press release.
The global fish catch peaked in 1989 at 89 million metric tons and has remained near 85 million tons ever since. The UN Food and Agriculture Organization (FAO), however, estimates that 60 million tons is the maximum sustainable harvest of wild fish which can be captured for human consumption. Globally, protein from fish comprises slightly more than 5% of the average person's protein intake from animal and vegetable sources. For at least 640 million people in 39 countries, fish consumption accounts for an average of more than 10% of their total protein intake, while at least 950 million people rely upon fish for more than one-third of their animal protein. The FAO estimates that almost 70% of the world's conventional fish species such as cod, hake, and haddock are already fished up or beyond sustainable limits. Demand for fish, however, increases as the population grows. Population growth has already reduced the average human consumption of fish to 13 kg per capita in 1993 from a peak of 13.5 kg in 1989. The UN projects world population to reach between 7.9 billion and 11.9 billion people by the middle of the next century. On the one hand, burgeoning global population will demand larger quantities of fish for consumption. On the other hand, the larger number of people on the planet will generate more waste and pollution to contaminate the coastal waters upon which fish depend. The supply of fish will therefore be increasingly threatened in the face of higher demand. Aquaculture, fish farming in either marine or inland waters, cannot long compensate for the declining availability of fish caught in the wild. In addition to working to stabilize population growth, governments are urged to reduce bycatch, the throwing away of unwanted fish, by encouraging methods which discriminate between target and non-target species; improve storage and distribution technologies to reduce post-catch losses; eliminate subsidies which support overcapacity in the fishing industry; and protect coastal and other fishery habitats by controlling development and pollution. It is nonetheless clear that in the next century, many species of fish will become luxuries which only the well-to-do can afford.
The current status of family planning as a component of CBHC / FP projects in Kenya.
Family planning activities began on a small scale in Kenya during the early 1950s. These activities have been national in scope since 1967. Up to 81% of respondents in the 1984 Kenya Contraceptive Prevalence Survey were aware of at least one method of family planning. The contraceptive prevalence rate was, however, only 15%. The cost of modern contraceptives, travel distances to clinics, fear of young nurses, and poor clinic services have been noted as obstacles to the more widespread use of modern contraception. Community-based distribution (CBD) of family planning services began to develop in the mid-1960s. The author discusses the beginning of CBD and family planning through community-based health care (CBHC/FP), resistance to community-based services, spearheading CBD and CBHC/FP strategy, improving access, community-based delivery of other services, the community health worker, remaining issues, and lessons learned. Many questions remain to be answered on the implementation of CBHC/FP. It is nonetheless certain that the multidisciplinary nature of CBHC/FP programs will promote the overall health of Kenyans and play a major role in enhancing the birth rate and population growth rate.
The long overlooked Latin man.
Men play a very big role in determining whether contraception will be used during sexual intercourse and, if so, which form of contraception. That role merits the inclusion of men in family planning programs. Family planning programs in Latin America, however, have long overlooked the importance of informing and motivating men. Program developers and implementors have erroneously assumed that men in Latin America are too macho to pay attention to family planning. The Johns Hopkins University Population Communications Services has enjoyed considerable success in involving men in the development of radio, print, and video materials aimed specifically at men with local family planning agencies in Bolivia, Brazil, Colombia, Costa Rica, Honduras, and Mexico. When given the chance and approached correctly, men in Latin America are eager to participate in family planning. Successful male family planning clinics in Latin America also demonstrate that men are very interested in family planning. Accordingly, and especially given the need to control AIDS and other STDs, men should be given higher priority in family planning programs.
Males' use of public health department family planning services.
The family planning service of the Winnebago County Public Health Department in Rockford, Illinois, long focused almost exclusively upon female clients, consistent with national trends. A condom distribution service for males was implemented, with condom availability advertised in brochures and the newspaper. Males had to be at least 13 years old to receive condoms. All males requesting condoms or visiting with their partner over a six-month period of data collection were asked to complete a questionnaire or be interviewed. 207 males responded, 74% of condom acceptors and 78% of males visiting with their partner. Condom acceptors were younger than males in the other group, more likely to be single, of lower educational level, and lived nearer to the health department. They reported a younger age of first intercourse, 12.7 years compared to 14.4, with more than 47% of condom acceptors being sexually active by age 12 compared to 26.2% of males accompanying their partners. At first sexual intercourse, 60% of all males reported using no contraception. Almost 66% of condom acceptors were repeat visitors to the service, more than 40% had visited within one month, and almost 42% reported the service as their sole source for condoms. The free provision of condoms, a friend's suggestion, and that no questions were asked by service providers were cited as the main reasons for using the service. 60% of males visiting the clinic with their partner did so for the first time, and 25% had used the condom distribution service. 72-77% reported they would buy condoms from the service if necessary or share in expenses for services. Both groups reported being satisfied with health department services. Finally, more than 55% of the respondents expressed interest in additional services including medical examinations, STD programs, and support for adolescent fathers.
Depo-Provera is a contraceptive drug which contains a synthetic hormone similar to the natural hormone progesterone. When injected into the muscle of the arm or buttock, the drug is gradually released into the bloodstream to prevent pregnancy for a period of three months. Depo-Provera was developed in the 1960s and has been approved for contraception in many countries. The Upjohn Company first submitted it for approval in the US in the 1970s. The US Food and Drug Administration (FDA) approved the drug for use in the US on October 29, 1992. Depo-Provera is more than 99% effective. It is available in 150 mg single dose vials from doctors and clinics and must be given on a regular basis to maintain contraceptive protection. If a patient decides to become pregnant, she simply discontinues the injections. As with any such products, however, the FDA advises patients to discuss the benefits and risks of Depo-Provera with their doctor or other health care professional before making a decision to use it. The most common side effects are menstrual irregularities and weight gain, while some patients may also experience headache, nervousness, abdominal pain, dizziness, weakness, or fatigue. The drug should not be used by women who have acute liver disease, unexplained vaginal bleeding, breast cancer, or blood clots in the legs, lungs, or eyes. Furthermore, doctors are advised to not prescribe the drug in pregnant women due to concerns about low birth weight in babies exposed to the drug. Recent data also indicate that long-term use may contribute to osteoporosis.
Nationalism, race, and gender: the politics of family planning in Zimbabwe, 1957-1990.
Nationalists in Zimbabwe opposed family planning when it was introduced in 1957, on the notion that it was a conspiracy to control the Black population. An official policy to reduce African fertility emerged eight years later in 1965 following the unilateral declaration of independence by the White settlers under Ian Smith. Nationalists used propaganda to fight the policy, while the facilities which were established under the policy, as well as their personnel, became military targets during the guerilla war in the late 1970s. The nationalists held their pronatalist position after independence in 1980, but a postwar baby boom during the early 1980s made it clear to officials in charge of economic and social development that society could not sustain such high fertility. The pronatalist policy was therefore reversed and by 1990 Zimbabwe had become an internationally recognized leader of family planning among developing countries. The author notes that these changes occurred without any real input by African women who were generally excluded from power.
This paper presents preliminary findings on the levels and causes of infant mortality from rural areas of Balochistan province and three districts of Hazara division of NWFP. 20,486 households were interviewed in Balochistan and 959 infant deaths were reported during the past year. In the Hazara division, 7500 households reported 208 deaths during the same period. Verbal autopsy interviews were conducted on infant deaths reported in the past year to identify the major causes of death. The infant mortality rates (IMR) in the four districts of Balochistan are as follows: 172 deaths/1000 live births in Loralai, 142/1000 in Khuzdar, 121/1000 in Pishin, and 112/1000 in Lasbela. IMR in Hazara was 82/1000. Diarrhea was the most common cause of death in the two regions followed by acute respiratory infections (ARI), birth asphyxia, low birth weight, and neonatal tetanus. IMR was significantly related to the availability of clean drinking water and proper toilet facilities, birth spacing, and the death of a previous child under five years of age in the family during the past five years. Study findings suggest that a significant reduction in levels of IMR can be achieved by providing safe water and sanitation facilities in rural areas, accessible family planning services, active follow-up and support to mothers who have experienced a previous child death, an aggressive promotion of oral rehydration solution, and the case management of ARI.
Maternal and infant mortality policy and interventions. Conference summary.
Greater effort needs to be made to reduce levels of maternal mortality. Strong commitments to improving women's social status; strengthening health services to provide equitable, universal coverage; incorporating social and epidemiological oversight of the population to ensure that people at risk and in need will not be overlooked by the health care system; university development of education, research, and health services, and cooperation with policy makers, government health personnel, nongovernmental organizations, and communities in building and sustaining effective programs; and encouraging others toward global commitments to support the roles of women and protect them from unnecessary risk, disability, and death are needed to lower levels of maternal, perinatal, and infant mortality. Participants at a conference on maternal and infant mortality policy and interventions discussed health policy reform, the complexity of the issue, factors contributing to maternal and infant mortalities, and what needs to be done.
Interventional strategies to reduce infant mortality rate.
The Aga Khan Health Service (AKHS) is a non-profit organization which provides primary and curative health care in Pakistan, India, Bangladesh, Kenya, Tanzania, and Syria. The organization began working in Pakistan in 1924 with the establishment of the Jan Bai maternity home in Kharadhar, Karachi, followed by a maternal and child health center in the same area. These facilities were opened to address an urgent need for good quality maternal and child care in the area. AKHS now has five maternity homes, 212 health care outlets, and one medical center in Pakistan. The maternal and child health center is the basic unit of service, with the Lady Health Visitor (LHV) being the basic provider of service. The LHVs are supported by local health committees and supervised by a team of field directors and LHVs. Infant mortality in Karachi is 17 deaths/1000 live births, 42/1000 in the North, 48/1000 in Sindh and Punjab, and 63/1000 in Chitral. AKHS has offered immunization and growth monitoring in the attempt to reduce infant mortality. Breast feeding up to two years, early weaning, proper nutrition of children and mothers, oral rehydration therapy against diarrhea, personal hygiene, and child spacing are also promoted.
Development and trial of interventions for infant survival: the Chandigarh experience.
Despite declines, levels of infant mortality remain high across most of India. This paper describes the strategy adopted by the Community Medicine Department of the Postgraduate Institute of Medical Education and Research, Chandigarh, in establishing a demonstration project for trial of the following interventions for reducing infant mortality: the ongoing training of primary health care workers, a safe care cord kit, diarrheal diseases control, case management of pneumonia, universal immunization, domiciliary care of low birth weight babies, case management of birth asphyxia, and home-based maternal and child record. The community project was started in collaboration with Haryana State Health Services in Raipur Rani Community Development Block in 1975. Each block covers approximately 100,000 population, with health services comprised of a community health center, approximately four primary health centers staffed by doctors, and twenty sub-health centers each manned by a male and female health worker. Each village has traditional birth attendants supported by the community. The interventions were implemented through the existing primary health care infrastructure of these government health services. Drugs, equipment, and training support were provided by the Community Medicine Department.
The experiences of the Islamic Republic of Iran in reduction of maternal and child mortality.
Before the Islamic Revolution in Iran, and despite an acceptable level of GNP, access to health services in Iran was generally inadequate. As may be expected under such circumstances, health indicators were poor. After the revolution, however, primary health care was chosen as the model by which health and treatment services would be provided through the health network. Manpower training and community participation were adopted as central to the provision of health services. Priority was given to rural and deprived areas over urban areas, prevention over treatment, outpatient treatment over hospitalization, and general medical treatment over specialty treatments. A 1974 survey found the level of maternal mortality to be 120 and 370 per 100,000 live births in urban and rural areas, respectively, declining to 77 in urban and 233 in rural areas in 1985. Following the expansion of health houses in rural areas and expansion of the family health programs in cities, a 1988 survey found rates of maternal mortality to have declined to 41, 138, and 91 per 100,000 live births for urban, rural, and the whole country, respectively. Maternal mortality rates in 1991 were 26, 53, and 40 per 100,000 live births for urban, rural, and the whole country, respectively, having declined even further than in 1988 due mainly to the expansion of health houses in rural areas and the increased frequency of the presence of trained personnel during deliveries. The 1988 survey on 10% of the total population found that the deaths of children under age five years accounted for 55% and 32% of total deaths in rural and urban areas. The study indicated that 26% and 24% of deaths in the under-five age groups were due to infectious diseases, mainly respiratory infections and diarrheal diseases. A 1991 survey found a declining trend of mortality among neonates, infants, and under-fives from 1975-91. Despite the Iran-Iraq war, economic sanctions, and natural disasters, Iran has made inroads against maternal and child mortality.
Following the Alma Ata conference on Health for All using primary health care as the key approach, traditional birth attendant (TBA) training and use programs were accepted by almost all governments of Southeast Asia. Training programs were launched in many countries. Since 1960, Lady Health Visitors (LHV) working in Basic Health Units and Rural Health Centers in Pakistan have been responsible for training two TBAs per year. Although not necessarily practicing TBAs, the women chosen from nearby villages for the training were interested in learning midwifery. They received hands-on training for one year and were expected to complete 15-25 supervised deliveries in order to qualify for certification as a trained TBA. Many certified TBAs were then employed at the health facility, while others worked in their own villages. The Government of Pakistan in 1982 implemented the Accelerated Health Program, a program to address the major causes of maternal and infant mortality and morbidity. The program was comprised of immunization, diarrheal diseases control, TBA training, and health education. The TBA is the only health worker who is available and is in regular contact with women in rural communities in Pakistan. The focus of the TBA component was upon upgrading the skills of practicing TBAs and on greatly increasing the number trained. TBA training in Pakistan is described.
Faisalabad obstetric flying squad: a four year study.
The obstetric flying squad is an emergency ambulance equipped with medicines and trained staff first established by Bellshill in Lancashire in 1935 as a way of managing obstetric emergencies. The squad rushes to patients' homes in response to complications during pregnancy, labor, and puerperium in domiciliary practice, resuscitates the patient, then transfers her to the hospital for further management. Even with the best antenatal care, unexpected complications can arise at home, although the patient has been booked for hospital delivery. Flying squad service was started in Faisalabad, Pakistan, on March 16, 1988, but the first call was not until nine months later. Indications for calling the Faisalabad Obstetric Flying Squad include abortion, ectopic pregnancy, pregnancy-induced hypertension, eclampsia antepartum hemorrhage, postpartum hemorrhage, retained placenta, ruptured uterus, inversion of uterus, obstructed labor, malpresentation, primigravida, and grand multigravida. The level of maternal mortality in the city subsequently declined over the past five years to 0.77 deaths per 1000 live births, 215 maternal deaths for 276,171 total births over the five-year period. The squad received 394 calls during 1989-92, saving many lives. Relatives, traditional birth attendants, and lady health visitors are the primary callers of the flying squad.
Studies have been conducted since 1980 to assess the levels of maternal mortality in various parts of Egypt. Maternal mortality ratios have been in the range of 150-299 per 100,000 live births. Since different methodological approaches were used in the studies, no national rate could be calculated. The Child Survival Project of the Ministry of Health therefore conducted a broad-scale survey of maternal mortality in the country. 122 randomly selected health bureaus reported all deaths of women aged 14-50 years weekly for one year starting March 1, 1992. Maternal deaths were identified through screening questionnaires by the trained health bureau directors. The study covered 21 governorates, with the remaining five frontier governorates excluded from consideration due to their atypical nature compared to the rest of the country. The report of survey findings is in publication. The author defines maternal mortality and its causes, then describes the survey design. It already seems apparent, however, that better care by medical professionals and less delay among women and their families in seeking antenatal care and medical advice could lead to reductions in the level of maternal mortality.
Government policies on maternal mortality: theory and practice.
National health policy in Pakistan as of 1990 clearly stresses the importance of maternal and child health (MCH). The World Bank recently introduced the Family Health Project (FHP) in each of the country's provinces. Indeed, the provincial health department is already implementing the FHP in Sindh province with the following objectives: to increase the availability and quality of maternal-child health services, including family planning, in order to reduce the levels of maternal and infant mortality; to improve the quality and integration of primary health care services to enhance the effectiveness of the existing health care network; and to build institutional capacities to realize these objectives. High-risk pregnancy cases will be referred to higher levels of service, while difficult labor cases will be referred to secondary and tertiary care hospitals. Traditional birth attendant and community health worker training programs are being revitalized in the interest of maximizing the proportion of safe deliveries and the proper referral of risk cases, population control measures and breast feeding are encouraged, and a committee of experts has been formed to advise the government on maternal mortality and how to reduce it. Actual practice and constraints are discussed.
Pragmatic strategies for safe motherhood in developing countries.
Recognizing and providing prompt, effective treatment for bleeding, eclampsia, obstructed labor, sepsis, and abortion are key to the rapid reduction of maternal mortality. Family planning information and services also reduce mortality by reducing the number of pregnancies which are too early, too numerous, too closely spaced, and/or too late. The essential strategy, as outlined in the World Health Organization's Mother-Baby Package, is a continuum of obstetric care from community to first referral level. This continuum consists of community-based routine care for mothers and newborns during pregnancy, delivery, and postpartum in addition to emergency obstetric care and community information, education, and communication to increase levels of awareness and participation in emergency obstetric care activities. Per 500,000 population, it is proposed that there should be a minimum of one hospital providing all essential obstetric functions and four health centers which provide certain obstetric functions.
The Pakistan Child Survival Project: present implementation status and lessons learned.
The Pakistan Child Survival Project was launched in 1990 with the goal of expanding and institutionalizing child survival programs in order to decrease infant and child mortality, especially from diarrheal diseases, acute respiratory infections, vaccine-preventable diseases, and malnutrition. Program funding was slashed by 70% in 1991. The project focuses upon health information systems, integrated child survival training, communications, drugs and logistics systems, and research, but the technical assistance team since 1993 has concentrated mainly upon health information systems and integrated child survival training. Under the health information systems component, a comprehensive national health management information system for first-level care facilities has been developed and is being implemented throughout the country. The system focuses upon the planning and management of child survival interventions, with data processing already computerized through the establishment of 31 computer centers. An integrated child survival training curriculum has been developed which trains health personnel to treat children under age five years in a holistic manner, integrating preventive and curative care, and considering the interaction between nutrition and infectious diseases. Training has been implemented through the establishment of 28 child survival training units. Both UNICEF and WHO have recognized the importance of this new training strategy and are actively supporting the training program. Communication activities in the basic health services cell focus mainly upon the promotion of breast feeding, while the drugs and logistics systems component has produced mainly policy-oriented studies aimed at improving procurement and prescribing practices of strategic child survival drugs. Major progress has been made in strengthening the research capability related to child health in the medical colleges. More than thirty research studies are currently underway. Lessons learned are presented.
Maternal health in Pakistan -- current situation and policy options.
The World Bank estimates the level of maternal mortality in Pakistan to be 600 per 100,000 live births, among the highest in the world. Mothers risk death and disease during every step of the reproduction process, such as from sexually transmitted diseases, during early pregnancy, from poor nutrition, lack of antenatal care, during the prepartum period, related to delivery, and as a result of subsequent pregnancy. Maternal deaths are, however, avoidable. The author notes the need to understand the sociocultural context of maternal mortality in Pakistan. The society is highly segregated with a strong extended family system in rural areas, women have male oversight throughout their lifetime regardless of their marital status, social norms restrict women, and the level of female literacy is lower than that of men. Women's bodies cannot sustain unlimited pregnancies. Unwanted pregnancies must therefore be prevented through family planning.
Socioeconomic consequences of blinding onchocerciasis in West Africa.
The author assesses the impact of decreased visual acuity, including irreversible blindness, on 319 individuals in northeast Guinea, an area in which onchocerciasis (river blindness) is highly endemic. 136 of the individuals in the 1987 study were blind, 94 visually impaired, and 89 well-sighted. Subjects' visual statuses were classified based upon the international classification of impairment, disability, and handicap (ICIDH). Analysis found individuals' decreasing visual acuity to be strongly associated with mobility, occupational, and marital handicaps. Individual, household, and disease correlates were explored. The implications of these findings for the ICIDH concept of handicap are discussed with particular emphasis upon the need to extend analysis beyond the individual when assessing the socioeconomic consequences of disabling disease.
Every year, more than 550 million injections are administered in developing countries through the Expanded Program on Immunization. It is imperative that great care be given to providing these immunizations with only sterile injection equipment. Otherwise, children may be subjected during immunization to infections such as hepatitis B virus and HIV. Sterilizable needles and syringes, standard disposable needles and syringes, autodestruct needles and syringes, and jet injectors are currently available for administering vaccines. The design and operation of the former two types of needles and syringes are, by definition, evident. The design of autodestruct needles and syringes and jet injectors, however, is less directly apparent from their nomenclature. Autodestruct syringes have a device in the barrel which prevents the plunger from being redrawn after a single use, thereby automatically blocking the syringe and preventing it from being reused. Jet injectors deliver immunizations with a high pressure jet of fluid generated by either a hydraulic or mechanical compression system. This equipment was developed for high workload use and has been employed in immunization campaigns for many years. Low workload injectors are being developed for use in the small immunization clinic setting. In general, the cost per injection is lowest with sterilizable equipment and highest with the autodestruct device. Only autodestruct syringes, however, virtually eliminate the risk of unsafe injection practices. It must be emphasized that technology alone cannot eliminate the risk of accidental infection using unsterile injection equipment. The authors note that it may be appropriate in some settings to use a combination of equipment. For example, autodestruct syringes may be used in areas where it is difficult to ensure adequate supervision, while in medium-sized, fixed-site clinics with safe injection practices, sterilizable equipment will be the most cost-effective.
Noma: a neglected scourge of children in Sub-Saharan Africa.
Noma (cancrum oris) is a severe gangrene of the soft and hard tissues of the mouth, face, and neighboring areas observed especially in children. Without the timely intervention of appropriate antibiotics, noma is almost always quickly fatal. Survivors of the disease may exhibit facial mutilation, impaired growth of the facial skeleton, nasal regurgitation of food, leakage of saliva, defective speech, and chewing difficulties. Noma is frequently seen in developing countries, especially in sub-Saharan Africa, where it occurs almost exclusively among poor children usually aged 3-10 years. It may be that noma results from oral contamination by a heavy load of Bacteroidaceae and a consortium of other microorganisms. The opportunistic pathogens invade oral tissues when an individual's immune response is compromised by malnutrition, acute necrotizing, gingivitis, debilitating conditions, trauma, and other oral mucosal ulcers. Accordingly, malnutrition, poor oral hygiene, and debilitation resulting from HIV infection, measles, and other childhood diseases prevalent in the tropics are factors associated with an increased probability of developing noma. Poverty, however, is the most important risk indicator for the condition. The current escalation in the incidence of noma in Africa can be attributed to the worsening economic crisis in the region. The prevention of noma in Africa will require measures which address these problems and, most importantly, eliminate the fecal contamination of food and water supplies.
Monograph on abortion issues in east, central and southern Africa.
Abortion was identified at the November 1993 Conference for High Ministers for East, Central, and Southern Africa in Lesotho as a major cause of maternal morbidity and mortality. Specific actions to address the problem in the region were also recommended at the conference. To document the magnitude of the abortion problem in the region and in sub-Saharan Africa overall, the Commonwealth Regional Health Community Secretariat undertook a study in 1994 in which literature on abortion covering the period 1980-94 was reviewed and primary data collected from Zambia, Uganda, and Malawi. 99 published and 195 grey literature documents were reviewed. The data suggest that there is a high percent of incomplete abortion patients among all hospital gynecology admissions. The researchers also identified a need for more community-based studies. The clinical literature identifies hemorrhage and sepsis as the two most common complications of abortion. Data collected from the countries largely confirm findings in the comprehensive literature search.
The UN Administrative Committee on Coordination, Subcommittee on Nutrition held its annual symposium in 1991 on nutrition and population at UNFPA headquarters in New York. The symposium papers, discussions, and related literature form the basis for this paper. The symposium focused upon issues of direct relevance to programs, with attention to breastfeeding, birth spacing, infant nutrition, and maternal health. The authors discuss breastfeeding, birth spacing, and nutrition; breastfeeding for infant health and nutrition; breastfeeding and birth spacing; the benefits of birth spacing to child nutrition; how child survival affects birth spacing; mother's health and nutrition; integrating nutrition and family planning activities; and future challenges.
Nutrition and family planning linkages: what more can be done?
Although much has been learned over the past twenty years about the rationale for integrating nutrition and family planning activities, few programs have linked the two. The greatest constraint to the linkage of nutrition and family planning activities has probably been the narrow focus of various programs. Family planning programs, for example, focus mainly upon women, while nutrition programs focus mainly upon children. The promotion of breastfeeding, however, naturally addresses and integrates both population and nutrition issues. The promotion of breastfeeding may therefore be a very good point of departure toward the integration of nutrition and family planning activities. Evidence exists on how programs can successfully integrate breastfeeding promotion with family planning. Through the replication of such activities, it may be possible to convince program managers that linking additional nutrition and family planning activities will have benefits for both.
Reproductive stress and women's nutrition.
Review of the literature on reproductive stress and nutrition reveals that researchers have focused upon influences on fetal and infant outcomes without much or any attention to the possible impact of reproductive stress upon women's nutrition. Women's reproductive stress, often regarded as a syndrome, should instead be seen as a continuum measured in terms of the range of outcomes understood to relate to nutrition, such as diet, body composition, and biochemical indicators. The Institute of Nutrition of Central America and Panama (INCAP) conducted research during 1969-77 in four villages of eastern Guatemala to document the effects of improved nutrition upon the physical and mental development of children, with the research focused upon examining women actively exposed to different degrees of reproductive stress. Of policy importance, the study and the literature indicate that it is common for pregnancy and lactation to overlap in traditional societies in the Third World. Such overlap should be prevented. Since breastfeeding fails to be an effective means of birth control after an infant reaches age six months, the mother resumes menstruation, or the infant ceases to be fully breastfed, alternative methods of contraception should be employed once one of these events occurs. The INCAP study also found strong evidence that reproductive stress affects women's nutritional status and subsequent infant growth under certain circumstances. The question is therefore not whether maternal nutrition is affected by reproductive stress, but rather under which circumstances are effects noted and to what degree and in what aspects.
Breastfeeding, fertility and population growth.
The inconvenience of breastfeeding has led people since the dawn of civilization to circumvent the practice. Breastfeeding, however, is very important for the well-being of both mothers and children. Breastfeeding gives mothers natural contraceptive protection as well as protection against the development of ovarian and breast cancer later in life. On the other hand, the survival of breastfeeding infants is benefitted by appropriate time intervals between births of siblings and short- and long-term protection conferred against gastrointestinal and respiratory diseases. Bottle-fed babies are also far more likely to develop fatal necrotizing enterocolitis, to be prone to a range of allergies in later life, and to possibly even be less intelligent than their breastfed peers and more likely to develop early age onset diabetes. Despite these numerous advantages of breastfeeding, infants continue to be reared on substitutes for breastmilk. This practice has brought enormous suffering, disease, and death to millions of babies. Moreover, the lack of maximization of breastfeeding practice, and the related natural contraceptive effect, have helped facilitate the recent explosive growth of human population. Promoting breastfeeding is the most affordable and effective way to improve maternal and infant health and lower fertility. Sections discuss the history of breastfeeding, the uniqueness of human milk, and the effects of nutrition on lactation.
Nutrition and its influence on the mother-child dyad.
Data from recent studies on nutritional status and its influence upon the mother-child dyad are briefly reviewed. There is no question that mild and moderate levels of maternal undernutrition continue to be widely prevalent among poorer segments of the population in developing countries. The majority of those women consume only 1200-1800 kcal per day throughout their reproductive years. Chronic mild and moderate maternal undernutrition, however, have no adverse effect upon the duration of lactation or the quantity or quality of milk secreted. Food supplementation programs were launched during the 1970s, but failed to yield the expected beneficial impact upon maternal and child health. The author notes that substantial beneficial impact could nonetheless be had were efforts focused upon reaching women whose dietary intakes fall below habitual level, women who perform heavy manual labor, and women who are both pregnant and lactating, and providing them with food supplements and health care as a package.
Breastfeeding, family planning and child health -- final comments.
There are seven periods in a woman's life when interventions can be made to support women's health and nutritional status: during infancy, childhood, adolescence, pregnancy, lactation, weaning of an infant, and at menopause and beyond. Synergy exists between nutrition and population growth. Breastfeeding and child spacing are important to promote in the best interest of the infant's survival. The provision of adequate nutrition must then be stressed during childhood, adolescence, and pregnancy. Family planning is an important intervention during adolescence and young adulthood. Mothers should be encouraged during the postpartum period to breastfeed their infants; lactational amenorrhea will block fertility during this period. Once weaning begins, however, an alternative form of family planning must be adopted. Women during their post-fertile years can then be educated about breastfeeding nutrition and family planning since it is the elders who teach the social and cultural norms. Edmonston notes how breastfeeding and contraception are the two principal determinants of fertility in the developing world, while Winikoff considers what can be done to integrate family planning and breastfeeding on a programmatic level.
The efficacy of prevention: improving the status of children in southern Africa.
Population size is growing rapidly in southern Africa in the context of constrained resources, sociopolitical turmoil, and weak economies. Child health suffers as a result. Smaller families and a reduced rate of population growth would, however, reduce the level of demand upon available resources. A comparatively greater share of resources would therefore be available for investment in each child. It tends to be taboo to publicly endorse population control in southern Africa. It is instead common practice in Africa to attach great value to large-sized families. These prevailing religious, cultural, political, and ideological beliefs opposed to political control over fertility should be respected. In the interest of maximizing child survival, however, people in the region must begin to understand that the large-family norm is outdated and that they should try to understand when population control policies can be effective. Indeed, the economic and political situations in the region warrant the discussion of population control mechanisms, with understanding in the interest of communal well-being rather than individual self-determination.
Bringing mass media to rural populations through mobile video vans.
Population Services International (PSI) uses mobile film units (MFU) to disseminate its messages on family planning, AIDS prevention, and child survival among rural audiences. The approach has been successful in Bangladesh and India, and will soon be integrated into PSI's programs in Africa. Each MFU is equipped with a generator, two 16mm projectors, a giant portable screen, a public announcement system, and a supply of socially marketed products and promotional items. The 16mm projectors will soon be replaced with video projectors. Generally lasting approximately 2.5 hours, the MFU show includes educational documentaries, product advertising, a participatory video unit, entertainment, and news and sports reels. During the break, the promoter makes a pitch while distributing sample products such as oral contraceptive pills, oral rehydration salts, or condoms. In Bangladesh, the Social Marketing Company (SMC) began using mobile film units on a small scale in the early 1980s. The SMC now has a fleet of 17 MFUs, with two units based in each of the SMC's eight regional offices.
Saving children's lives in Bangladesh.
As the world celebrates the 25th anniversary of the invention of oral rehydration therapy (ORT), the low-cost approach to preventing child mortality from diarrhea-induced dehydration, Population Services International (PSI) has cause to celebrate its successful marketing of oral rehydration salts (ORS) in Bangladesh. PSI first became involved in the social marketing of ORS in its 1986 pilot program in Bangladesh. The pilot successfully led to backing for the social marketing of ORS nationwide and the development of a comprehensive ORT educational program targeted to parents and caregivers of children under age five years, and at private sector health providers. PSI's ORS product, ORSaline is neither donated nor subsidized. Instead, sales revenues defray the cost of manufacturing. The sales force of the PSI-affiliated Social Marketing Company (SMC) sells the product through pharmacies and other outlets at government-fixed prices. The marketing effort is supported with consistent consumer advertising, trade promotion, and detailing to doctors and pharmacists. Net sales revenues pay for the cost of the product and some operating expenses, while US Agency for International Development funding supports other marketing costs and the costs of the educational and training programs. The Bangladesh program is a huge success. Since 1986, the project has marketed more than 87 million sachets of ORS, with 25 million sold in 1993 alone. The ORSaline brand has an estimated 75% share of all ORS moving through commercial channels, ORSaline has become the generic term for ORS, and PSI has become the world's largest marketer of ORS in the private sector. This brief describes the development of the information, education, and communication program, and lessons learned.
Zambia social marketing project has MAXIMUM impact on war against AIDS.
Zambia has a population of 8.6 million people. 15-25% of those individuals in the country who are sexually active are infected with HIV. As recently as 1992, however, condoms were not readily available in Zambia. Commercial condom brands sold in private sector outlets were too expensive for the average Zambian to afford, while free condoms were often not in stock in public health clinics or were inconvenient to procure. Population Services International (PSI) on December 1, 1992, launched MAXIMUM, a low-priced, high-quality condom which is now available through hundreds of sales outlets across the country. 4.6 million units were sold in the first year, with sales averaging 400,000 units per month since the launch. MAXIMUM has become the most popular and ubiquitous condom in Zambia. It is available in pharmacies, drug stores, health clinics, grocery stores, supermarkets, department stores, bars, hotels, filling stations, markets, and street stalls. Four sales representatives canvas each region of the country in regular cycles to ensure product availability. No other social marketing project by any organization, except PSI's program in Botswana, has had such early success. The introduction of MAXIMUM has encouraged new condom use, with 50% of reported current condom users indicating that they first used a condom within the preceding nine months, since the introduction of MAXIMUM. Although the social marketing project has met resistance from the religious community, the government has made it clear that while abstinence and fidelity are preferred, condom use saves lives. For 1994, the second year of the project, MAXIMUM will be promoted through expanded mass media advertising, targeted communications such as theater and bar promotions, and the use of promotional items distributed through sales outlets and at promotional events.
Few studies have investigated how nutrients such as iron and vitamin A promote adolescent growth or whether the effort of catching up on growth may result in a reduction of iron and vitamin A stores. The intake of these nutrients probably does not rise along with maturational requirements in many developing countries. In situations where adolescent females have a heavy workload, low social status, low priority in food distribution, and high infectious disease rates, growth may be achieved, but at the cost of reductions in stores of certain nutrients. Women's health will be compromised during pregnancy. It is proposed in this paper that growth requirements increase demands for iron and vitamin A and that deficiencies of these nutrients may be a consequence of growth and sexual development in adolescent females on marginal diets. One consequence of reduced iron and vitamin A stores in nonpregnant adolescents may be increased risk of menorrhagia, which contributes further to the problems of anemia in poorly nourished girls in their prereproductive years and beyond. The costs of achieving growth may also include cephalopelvic disproportion in girls becoming pregnant. Sections discuss iron and vitamin A requirements during adolescence, the cost of successful growth, and interactions of vitamin A and iron.
Collaboration between the public and private sectors in ORS production, supply, and distribution.
A partnership was formed between Ghana's Ministry of Health (MOH), UNICEF, the US Agency for International Development, and DANAFCO Limited, a private pharmaceutical company, to produce and distribute oral rehydration solution (ORS) in Ghana. The program was officially launched April 1988 and ORS is now being distributed to all DANAFCO depots, with a first consignment already provided to the MOH. A coordinated public and private sector promotion campaign has started, retailer training is underway throughout the country, and DANAFCO is running two production lines producing 6000 packets per day per line. Central to the success of this public-private sector collaboration is that regular and effective communication be maintained between partners, and that balance be maintained between the private sector's interest in maximizing profit from product sales and the government's desire to ensure the widest availability of ORS by making the packet available at the lowest possible price. Potential constraints to local production, the establishment of local production and commercial distribution, current concerns, and additional information and observations are presented.
Male motivation program, AF-ZIM-01.
The Zimbabwe male motivation program is being conducted with the goal of improving attitudes toward family planning and increasing levels of both knowledge and use of family planning methods among males of reproductive age through a combination of mass media and interpersonal communication activities. The program's institutional development objectives are to strengthen the capability of the Zimbabwe National Family Planning Council (ZNFPC) to design, implement, and manage information, education, and communication (IEC) programs with the private sector; strengthen ZNFPC's ability to evaluate IEC programs; and upgrade the skills and knowledge of ZNFPC Senior Educators, Provincial Managers, and selected staff in organizing and conducting motivational/educational family planning talks and outreach activities. Joint family planning decision making between males and their spouses will be promoted. The extent of expected changes in knowledge, attitudes, and practices among the target group will be specified after initial research is completed. Project outputs are described followed by an overview of the Zimbabwe male motivation program, status of project activities, and copies of related newspaper articles.
The author presents findings from a re-examination of the protective effect of breastfeeding upon hospital admissions for gastroenteritis based upon the combined data of 3285 infants from the Jing-An and Chang-Ning epidemiological studies of children's health in Shanghai. The subjects were classified into "never" and "ever" breastfeeding groups. Analysis found the risk of hospitalization for gastroenteritis in the ever breastfed infants to be significantly lower than that in the never breastfed infants, 3.4% vs. 5.3%, respectively. The odds ratio was 0.66 after controlling for covariates. These data suggest that breastfeeding offers moderate protection against hospitalization for gastroenteritis in Shanghai infants.
Infant feeding practices in a Russian and a United States city: patterns and comparisons.
Human milk provides total nutritional requirements for an infant up to age six months. Moreover, breastmilk contains anti-infective and immunological properties which protect infants from disease. Breastfeeding may therefore be one of the world's most cost-effective child survival practices. Few current research data are available about breastfeeding practices in Russia. The authors compared infant feeding practices in the rural cities of Stevens Point, Wisconsin and Rostov-Veliky, Russia. The two locales are Sister cities, paired in 1984 because they share similar populations, climates, and agricultural bases. Each city has one county hospital in which the majority of births occur. The 58 mothers in Stevens Point and the 63 mothers in Rostov-Veliky who gave birth during October 1991 responded to study questionnaires. All new mothers in Rostov-Veliky were breastfeeding their infants at the time of hospital discharge, while only 60% of new mothers in Stevens Point were breastfeeding. Russian mothers received more societal support for breastfeeding, with an average of 25 months maternity leave and childcare facilities provided in the workplace. The authors warn public health workers in Russia to remain vigilant against baby milk companies as Russians gain purchasing power. Breast feeding must continue to be promoted as these companies, both foreign and domestic, market their products as a convenient and healthy alternative to breast feeding.
Operations research diagnostic studies: formative evaluation in India, Indonesia, Pakistan.
This article summarizes findings from three family planning operations research (OR) diagnostic studies conducted during 1991-93 by the Population Council in collaboration with national family planning staff in India, Indonesia, and Pakistan with US Agency for International Development funding. The research was under the auspices of the Asia and Near East Operations Research/Technical Assistance Project. The studies yielded important empirical data upon which managers can make sound program decisions. It is clear that much remains to be accomplished with regard to strengthening program policy, in-service training, field supervision, counseling, and the quality of care in all three countries. The evolution of family planning OR and the reporting and use of findings are discussed. Executive summaries are also presented for the situational analysis of public family planning services in Pakistan, the Norplant implant use-dynamics diagnostic study in Indonesia, and a literature synthesis on the state of family planning in Uttar Pradesh, India.
Prisoners in France have ready access to high-quality condoms and lubricants from containers placed around prison health centers and reception areas. It was recently recommended that prisons in England and Wales also provide inmates with easy access to condoms in the interest of stemming the spread of HIV and AIDS through otherwise unprotected sexual intercourse. This effort was strongly rejected by the British government, with officials arguing that providing condoms would be a tacit endorsement of illegal gay sex in the relatively public prison environment and, in the case of young offenders' institutions, sex between under-age inmates. The British government did, however, agree to other recommendations such as the need to issue inmates cleaning agents, ostensibly to clean injecting equipment unobserved by prison officers. One could therefore conclude that the government accepts IV drug use as part of prison life, but denies the existence of same-sex sexual relations involving penetrative anal sex. Current policy is for doctors to prescribe condoms if they judge inmates to be at risk of exposure to HIV. Elmley jail in Kent, like most prisons, integrates inmates it knows to have HIV with other prisoners. Policymakers at the jail have considered issuing condoms to their 600 male inmates, but any inmates known to be having sex in their cell are separated, with relationships between inmates discouraged. Finally, the RCN regional officer for Glasgow believes that condoms could be used to jam the doors in prisons' electronic security systems.
Research on human reproduction and the United Nations.
Thomas Robert Malthus in his 1798 publication sparked considerable debate and criticism when he pointed out that population, when unchecked, grows geometrically, while subsistence increases arithmetically. The author discusses Malthusianism, some of the history of family planning, and the evolution of ideas and institutions. The Special Program of Research, Development, and Research Training in Human Reproduction was established in 1972 by the World Health Organization to promote, coordinate, support, conduct, and evaluate research on human reproduction with particular reference to the needs of developing countries. This program is the main instrument of reproductive health research in the UN system. Since its inception, 339 scientists from 46 developing countries, 300 scientists from 17 developed countries, and 23 scientists from six countries in economic transition have participated in the program's advisory scientific committees. The program advises member state governments and supports research and development in the assessment, development, introduction, and transfer of technology, as well as epidemiological and social science research on reproductive health and essential national health research. Another important area of activity consists of strengthening the research capability of developing countries to enable them to address reproductive health problems of national relevance.
Babies on the verge of having babies.
The author used to be employed as one of two doctors at a community clinic on Minneapolis's south side. He now lives in New York City. His discussions with two female adolescent patients at the clinic are described. A 13-year-old girl presented to determine whether she was pregnant. The girl had been having unprotected sexual intercourse with a male friend and wanted to have a baby. When asked whether she was prepared to raise the child, the young woman replied that her mother would help and that her cousin also was raising a child. The patient appeared disappointed when informed that she was not pregnant. The second case presented is of a 14-year-old female requesting birth control. The patient was not sexually active, had no immediate prospect for becoming sexually active, was terrified at the prospect of a pelvic exam, and was at the clinic simply to comply with her mother's wishes.
Overview of Norplant litigation.
Norplant is a long-acting subdermal contraceptive implant system introduced to the US market in February 1991. More than one million women in the US and more than 2.5 million women internationally use Norplant. Within two years of Norplant's arrival on the US market, litigation was filed, mainly against the Norplant manufacturer, Wyeth-Ayerst Laboratories, by women who have suffered or who will suffer permanent injuries as a result of the system. Some medical malpractice claims are being filed against health care providers who prescribe and/or remove the system. Current litigation questions the safety of Norplant, the adequacy of warnings about side effects and potential adverse reactions, the degree of disclosure for informed consent, and the adequacy of training involving the product. Nurse practitioners involved with Norplant need to be aware of related litigation in order to provide the highest quality health care and avoid exposure to liability. In particular, nurse practitioners who have been trained in the insertion and removal of Norplant must be sure that they have the requisite skills and experience to respond to the known complications of the system. The author offers an overview of litigation against Norplant.
Adolescent development and transitions to motherhood.
Each year 500,000 American teenagers give birth for the first time and, nationally, 18% of all firstborn children are born to teenagers. Research was conducted to examine the experience of motherhood during adolescence and to evaluate the developmental influences upon the concept of maternal role. Qualitative methods were used to identify the phenomenon of understanding how an adolescent experiences mothering in relation to her own adolescent development, while quantitative methods were used to test the association between responses on self-related and mother-related questions. Group and individual interviews over a two-year period with 42 mothers aged 14-21 years (mean age, 17.7 years) comprised the qualitative component, and individual interviews with 25 mothers aged 14-18 years (mean age, 16.0 years) comprised the quantitative component. Subjects' race and ethnicity were heterogenous and 100% received Aid to Families with Dependent Children. The qualitative study determined that an adolescent mother's conceptualization of her maternal role is related to her own psychosocial and cognitive development. The quantitative study revealed a strong correlation between the developmental complexity of responses to questions about self and the complexity of responses to questions about motherhood. The authors conclude that the experience of motherhood and the conceptualization of the maternal role in adolescence is related to young mothers' psychosocial cognitive development.
The glucocorticoid receptor and RU 486 in man.
Glucocorticoids are so important in maintaining basal and stress-related homeostasis that glucocorticoid inaction is incompatible with life in primates. Cortisol is the major glucocorticoid in humans. The peripheral and central effects of cortisol are mediated by the intracellular glucocorticoid receptor (GR), a ligand-dependent transcription factor expressed in almost every tissue of the human body. The authors discuss glucocorticoid resistance. Search for a glucocorticoid antagonist led to the development of RU 486 in the early 1980s. It soon became clear, however, that RU 486 also had strong antiprogestin activity, leading to its application as a contraceptive/contragestive agent. The antiglucocorticoid properties of RU 486 have also been extremely useful in elucidating the molecular events leading to GR activation. RU 486 has been used successfully in the treatment of patients with Cushing's syndrome due to ectopic ACTH-production or adrenal carcinoma, and has helped to determine the underlying effects in animal disease models or human diseases involving the HPA axis, such as major depression or anorexia nervosa. The authors summarize the pharmacokinetic and pharmacodynamic properties of RU 486 as a glucocorticoid antagonist in humans.
Clinical uses of mifepristone (MFP).
Synthesized by Roussel-UCLAF, mifepristone (RU 486, MFP) is the first antiprogestin available for clinical use. The compound possesses both antiprogesterone and antiglucocorticoid properties, and is now marketed in France, the United Kingdom, and Sweden as a medical abortifacient. Many other potential uses may, however, be linked to MFP's antiprogesterone activity. The authors review the use of MFP as an abortifacient and its other obstetrical and medical applications. Obstetrical applications of MFP would include second-term pregnancy termination, MFP for intrauterine fetal death, cervical ripening with MFP prior to surgical abortion, and MFP for labor induction. MFP may also potentially be used for contraception and endometriosis, against advanced breast cancer, and as a cortisol-blocking agent.
Care of critically ill newborns in India. Legal and ethical issues.
The nature of neonatal care in India is changing. While the quality of care will most likely improve as the economy grows, the eventual scope of change remains to be seen. Attitudinal and behavioral changes, in addition to better economic conditions, are needed to realize more appropriate interventions in neonatal care. Economic, cultural, religious, social, political, and other considerations may limit or affect neonatal care, especially for ELBW infants or infants with congenital malformations or brain injury. Various protections for critically ill newborns exist under Indian law and the Constitution of India. New laws are being enacted to enhance the level of protection conferred, including laws which ban amniocentesis for sex determination and define brain death in connection with the use of human organs for therapeutic purposes. The applicability of consumer protection laws to medical care is also being addressed. It is noted, however, that India lacks a multidisciplinary bioethics committee. An effort should be made to discuss the legal and ethical issues regarding the care of critically ill newborns, with discussions considering religious, cultural, traditional, and family values. Legal and ethical guidelines should be developed by institutions, medical councils, and society specific to newborn care, and medical, nursing, and other paramedical schools should include these issues as part of the required coursework. Physicians, nurses, philosophers, and attorneys with expertise in law and ethics should develop and teach these courses. Such measures over the long term will ensure that future health care providers are exposed to these issues, ideally with a view toward enhancing patient care.
The authors conducted a case-control study in the periurban community of Bandim 1, Guinea-Bissau, to test the hypothesis that colostrum protects newborns from intestinal infection by its content of secretory immunoglobulin A and other immediately acting factors. It may be that the colostrum also induces maturation of the child's gastrointestinal immune defenses, contributing to the protection against diarrheal disease later in infancy. 734 full-term, vaginally delivered, singleton, healthy newborns were registered during the period January 1984 to April 1986. The child's age at the start of breastfeeding was ascertained in interviews with mothers within 28 days after birth. The prevalence of breastfeeding and diarrhea was recorded from January 1984 to March 1985. Follow-up data on diarrhea were available for 279 of the 343 children born during the period. 66 subsequent cases of acute diarrhea were identified at three-monthly examinations and four concurrent controls were randomly selected among attendants. Three separate estimates of association found that the cases tended to have started breastfeeding later after birth than the diarrhea-free controls, but no single test was statistically significant. It is therefore concluded that early breast feeding may have consequences for diarrheal morbidity after the neonatal period.
Teenager mothers' narratives of self: an examination of risking the future.
The author interviewed and observed sixteen young mothers in the attempt to learn about their perceptions of self and their life courses as participants and members of families and communities. Nine non-Latina White, six African American, and one biracial mother under age 19 years at the time of delivering their first-born healthy infants were recruited from several programs serving adolescent parents in a large metropolitan area on the West Coast of the United States. The women were aged 14-18 years at the time of delivery (mean age, 16 years) and entered into the study when their first-born child was aged 8-10 months. At entry to the study, five had dropped out of school, six were currently enrolled, and five had completed high school or gained an equivalent degree. Two high school graduates were attending a community college or vocational program. There was a diversity of social class and household composition among the participants. The young mothers and three male partners participated in three monthly, home-based interviews. In the first interview, each mother was asked to describe her life before the pregnancy and her decisions, emotions, and considerations regarding the pregnancy, birth, and early months of mothering. In the two subsequent interviews, the Berkeley Stress and Coping Interview was used to elicit recent situations which were pleasurable, rewarding, and difficult in being a parent. The researcher also observed caregiving practices in each home for a maximum of fifteen hours over the three-month period. Study findings and their implications are discussed with particular regard to community-based, community-focused primary health care.
In the West, Kaposi's sarcoma and non-Hodgkin's lymphoma have been closely associated with HIV-induced immunosuppression. To date, however, there has been no published account of the impact of HIV infection upon malignancies prevalent in Africa where the HIV epidemic is widespread. The authors describe the pattern of malignant disorders among adult indigenous Zambians over the period 1980-89 in the attempt to discern the impact of HIV infection upon the prevailing malignancies. Histopathological and hematology records of 7836 neoplasms seen during 1980-89 at the University Teaching Hospital in Lusaka, Zambia, were analyzed. The crude incidence rate of each malignancy per 100,000 adults per year was calculated and the patterns of malignancies compared for the periods 1980-83 and 1984-89. The latter period corresponds to the advent of the HIV epidemic. Carcinoma of the cervix, Kaposi's sarcoma, bladder carcinoma, hepatoma, lymphoma, and carcinoma of the breast were the six most commonly observed tumors, occurring, respectively, among 19.6%, 7%, 6.3%, 5.8%, 4.6%, and 4.4% of cases. The crude incidence rates of Kaposi's sarcoma and carcinoma of the breast increased significantly during the last six years of the study period, with nodal KS exhibiting the most significant rise from a crude incidence rate of 0.25 per 100,000 adults per year during 1980-83 to 1.11 during 1984-89. In contrast to findings from Europe and the US, no significant increase in non-Hodgkin's lymphoma was detected in Zambia following the arrival of the HIV epidemic.
The effect of stay in a maternity waiting home on perinatal mortality in rural Zimbabwe.
Obstructed labor, prematurity, and antepartum hemorrhage are some of the important causes of perinatal mortality in developing countries. The development and use of maternity waiting homes (MWH), lodgings close to hospitals, have been recommended by the World Health Organization as a strategy for reducing levels of maternal morbidity and mortality. Although MWHs are designed mainly to reduce levels of intra- and post-partum maternal complications of high-risk pregnancies, they also have the potential to reduce adverse perinatal outcomes for newborns. This paper reports findings from a study conducted under routine program conditions in Zimbabwe which compared intra-hospital perinatal deaths among women who stayed in a MWH and those who came directly from home during labor, adjusted for potential confounding factors which may affect the incidence of perinatal mortality. Information was collected on the antenatal risk factors, use of antenatal care, access to the hospital, and stage of labor on arrival for each of the 6438 women delivering at Chipinge Hospital during the period 1989-1991. Women who stayed in the MWH had a lower risk of perinatal death compared to women who came directly from home to the hospital during labor; the crude relative risk of perinatal death for the women coming home was 1.7. Once adjusted for the effect of potential confounding, relative risk fell to 1.5. Among women with antenatal risk factors, however, those who stayed at the MWH were 50% less likely to experience a perinatal death than women who came from home during labor. The authors therefore conclude that the use of MWHs has the potential to reduce perinatal mortality in rural areas with low geographic access to hospitals and merits further evaluation.
The authors assessed the performance of 123 health workers in Ife Central local government area (LGA) and 50 in Ojo LGA in managing children with acute respiratory infections (ARI) with the goal of deriving information useful in the development of a national ARI control program. Health workers were observed at nineteen public health facilities in Ife Central LGA and in fourteen in Ojo LGA. Most health workers took good general histories, but specific ARI-related history and physical examination were frequently omitted. ARI was commonly treated on the basis of symptomatic diagnosis. Chloroquine, paracetamol, and antibiotics were most commonly prescribed to treat ARI, although essential drugs and supplies for ARI management were unavailable in some facilities. Communication with mothers was generally unsatisfactory and instruction on home management incomplete. Many of the health workers had not attended a continuing education program in the previous two years, while supervision was irregular. Attention to policy, logistics, training, and supervision will be required to improve ARI case management in Nigeria. The authors discuss the potential role of an integrated approach to managing sick children.
The effects of Operation Rescue on pro-life support.
Operation Rescue is a militant anti-abortion group. The organization conveys its position against abortion by targeting a city in which it will mount speeches, rallies, pickets, and media barrages. Operation Rescue held activities in Greater Buffalo, New York, in 1992. The authors investigated the effect of the anti-abortion campaign upon a sample of non-activist university undergraduate students and the anti-abortion cause in general. 114 male and 195 female students of the State University of New York College at Buffalo participated. 60% were younger than age 22 years and 17% were 46 years of age or older. 87% were sexually active, but only 18% were married. 11% reported having an abortion themselves or dating someone who had. 150 subjects were surveyed each spring for three years with regard to their abortion-related attitudes and behaviors. 18% of the participants identified themselves as pro-life in 1991, 22% in 1992, and 12% in 1993, the year after the Operation Rescue campaign. 70% identified themselves as pro-choice in 1991, 60% in 1992, and 57% in 1993. The percentage of respondents reporting that they would not have an abortion themselves, but support a woman's right to free choice with regard to abortion steadily increased from 11% in 1991 to 19% in 1992 and 30% in 1993. In general, support for the anti-abortion camp increased during protest activities, but decreased overall over the long term. The campaign had a particularly negative effect upon males.
Patterns of activity and use of time in rural Bangladesh: class, gender, and seasonal variations.
Tarapur is a village in the district of Rajshahi, Bangladesh, covering an area of 821.05 acres. 342 households with a total population of 1981 were identified in the village by the 1985 census. The author investigated the use of time during 1984 and 1985 in busy, intermediate, and slack seasons among the village population to examine the variation in time use by gender and social class. Activity patterns were found to vary from one season to another, and also across social classes. The study highlights the need to refine some of the conceptual and methodological issues in the collection of data on women and work. The study also presents useful data on home-based production and market-oriented work. It could be useful to adopt an anthropological approach in order to understand the allocation of time by men and women from the perspective of household production and the local economy and culture. Study findings focus upon the following policy issues: the need for a better understanding and recognition of the significant role of women in field agriculture and postharvest processing, creation of further nontraditional employment and business opportunities for poor women in rural areas, and consciousness-raising and the challenge of cultural barriers affecting women. Rural women, especially those in need of employment and involved in market-oriented production, should be the target of mainstream development activities in future planning.
A contrast of mothering behaviors in women from Korea and the United States.
In both the US and Korea, culture heavily influences a mother's behavior toward her infant. The author explores the effects of differences between these two cultures upon mothering in each country. Her findings and recommendations are based upon the author's work and experiences in both cultures. Sections discuss cultural beliefs, values, and practices; family function and structure; traditional Korean mothering behaviors; and implications for the practice of American nurses who provide perinatal care for Korean immigrant women. The author explains how American culture encourages independent behavior from infants, while Korean culture leads mothers to perceive infants as dependent and passive. American mothering is individually fashioned and relies upon the expertise of health care providers, while mothering in Korea reflects the highly ritualistic nature of the culture. The nature of mothering in Korea is determined more by societal rules than by individual design, and professional advice is less sought for guidance than is folklore information. American mothers tend to rear their infants in a nuclear family setting, while Korean mothers rear their infants in an extended family or at least in a highly social environment.
Student opinions of condom distribution at a Denver, Colorado, high school.
Students at a high school in urban Denver, Colorado, in October 1992 initiated and helped conduct a school-wide survey on student opinions about making condoms available in their school. Students simultaneously and anonymously completed the survey. Only 994 of the school's 1330 enrolled students, however, had the opportunity to complete the survey due to the absenteeism of students, attendance at physical education class during the block, or the teacher's failure to administer the survey. 336 enrolled students simply did not receive a survey. Moreover, only 931 completed surveys figure in the final analysis since 63 were excluded due to illegibility or ambiguities in the responses. A larger percentage of students in the lower grades responded to the survey, corresponding to increased attrition as students advance in school and a higher absenteeism rate for upperclassmen. 85% of the surveyed students replied that condoms should be distributed in their school. 76% noted that making condoms more accessible will neither increase nor decrease the frequency of sexual activity among teens. Proponents of in-school condom distribution pointed to the ability of condom use to prevent the spread of AIDS and other STDs, and unwanted pregnancy as the most important reasons to support condom distribution, followed by the belief that increased condom availability will prompt more students to use them when having sexual intercourse. The embarrassment and financial cost of having to buy condoms were also cited by 24% and 17% of students, respectively, as reasons for making condoms available in school. 45% of students feel that condoms should be distributed from machines in bathrooms, 42% from the school nurse, 8% from other students, and 5% from teachers. 61% of condom distribution opponents were female. 59% of the opponents, while claiming to not be against condoms, believe that school is just not appropriate point of distribution for them. Other opponents believe that condom distribution will stimulate the incidence of sexual activity, that individuals should not have sex until they are older or married, that distributing condoms is religiously wrong, that condom distribution would be wasteful since some people do not use condoms every time they have intercourse, and that it would be embarrassing to procure condoms at school. Students in lower grades tended to be more conservative with their beliefs.
Assessment of home management of fever among children in the Ashanti region of Ghana [letter]
The authors studied how caregivers managed fever in the home in children before seeking help at a health clinic in the Ashanti Region of Ghana. The knowledge of caregivers on malaria was also assessed among individuals bringing children for assessment and treatment of fever during April-May 1989 to five outpatient clinics in the Ejisu-Juaben-Bosomtwe and Kumasi districts of the region. Study participants responded to questions about their child's fever duration, treatment before clinic attendance, and malaria knowledge. Appropriate home management of fever in a child was considered to include acetaminophen and, if fever persisted, prompt seeking of care at the nearest health facility. 95 of 100 caregivers brought their children for assessment within one week of fever commencement, with 68% of children having been administered acetaminophen at home. 78% of children had been sponged with tepid water, an approach learned from health personnel in 81% of cases. Sponging with tepid water may be useful if the patient has been given acetaminophen. Otherwise, the child's temperature often returns to its previous level following the cessation of sponging. This study could not ascertain whether acetaminophen was administered in appropriate dosages and frequencies or with appropriate sponging. Chloroquine and antibiotics were administered in 27% and 12% of the 59 children who received drugs at home, respectively, while two of the 52 children with diarrhea accompanying their fever were administered oral rehydration solution at home. The recommended total dose of chloroquine to cure malaria in Ghana is 25 mg/kg of body weight. Home treatment regimes, however, often fall well below that desired level and is one of the major factors promoting the selection of chloroquine-resistant strains of Plasmodium in Ghana. Education seems central to improving the means by which fever is managed and malarial morbidity is prevented in children in Ghana.
Neonatal sepsis in Dubai, United Arab Emirates.
Neonatal septicemia remains one of the most important causes of mortality among neonates. In recent decades, there has been a change in the pattern of organisms which cause neonatal septicemia. Patterns also vary by geographical area. The authors analyzed case records of all neonates admitted to the neonatal unit of Al Wasl Hospital, Dubai, United Arab Emirates, over the period May 1987-April 1992 in their investigation of the pattern of organisms causing neonatal sepsis and/or meningitis. 106 neonates had confirmed sepsis. 23% had group B streptococci, 17% E. coli, 17% Staphylococcus epidermidis, and 16% Klebsiella pneumoniae. Group B streptococci presented as the most common organisms in the very early and early onset of sepsis, while Klebsiella pneumoniae, Staphylococcus epidermidis, and Candida were the most common causative agents of sepsis between 7 and 30 days. Pseudomonas aeruginosa and Klebsiella pneumoniae had the highest mortality at 71% and 59%, respectively. Lowest mortality was observed in group B streptococcus sepsis. Prematurity, low birth weight, and nosocomial sepsis were high risk factors associated with fatal outcome.
Bacterial meningitis remains an important cause of death and/or persistent nervous system damage among children living in developing countries. The authors report their findings from an evaluation of the effectiveness of steroids in reducing mortality and neurologic sequelae in children affected by bacterial meningitis in Mozambique. 70 children with bacterial meningitis were randomized to receive either conventional antibiotic therapy or antibiotic therapy plus dexamethasone. On admission to the hospital, there was no statistically significant clinical and laboratory difference between the two groups. Mortality within 24 hours was significantly reduced when dexamethasone was used. Furthermore, total mortality among steroid treated patients declined, fewer serious neurologic abnormalities were observed among survivors in the steroid treated patients, and fever and CSF abnormalities disappeared more rapidly in patients receiving dexamethasone. Study findings therefore demonstrate the beneficial effect of adjunctive steroid therapy in children with bacterial meningitis, even in areas where the case-fatality rate of the disease remains very high.
Baby check in India: assessing the severity of illness in babies in a Calcutta out-patient clinic.
Baby Check is a scoring system which assesses the severity of acute systemic illness in babies. It involves the recognition of a combination of seven symptoms and twelve signs derived from the ordinal regression analysis of symptoms and signs among 1007 babies, 0-6 months old, studied at home or in hospital in Melbourne, Australia, and Cambridge, UK. The higher a baby's score, the more serious the illness is likely to be. This study was designed to determine whether Baby Check would be useful for assessing a baby's acute illness in West Bengal, India. 100 babies aged 0-12 months in outpatient clinics at the Child in Need Institute, Calcutta, India, were scored using Baby Check and then assessed by a physician who had no knowledge of the score. Researchers encountered several difficulties using Baby Check in Calcutta. Many babies seen had chronic conditions such as malnutrition, as well as acute illness, and there were problems translating some of the checks. Furthermore, there is no reference standard in the study design against which to test physicians' grading of illness or the Baby Check score. Baby Check did, however, detect the majority of ill babies in the study. It follows that the use of Baby Check may have important implications for decreasing levels of infant mortality and morbidity in many developing countries.
Epidemiology of cholera in Delhi -- 1992.
Vibrio cholerae O1 biotype E1 Tor was first identified in India in 1965, after which cholera became endemic in the country. In early 1993, however, V. cholerae Non O1 became a major cause of epidemic in Delhi and other parts of India. The authors describe the epidemiology of cholera in Delhi during 1992, when it was highly epidemic. 1075 of 2783 stool samples from patients admitted to the Infectious Diseases Hospital, Delhi, during 1992 were positive for V. cholerae O1 biotype E1 Tor. The first isolation was made on April 3 and the last on December 14, although 87% of isolations occurred during May-September, summer and monsoon months. Detailed epidemiological information was collected for 198 cases of diarrhea, of which 103 were confirmed cases of cholera. Half of these cases occurred in children younger than age 10 years. Adult females, especially housewives, comprised the other major group of individuals affected by cholera. Most cholera cases occurred in those who were illiterate or educated up to primary level. Important risk factors were contact with a person having similar illness, storage of water in wide-mouthed containers, use of glass or mug to draw water from containers, absence of sanitary latrines, and the habit of washing hands with water alone after defecation and before cooking and eating food. Approximately 30% of cases had access to a piped water supply which was found safe in Delhi during 1992. These findings suggest that hygienic practices were more important than contaminated water sources for the transmission of cholera in Delhi during 1992.
On the needless hounding of a safe contraceptive.
Norplant is a contraceptive device comprised of six matchstick-sized silicone tubes which are placed under the skin of a woman's upper arm. The tubes contain levonorgestrel, a synthetic hormone, which diffuses slowly into the bloodstream, protecting against pregnancy for five years. The tubes are removed either at the end of the five-year period or earlier if the woman desires to become pregnant. Norplant was approved first for use in Finland in 1983 and has now been introduced in more than forty other countries. The US Food and Drug Administration approved it in 1990, and since then, approximately one million American women have used the device. In the first three years during which Norplant was available in the US, less than twenty lawsuits were filed against Norplant's US makers, Wyeth-Ayerst Laboratories. Over the past twelve months, however, 235 lawsuits have been filed, including fifty class-action suits. This litigation and the resulting press attention have caused a dramatic slump in product sales. Norplant is a safe and effective contraceptive method. The recent legal assault against Norplant is simply driven by the desire of lawyers and plaintiffs to be awarded large financial settlements in a court decision by Norplant's manufacturer. Allegations have been leveled against the levonorgestrel used in Norplant, the silicone content of the device's tubes, and the positioning of the tubes. Levonorgestrel has been used in formulations of the oral pill for many years. The slow, steady manner in which it is delivered through Norplant will result in fewer side effects than that experienced from hormonal intake through the use of Depo-Provera and the oral pill. Silicone, used in almost all prosthetic medical devices, is the safest and most versatile biomedical material known. There is no evidence that silicone causes autoimmune disorders. Even so, the tubes in Norplant contain 100 times less silicone than breast implants, and rather than being made of gel, they are hard and thus less likely to be absorbed into surrounding flesh. Finally, Wyeth-Ayerst recommends that doctors be trained in the insertion and removal of Norplant, and offers such a training course. Some doctors, however, proceed without training. Faulty insertion and problematic removal are practitioner-related problems, and not the fault of the product manufacturer. Unwarranted litigation against Norplant may have a devastating impact upon the use of the device and the development and marketing of other forms of contraception.
Oral contraceptive use induces changes in serum lipid, carbohydrate, and hemostasis variables. Progestin-dominant oral contraceptives are associated with increased levels of serum low-density lipoprotein cholesterol and triglycerides, and lower levels of high-density lipoprotein cholesterol. High levels of lipoprotein (a) have been associated with coronary heart disease and other vascular diseases in most cohorts studied. Unfavorable lipid effects are, however, less pronounced with newer, more selective progestins, such as desogestrel. The authors studied the influence of oral contraceptive use upon lipoprotein (a) levels in a cohort of 559 women aged 18, 21, and 24 years. Lipoprotein (a) levels were determined by radioimmunoassay. 40% of the women used oral contraceptives. The use of desogestrel-containing monophasic preparations was associated with lower levels of lipoprotein (a) compared to the use of triphasic/levonorgestrel formulations or to non-users. This effect was observed only in non-smoking women. Oral contraceptive users had higher levels of serum apolipoprotein B, HDL(3)-cholesterol, apolipoprotein A-1, triglycerides, and systolic blood pressure, and lower serum lecithin:cholesterol acyltransferase activity. Smoking and exercise did not significantly influence lipoprotein levels.
Considerable attention is being given to new ways of assessing vitamin A status in humans. Twelve experts in various methodologies describe current dietary, physiological, biochemical, histological, and clinical procedures as well as promising developments. The physiological basis of the method, a description of the procedure, a discussion of its advantages and limitations, and its application in at least one instance are summarized. This publication is intended as an introduction to various assessment techniques and not as a comprehensive description of procedures. It will nonetheless help investigators and program planners select assessment methodologies best suited to their specific situations and available resources. Recent references are given for each procedure.
Implementation of child spacing programme within PHC.
It is important when using a community-based approach to implement family planning/child spacing activities to determine community needs, which services are already available, and how they are appreciated. The Bagamoyo Family Health Project surveyed 2000 men and women from different villages in Bagamoyo District, Tanzania, in 1987 on their relevant knowledge, attitude, and practices. Half of the men and women thought 5-8 children to be the ideal. 66% of men and 75% of women knew about child spacing and thought positively of it, but contraception is seldom discussed between sex partners. Approximately 33% of men and women reported using contraception, with men usually reporting abstinence and withdrawal or other traditional methods, and women reporting use of both modern and traditional methods. Only 2% of the women practiced prolonged breastfeeding. The author explains the need to simply accept that the rural population of Bagamoyo District prefers large families, women even more so than men. A campaign is nonetheless warranted to create awareness among couples, especially husbands, about the need to take responsibility for maternal and child health. Village health workers will be trained in family planning. Family planning services in the district are generally limited to the distribution of oral contraceptive pills, with all but one of the 35 health services facilities in the district stocking contraceptive pills. Neither injectable contraceptives nor IUDs are available in the district. There is a very small supply of condoms in 9 of 28 facilities; demand for condoms is extremely low. The author also stresses that family planning service providers need better training.
Family planning / child spacing objectives and activities.
Maternal and child health care services must include family planning. The government of Tanzania therefore officially recognized the importance of family planning/child spacing as part of its development effort, directing in 1974 that child spacing services be provided as an integral part of maternal and child health services in all health facilities. A survey conducted by the Ministry of Health in 1982, however, determined that the quality of child spacing services was less than what was expected, significantly less than 10% of women of child-bearing age were using the services, the training of personnel in those services was inadequate, and personnel were not motivated to promote family planning/child spacing services. The author describes training activities, seminars and meetings, and data collection, monitoring, and evaluation conducted to improve child spacing in Tanzania. Measures to strengthen administrative capacity and the availability of equipment and commodity supplies are also discussed.
Measuring the impact of family planning services in Tanzania.
This paper presents some basic family planning service statistics for Tanzania with the goal of providing baseline data against which future impact assessment may be measured. The paper also presents some methodological considerations for measuring the impact of family planning services. Sections present the population profile of Tanzania, basic family planning service statistics, the potential impact of family planning upon infant, child, and maternal mortality, and general considerations with regard to methods for measuring the impact of family planning programs upon fertility. Tables provide data on age-specific and total fertility for 1985 and projections for 2000; MCH clinics, MCH aides, and percent of MCH clinics providing family planning services in 1985; new contraceptive acceptors by method and region in 1985; and contraceptive prevalence for 1985 and annual projections through 2000.
Female circumcision: the view from Sudan. Interview [with Ikhlas Nouh Osman].
Female circumcision involves removing either all or part of the clitoris, labia minora, and/or labia majora. The practice is therefore increasingly being described as female genital mutilation. More than 90% of women in Sudan have undergone female genital mutilation. Pharonic circumcision is the most prevalent in Sudan. This form of mutilation involves the full removal of the clitoris and the labia. The two sides of the wound are then sewn together, leaving a small hole through which urine and menstrual blood may pass. Female genital mutilation occurs because women believe that the resultant narrow vaginal entrance will give pleasure to a future husband, due to tradition, uncircumcised women have great difficulty finding a spouse, and from the belief that the practice is mentioned in Islam. Koranic law is widely respected and followed in the Islamic areas of Sudan. Contrary to the belief of women that female circumcision keeps the vagina very clean, considerable health and psychological problems may result following the operation and throughout the woman's life. An activist against female genital mutilation describes her experience undergoing the operation, the trauma of first penile penetration with her husband, giving birth, and how women have their genital orifice restitched after delivery to the size before penetration. Nongovernmental organization efforts in Sudan against female circumcision are described.
Counter-urbanization in the United States: facts of the 1980s and theories of the 1970s.
Confused by the trends in counter-urbanization in the US during the 1980s, the authors are nonetheless unprepared to assume that the net migration trends during the decade suggest a return to the forms of social organization which generated net outmigration in the 1950s and 1960s. The net outmigration trends observed during the 1980s have a different set of explanations than those used previously, but the new set of explanations is more likely to be a new composite of existing explanations than it is to consist of a set of entirely new factors. The authors ultimately conclude that their critique of definitions and explanations of the turnaround is warranted regardless of subsequent empirical trends in migration between metropolitan and nonmetropolitan places, and that some sociodemographic examination of economic explanations of migration is necessary. The events of the 1980s make the values-change arguments of the 1970s more difficult to support without either arguing that residential preferences are so transitory as to be of questionable utility in explaining migration, or situating those arguments more fully in the dominant value theories of social psychology as well as in changing economic conditions. The equilibrium-convergence theory developed in response to the changes in migration and growth rates of the 1970s seems most able of all explicitly other-than-economic explanations to account for the new patterns observed in the 1980s. That theory did not, however, explicitly forecast that those changes would occur. Finally, the recession demonstrates how much more closely small towns are now integrated with and dependent upon national and international systems.
The Third Preparatory Committee Meeting for the International Conference on Population and Development (ICPD), PrepCom III, was held at UN headquarters in New York on April 4-22, 1994. It was the last big preparatory meeting leading to the ICPD to be held in Cairo, Egypt, in September 1994. The author attended the second week of meetings as the official delegate of the Institute for Social Studies and Action. Debates mostly focused upon reproductive health and rights, sexual health and rights, family planning, contraception, condom use, fertility regulation, pregnancy termination, and safe motherhood. The Vatican and its allies' preoccupation with discussing language which may imply abortion caused sustainable development, population, consumption patterns, internal and international migration, economic strategies, and budgetary allocations to be discussed less extensively than they should have been. The author describes points of controversy, the power of women at the meetings, and afterthoughts on the meetings.
Females in Indian society are expected to serve, while males are meant to be served. To be born female in India is like being born less than human. Infanticide, especially of females, is rampant, with 40,000 known cases of female feticide in Bombay alone in 1984. Relative to boys, girls in India have a higher level of mortality, are less likely to be breast fed, are more widely and seriously malnourished, undereducated, sexually exploited, and otherwise abused. Indeed, female child abuse is common in Indian families. A study was launched in November 1985 in nine slums in the eastern part of Nagpur City with the following objectives: to determine the extent and nature of female child abuse in the home, to learn the personality traits and social background of girls and their abusive parents, to determine whether the parents could respond to treatment, to determine whether such families can remain intact without further risk to the girls, and to outline ways in which battered girls can be helped. 5208 households were identified in which girl child abuses had been occurring. 680 households and 720 girls whose both parents were alive were randomly selected and followed through interviews and observation over the course of five years. Lack of fear of punishment, intramarital conflict and tension, parental psychological maladjustments and serious behavioral problems, parental background as abused children, overcrowding, poverty, and forced motherhood were positively associated with the likelihood that parents abused their children.
The struggle for survival of the girl child.
Human rights efforts in India in recent years have identified the female child as a priority target, focusing upon her rights and status. Attention is also focused upon the need for her integration into the social and national mainstream. Female children need help from adults to develop into adults themselves. However, while female children have rights derived from their status as dependent, young individuals, female children's rights are not the same as their needs. Moreover, while female children's needs may be known, they are not necessarily assured as their rights. The authors discuss the rights of female children, abuse of the female child, literacy and education, school dropouts, and female child labor. The National Workshop of Awareness Generation on the Girl Child action plan to create awareness on issues relating to female children is presented. Concerted effort is needed to reduce the level of marginalization of female children in India.
Gender, class and culture: situation of girl children in India.
Identifying female children as a special group with specific problems is a relatively recent phenomenon. The existing database remains, however, too limited to provide comprehensive, useful data on female child as a distinct population subgroup. Longitudinal studies covering the lifespan of girl children are rare. The author therefore notes that describing some of the major features related to female children may be the best available option, and proposes looking at the social situation of girl children in terms of the domestic, occupational, and educational spheres. These spheres are discussed. Although female children are discriminated against in both higher and lower socioeconomic strata, girls in lower strata households will be especially deprived of opportunity.
Human rights of the girl child.
Sons in India are preferred over daughters because of traditional beliefs that unlike girls, boys will remain with the family even after marriage, only boys carry the family line, only a boy has the power to offer Shraddha to his ancestors for their spiritual benefits, and sons receive dowries upon marriage. Girls from birth in India are therefore treated by parents and society overall as problem children. The author discusses human rights and the female child, and legislative measures to protect those rights. The author concludes that female adolescents should be allowed to pursue their education, especially in order to develop individual self-image. The burden of child care and domestic work upon females should be reduced through the provision of supportive services and facilities, and special education programs should be targeted to the female child which include not only health and nutrition education, but also vocational training. The status of and opportunity for female children will, however, be improved only by enhancing public consciousness and by building a national, political consensus on the rights and development of a child.
Amniocentesis and the future of the girl child.
Concerned about the widespread abuse of sex test facilities in aborting female fetuses, the government of Maharashtra passed the Maharashtra Regulation of Prenatal Diagnostic Technique Act in 1988. Many doctors in India perform amniocentesis at 14-16 weeks pregnancy when sex can be differentiated and other parts of the body are developed. The Maharashtra Act allows prenatal testing on the following grounds: chromosomal abnormalities, genetic metabolic diseases, hemoglobinopathies, sex-linked genetic diseases, congenital abnormalities, and other abnormalities or diseases as may be declared by the appropriate authority. Medical practitioners can be prosecuted, fined, and imprisoned for one to three years if they disclose the sex of the fetus and perform an abortion with the knowledge that it is a female fetus. Anyone owning centers, laboratories or clinics must be registered with the appropriate state authority if he wants to conduct prenatal tests. Furthermore, it is prohibited to advertise any facility or test available for determining the sex of a fetus. There are, however, many fallacies and loopholes in the Maharashtra Act which allow amniocentesis to be perpetuated and abortions performed solely because a fetus is female. These loopholes are discussed followed by consideration of the Indian sociocultural context and the debate over abortion in the US.
Girl child: victim of gender bias.
Gender bias is rooted in the family, with female children accepting the very values which impede their development. Discrimination against girls stems from this deep-rooted bias leading to the denial of basic services necessary for the survival, welfare, growth, and development of girls. This denial of services and opportunity results in higher levels of infant and maternal mortality, a lower sex ratio, and compromised nutritional status among girls. Lower levels of school enrollment and higher school dropout rates among girls result in low literacy rates among women. The author discusses the status of female children in other societies, female infanticide, traditional roles, social development, health, education, recreation, social values, gender bias, resocialization, and measures needed to improve the status of female children.
Socio-religious status of girl child in India.
Females in India are considered to be simply the bearers of children. As such, many women are killed as fetuses, infants, children, or young wives. If not murdered outright, females in India suffer from lack of health care, substandard nutrition, lack of access to education, early marriage, too high fertility, and rape. The 1981 census of India found there to be only 933 women for every 1000 men. All religions are male dominated. Religion is the most important factor of oppression in India. Religious practices tend to be followed meticulously by women. In the name of religion, however, women are deprived of many things. The religious festivals, myths, and legends all reinforce the image of the woman whose salvation lies in suffering in silence. In Hindu religion, it is the women who usually observe fast for the ostensible purpose of receiving abundant grace from God for their husbands. At home, women are the teachers of the faith for their children. Unless there is a conscious and successful struggle against oppression and violence against women in the name of religion, custom, tradition, and convention, no uniform civil code will result in India which incorporates the principles of equality, justice, and human dignity.
The status and education of the girl child.
The majority of the almost 130 million girls in India younger than age 20 years are deprived of their right to education, employment, health care, and food. While there have been marginal changes in the life of female children over the years, their sociocultural, religious, and economic conditions remain like that of the preceding generation. Girls remain voiceless and marginal, suffering from the same disabilities as their mothers and grandmothers. The author stresses, however, that the condition of entire families must be addressed and changed in order to garner better treatment for girls. The Indian sociocultural heritage and the historical perspective, women and the Indian Constitution, the disabilities of Indian women, legislative reforms, programs for woman and child development, the educational development of girls and women, and educational problems of the girl child and the strategy for solving them are discussed.
The author recounts her memories of growing up female in a Catholic Indian household. She remembers that dowries used to be given to girls as assets upon which to depend in the event of misfortune. The dowry was put in the girl's name and the girl was advised to never let her husband gain control of it. A dowry could also be in the form of a good education and the consequent ability to be economically independent. Parents tended to divide their possessions equally between their boys and girls. Furthermore, girls were not treated as second class citizens in the home, although boys were expected more so than girls to pursue an education. Women felt neither oppressed nor discriminated against. The author wonders whether her less than oppressive upbringing reflects life in a Catholic household or being raised in historical circumstances different from those which currently prevail. The author was pleasantly surprised to find that none of the forty Catholic college girls aged 16-21 years, representing all northern Catholic communities, with whom she had a group discussion mentioned dowry. It has been their experience that parents in Catholic families welcome the birth of both boys and girls, but prefer to not have only female children. Both boys and girls tend to be educated at great cost by the largely middle class Catholic families. Girls are not free to venture out at all times without an escort, girls are expected to be sedate and boys to be naughty, and most parents do not allow their daughters to take jobs away from home. The author believes that these limitations are placed upon girls' and women's freedom not so much due to tradition and conservatism, but out of the need to protect women in a truly dangerous society. Catholicism does seem to make a difference in how girls and women are treated in the Indian household.
It is tradition in India to neglect and be indifferent toward female children. They are considered to be a financial burden and less attention is given to girls' health, education, and upbringing. Tribal societies in India, however, have maintained some characteristics of matrilinealism. The status of women and girls must therefore be viewed in that context. The tribal female child is treated almost as an equal to the male child. Each new female born is a potential mother; the mother earth and the female child command equal respect in the tribe. Work in the house and on the farms, female children are assets to the tribal household. Upon marriage, the bride-groom is expected to pay a bride-price to the parents to compensate for their loss. The authors describe the attitude of tribes toward female children, the status of female children in tribal society, and tribal girls and education. They note in closing that women in tribal society still face many health hazards due to malnutrition and disease. The social position of an average female child has therefore always been more promising.
Among urban slum dwellers, poverty, large families, the rising cost of essential commodities, social attitudes toward women, and the economic dependence and poverty of women lead female children aged 4-12 years to earn money in the streets as a contribution to family income. Poor parents typically have no compunction about sending their prepubescent daughters to work in the street as beggars, rag pickers, prostitutes, domestic helpers, train compartment cleaners, and newspaper vendors. The girls on the street are also often either orphans or belong to a one-parent family, usually a homeless mother. Female adolescents over age 12 are not typically seen on the street. The uncontrolled growth of slums and pavement dwellers, and the unstemmed migration of families from villages will increase the number of girls already on the street in India.
Some victimization of female children in Indian society.
The criminal victimization of women and female children has been prevalent throughout the history of mankind. This victimization is a basic social problem in India which occurs in every community affecting female children and adolescents of all religious beliefs, castes, socioeconomic classes, and geographic regions. The phenomenon is reportedly more common in communities in which the status of women is significantly inferior to that of men. Female children have been the subject of various forms of abuse, discrimination, and exploitation at all stages, adversely affecting their physical, social, and psychological development. They are treated as inferior to the male child, deprived of food, education, and other important developmental needs. This paper considers victimization in the family, victimization related to marriage, and sexual victimization.
Maternal and girl child care in India.
Maternal and child care should be given priority in any plan of development because children are the future of all nations and communities, female children are particularly vulnerable and prone to disease, mothers and children comprise the majority of the population, and most diseases which cause morbidity and mortality in childhood and those associated with pregnancy are preventable. Mothers and children comprise 85% of India's population. This paper reviews provisions made for rural India in national five-year plans with regard to maternal and child health (MCH), the organizational structure of the services, financial outlay for MCH, the strengths and weaknesses of the program, program achievements, the impact upon the rural population, and plans for the future. MCH and other health services have successfully lowered maternal and infant mortality rates, but MCH services have recently become mere agencies of the family planning program. Furthermore, the quality of medical services in rural areas suffers from a lack of adequate personnel supervision.
Girl child with mental handicap.
Mental handicap, as opposed to mental illness, has been recognized by professionals and policy planners in only the past 10-20 years. Before then, mental handicap was perceived to be a psychiatric problem and handled accordingly. Mentally-handicapped persons are increasingly being trained and mainstreamed into society. The general trend in India, however, seems to be to neglect the care of females with mental handicaps. A mentally-handicapped female child in India suffers discrimination for both being born female and being born handicapped. Urgent and comprehensive efforts should be taken to make rehabilitative services equally available to both male and female children. Furthermore, education and public awareness on this issue will encourage self-awareness, informed decision-making, and appropriate action. The author discusses the rehabilitation scenario, prevalence of the problem, access to facilities, parents' attitudes, case studies, problems in care, the profile of a mentally handicapped female child, and normalization.
Juvenile Justice Act 1986 and girl child.
Juvenile Courts and Juvenile Welfare Boards were established in India under the Juvenile Justice Act of 1986 to rule in cases involving neglected orphans, victimized destitutes, and children who have committed offenses. The ages of majority for boys and girls are set in the act at 16 years old and 18 years old, respectively. Children cannot be sent to prison or jail. Moreover, the justice act stipulates that Juvenile Court and Juvenile Welfare Board cases must be settled within 2-3 months. An appointed advisory board will counsel the government and supervise operations. The Juvenile Justice Act of 1986 should be heralded as an important step toward improving the lives of children in India. The author does, however, note that some provision should have been made mandating municipalities, corporations, and other local bodies to share in the expense of managing children covered by the act.
In India, female children are discriminated against from birth and live lives of deprivation, ill health, and exploitation because of long-standing tradition, social customs, and prejudices. The media in India reinforces sex stereotypes and glorifies motherhood and subservient wifehood, making it difficult for women to break out of those prescribed roles, norms, and behavior patterns. The female child receives little attention in current-day media, although a few programs have cast female children in the central role. The female child is nonetheless inappropriately portrayed in the Indian media. The media in India includes the government controlled radio and television, commercial films, English language press, regional magazines and newspapers, and advertising. In the interest of helping the plight of female children in India, the media urgently needs to champion female children's right and need to receive an equal share of nutrition and health benefits, foster opposition to female infanticide and foeticide, and raise awareness among men of the need to curb their social discrimination and physical abuse of women. The author suggests potential strategies for change.
Bengalee girls of Calcutta at high-school leaving stage: a study on their social world perception.
The authors investigated the characteristics of the modal peculiarities in the behavior-adjustment of Bengalee girls in Calcutta in an effort to understand their views, ideas, attitudes, and problems with regard to their perceived world as they attempt to keep up with the sociocultural demands of a quickly changing society. Study findings are presented. 1200 Bengalee girl students from schools across Calcutta were involved in the study. The authors believe that their findings will help enlighten not only guardians and teachers, but young girls as well. The introduction of legislation to advance women's status will be of no benefit until girls are made aware of the demands of social life, limitations set by gender stereotypes within the community, and the constitutional rights and privileges to which they have access.
The birth of a female child remains unwelcome in India and female children in rural areas are denied food, education, development, and their basic human rights. The author is a journalist who has worked with many female children over the course of her career. 86% of 300 female children aged 5-14 years studied of middle class, upper middle class, and elite status reported that they were not discriminated against at all, neither in the home, school, nor society. They had the same opportunities and treatment as their brothers or boys of the same age group belonging to their socioeconomic level. Their small, single unit families welcomed the birth of a female child. Girls, especially the urban, educated ones, are given the same chances as their male counterparts and have almost all fields open to them. Affluence, education, broadmindedness, and modernity, however, go only so far, for at puberty, parents begin to pressure their daughters to conform to society's expectations of young ladies. These young girls who have spent their entire lives treated as equals to boys subsequently rebel against their parents.
Adoption of the girl child in India.
There is substantial social and cultural stigma in India against bearing a child outside of wedlock. Female children born outside of wedlock in India are therefore abandoned by their mothers shortly after birth. Surveys conducted in Maharashtra, Gujarat, and Goa indicate that almost 95% of the children abandoned are abandoned because they were born out of wedlock. Without national figures, however, one can only guess the magnitude of the problem. It is nonetheless clear that several thousand children are abandoned annually in India. Some of these children are adopted by Indian families, with the overwhelming majority being families who are childless due to medical reasons. Overall, sons are far more desired than daughters due to their ability to carry on the family name, support their parents in old age, and perform the last rites. Boys therefore find Indian homes unless they have some physical or mental handicap or serious medical illness. The proportion of girls being accepted in adoption has increased over the last decade, but many girls of dark complexion are still rejected by prospective adoptive parents. Indians settled abroad more readily accept girls. In North India, almost all applicants for adoption apply for boys, a good number of applications for girls are received in South India, and the desire for girls is somewhere between the two extremes in Central India. Efforts to encourage Indian families to adopt girls will make slow progress until the status of women and girls in India improves.
The Family Planning Operations Research and Training (FPORT) Program.
Part of a five-year effort started in 1990 covering Bangladesh, Egypt, India, Indonesia, Nepal, and the Philippines, the Family Planning Operations Research and Training (FPORT) Program seeks to build upon lessons learned from earlier operations research programs and to expand the availability of technical assistance and training for family planning programs. The FPORT program is part of the Population Council's Asia and Near East Operations Research and Technical Assistance Project. This paper presents background information on the program, highlighting past accomplishments and describing its current status and plans for the future. The FPORT program began in the Philippines in 1992. It has since generally emphasized consultations between researchers and program managers, LGU representation, and program manipulable factors. One major output of program activities is a group of study proposals which were to result in five operations research studies dealing with the family planning dropout problem, training courses of family planning providers, an industry-based family planning program, and the performance of community-based health and family planning workers.
Remarks of the family planning program manager.
Family planning coordinators thought they were doing a fine job implementing the family planning program in Bukidnon, but eventually realized that they had severe operational problems. One major problem was the extent of program dropouts. The Population Council and the RIMCU helped the region study its problem. Study results have since pushed program managers to strengthen and redirect their strategies in implementing the family planning program. Family planning clinical standards and the manual are now used to guide family planning service providers' daily clinic operations, areas with little or no access to family planning services have been prioritized, and a contraceptives logistics system is in place in the region. Furthermore, community-based workers have been mobilized to help in the follow-up and recruitment of clients; the importance of informing clients about side effects, complications, method advantages and disadvantages, and how to counteract misconceptions is stressed during provider training; and on-the-job training is provided. Existing strategies will complement other ideas in the future such as institutionalizing the Circle of SMART, organizations of women acceptors who will be mobilized as program advocates.
Remarks of the family planning program manager.
A study found that provincial trainers need to provide technical assistance in terms of monitoring trainees during the practicum phase and to seek administrative support from the local government units in upgrading the facilities of the preceptor areas. Action was taken on the basis of these study findings. Efforts are now made to ensure that participants are committed to both family planning and implementing the program, while the practicum site and the training venue have been changed. Training schedules have been synchronized with other activities such that provincial trainers who also coordinate other health programs can follow-up or monitor the training and trainees. Improvements with regard to the examination room and the preceptor areas were noticed once support was sought from local government units. Additional plans exists, but require action from the central office or Family Planning Service.
The role of operations research in the Philippines family planning program.
Although operations research has yet to be fully institutionalized in the Philippines Department of Health, progress has been made toward that goal. A number of operations research studies have been conducted and the results are being used to improve service delivery. The author notes that a fully institutionalized operations research program will have to include a strong regional emphasis, and hopes that conference participants will consider the many questions and issues which will require inputs from a full-fledged operations research program. A research agenda should be prepared. The author finally mentions some program-related questions such as the DMPA Reintroduction project and results of the Philippine Demographic and Health Survey into which it is hoped the Family Planning Operations Research and Training (FPORT) Program can explore.
The author discusses the operations research adopted in the diagnostic study of the implementation of the Department of Health training in region II, Cordillera. The paper on that operations research focuses upon the basic comprehensive family planning course for physicians, nurses, and midwives using the client-centered quality of care framework in family planning operations. Emphasis is given to the training process to increase the likelihood of basing program interventions upon research findings. The author then considers questions evolving from results of a study on factors affecting family planning dropout rates in Bukidnon. That paper considers the level of accuracy in Department of Health records, perceptions of family planning acceptors in local clinics and the services offered, reasons given for termination of use, and factors associated with the termination of use.
Remarks of the family planning program manager.
Operational problems were identified during operational research. Some problems were solved, however, as a result of meetings with the workers who are the beneficiaries of the project. First, researchers were able to learn what beneficiaries wanted and whether management is providing the kind of health package they desire. During the process, management warmed to the suggestion of providing an Ob-Gyne for the workers. Second, the research identified a shortage of contraceptives in some companies for which the local government code was blamed. The shortage was actually the result of some companies failing to have their names in the master list and the distribution team consequently overlooking them for supply distribution. The shortage of contraceptive supplies was eventually solved. Some of the ten companies in Mindanao were included in the study. Their inclusion gave program managers a better understanding of the culture in Mindanao and helped allow the fine tuning of IEC campaign strategies there. The author notes that this operations research finally documented what the people have really been doing and gave managers better insight to apply to their next project.
The author discusses Department of Health Training. Research more so emphasizes the training process than the outcome which the author finds somewhat ambiguous. If emphasis is placed upon the training process, one should also be equally concerned with the program outcome. He cites an example of a project evaluation. With regard to the Mindanao dropout rates, the providers were approachable, good, and knowledgeable. The outcome was thus good in terms of acceptance, but there was nonetheless a high dropout rate. The fact that Filipinos tend to not say exactly what they mean was probably a crucial factor in the Mindanao dropout rates. With regard to changes in the local government code (LGU) in the case of Bukidnon, the author sees no problem. The LGU is supportive of the family planning program, but other areas should still be explored where there is negative support from LGUs. The author notes the low absentee rate among physician trainees in region II and points out that such a rate may not exist in other regions. Finally, nurses need more support in their training of physicians who simply want a refresher course and who may pose questions simply to test the knowledge of nurse trainers. Additional physician trainers are suggested.
The author discusses the study of Dr. Cabigon and Ms. Magsino concerned about continued company support after PCPD withdraws its programmatic inputs. This study problem suggests establishing a basic comparison between companies still under PCPD support and companies which have completed the cycle. A second comparison would be between companies which continue to support the program after the cessation of PCPD support and those which decide not to offer support. The situation is not, however, so simple. Companies can re-enroll in the program and companies have made varying degrees of commitment. Indeed, no company has either dropped out completely or fully graduated from PCPD support. A wide gradient of program commitment therefore exists. The author notes that the study offers many conclusions, most which seem to be quite useful and sensible, but it would be greatly appreciated were the empirical foundations for the researchers' ideas more clearly presented. The research is discussed and a query made as to whether a sort of mutual dependency is built into the program.
The Vice-President of the PCPD explains the different inputs of her program's three cycles. Clear definitions of what were considered to be necessary ingredients were established in order to increase program sustainability. Most inputs at the start of the program were for having increased contraceptive prevalence rate. Those inputs were essentially training of clinic personnel, training of volunteers, and regular IEC activities to motivate and to inform potential clients in the companies. It was negotiated with company management in the second cycle that they assign a person to coordinate the program. The US Agency for International Development later gave the opportunity to correct mistakes made in the first and second cycles. Liaison officers and company trainers were trained in the third cycle. Moreover, participative planning was instituted involving workers, management representatives, and clinic personnel. These efforts are being made to institutionalize skills within the company so that the skills remain and the program continues after the PCPD pulls out.
The author thinks that the researchers of the diagnostic study on the implementation of the Department of Health (DOH) Health Volunteer Workers Program should be congratulated on their initial work. The focus of the paper, however, is upon the individual characteristics of which can contribute to good performance, to the neglect of other important factors. She is pleased to see that an attempt was made to explore program effort variables such as the supervision of BHWs by midwives and DOH nurses, but disappointed that the variables were excluded in the regression analysis. The author has reservations about the measurement of worker performance. She also feels that while incentives can encourage better worker performance, that approach merits some rethinking. The author's concerns over incentives and worker dissatisfaction underscore the need to incorporate program effort variables into any diagnostic study of program implementation. Finally, the author would have appreciated more discussion on the effects of gender upon worker performance.
The author writes that the spirit of a real devolution does not stop at the local government units, but goes all the way down to the community level. The only way to achieve such a level of devolution is through participation. The concept of the BHWs and maybe the BSPOs should be rethought, especially in light of existing confusion over the role of both volunteer workers and their supervisors. The BHWs are supposed to be the vital link to the community, but most see themselves as assistants in the health centers. In many cases BHWs help midwives or even act as midwives. With regard to the performance indicators used in the study, the author finds it unfair to rate the volunteers in terms of the number of motivations and referrals. It was also unfair to compare the BSPOs and BHWs in terms of performance because the BSPOs are really more focused upon family planning. Some vision needs to be developed for the BHW program twenty years into the future. Finally, individuals holding the positions of both BSPO and BHW should be paid for it, criteria for recruiting volunteers should be rethought, midwives cannot be expected to spend a lot of time supervising, and incentives should come in forms other than cash.
One common theme at the conference is that research should be used to improve program effectiveness and efficiency, as well as to achieve equity, especially in family planning. The other common theme is the need for users and researchers to interact upon pertinent questions which need to be answered. That interaction must be both on the determination of which questions are important and how to proceed in obtaining the answers sought. If there is no interaction, people may have different interpretations of the answers, and the interpretation of the researcher may not be one which is acceptable to the user. The continuing process of research utilization sometimes requires a synthesis of research results as they come. The author summarizes the framework by which the operations research has been conducted; uses that framework to summarize the range of questions which the studies have asked, additional questions which the studies have generated, and other questions from the open forum; and then summarizes study findings.
This Catholic author realized when growing up that the Roman Catholic Church hates women and is opposed to sex and sexual pleasure. She reacts to Fr. Tiong's paper, challenging him on several points. Most debate on abortion centers upon the assumption that the fetus is a complete human being. The Church therefore argues that since the fetus is a human being, abortion is murder. A fetus must be accorded the same rights and protection as the mother. This author counters, however, that a continuum exists from fertilization to maturity to adulthood, and an entity has neither the same form nor value at every stage. She discusses the definition of a person as a separate and distinct entity, fetal implications similar to fetal euthanasia, marriage for procreation and to avoid fornication, the celibacy of Church clergy, Church opposition to divorce, and contraception, and challenges Tiong to explain why the Church is so obsessed with sex and women, and why it has demonized sex throughout history.
Population growth and justice.
The author stresses the importance of linking population issues to matters of justice and injustice. He does so because of his belief that the theological image which best describes the goal of Christian existence is the metaphor of justice as right relationship with the Creator and God's creation. That centrality of justice is rooted in God's love for the world. That is, God's love for all of creation confers an intrinsic value to all of God's creatures and creations. It is that fundamental measure of worth which serves as the foundation of justice. The author explains that God acts on behalf of the poor and oppressed, and that it is because almost half of the world's population is not having their fundamental human needs met that we face the prospect of ecological peril. That ecological jeopardy is grounded in the unjust distribution of wealth and power between the wealthy and poor. Any effort to redress this suffering will demands recognition of the reciprocal relationship between ecological integrity and social justice. Areas in which social reform is needed include the more equitable distribution of land and income, improvement in access to education and employment, the elimination of discrimination based upon race or sex, and substantial improvement in access to affordable housing, food, and health care.
Poverty, population, and the Catholic tradition.
The author agrees with Pope Paul VI and US Catholic bishops that population growth may outstrip available resources; agrees with the Vatican's statement that unwanted migration is prevented by development and that population declines when people are confident that their existing children can survive; agrees with Pope Pius XII that there can be economic, social, and health reasons to limit births and even have child-free marriages; and agrees with the Vatican and others that limiting births will neither solve the world's problems nor substitute for radical redistributional justice. He strongly disagrees, however, with the Vatican position against artificial contraception and induced abortion. Contraception is not only licit, but may often be morally mandatory. Moreover, abortion is a moral option for women in many circumstances. This is common teaching among Catholic and Protestant moral theologians. The author discusses world population growth, Catholic theology, and social justice.
Family planning and Islamic jurisprudence.
The basic text providing guidance on all Islamic matters is the Qur'an and no Muslim can adopt a point of view contrary to that text. The Qur'an does not, however, explicitly address every possible situation which may face a Muslim. For cases not explicitly addressed therein, Muslims refer to the example and sayings of the Prophet Muhammad as their secondary source of guidance. That, too, often leaves some questions open to interpretation and application. At that point, Muslims rely upon the ability to analyze the Qur'an or a situation within the relevant cultural and historical context, and then develop an appropriate interpretation or solution based upon a thorough understanding of Qur'anic principles and the Sunnah. This approach results in a highly flexible jurisprudence rooted in the Qur'anic verse which instructs Muslims who disagree on a matter to seek its resolution by going back to the words of God and his Prophet. This flexibility of Islamic law is not accidental and is an essential part of Qur'anic philosophy. In discussing family planning, one must keep these principles and the basic legal framework in mind. The author discusses family planning in the Islamic tradition, contraception, and abortion. The majority view is that a Muslim family may practice family planning. Whether or not Muslim families should be encouraged by their institutions to practice family planning is, however, a bit more complicated.
An essay: "AIDS and the social body".
The author suggested in her recently published book that anthropological relativism is no longer appropriate to the currently contested political world and argued that cultural anthropology must be ethically grounded. The author in this paper considers the impact of AIDS on political/moral thinking and practice. Her goal is to examine the AIDS crisis from the perspectives of critical and feminist medical anthropology. Her reflections are raw and preliminary, based upon brief and episodic periods of research on AIDS and public policy in Brazil, Cuba, and the US initiated in 1991. The author therefore explains that this paper is not a scientific report, but simply an attempt to identify some problem areas in contemporary social science discourse, public policy, and grassroots activism related to AIDS. Thinking and practice, and theory and action are scrutinized. The text explores AIDS, the state and individual rights; AIDS and sexual citizenship; AIDS and sexuality in Brazil; women and AIDS in Brazil; street kids and AIDS; transvestites; AIDS discourses and AIDS activism; AIDS and the social body in Cuba; the Cuban AIDS program; the AIDS sanatorium; and lessons from Cuba.
The World Summit for Children.
This publication is adapted from the 1990 State of the World's Children Report as a UNICEF contribution to the World Summit for Children to be held at UN headquarters in New York, September 29-30, 1990. The report discusses the principle of first call and outlines the most obvious, specific, and universal opportunities available to protect the lives and normal physical and mental growth of the majority of the world's children in the decade ahead. No attempt is made to comprehensively address the problems facing children today. The hope is that the report will be useful to political leaders, press, and public, as well as the many organizations and individuals around the world who are beginning to mobilize public opinion in support of the summit's aims. Panels considered the summit, the year 2000 and what can be achieved, child survival and population growth, adjustment with a human face, the convention on the rights of the child, education for all by 2000, facts of life, the threat of AIDS to children, debt relief for child survival, action for children and the environment, and a breakthrough in education in Bangladesh.
Natural family planning: point, counterpoint.
The Humanae Vitae posits that periodic abstinence from sexual intercourse enriches one with spiritual values. The discipline required in natural family planning brings peace and serenity to the family, helps solve other problems, helps both spouses to be less selfish, and deepens one's sense of responsibility. Parents acquire the capacity to have a deeper influence in the education of their children, and the children grow up with a sound appraisal of human values. The case study of a married couple, however, suggests that only frustration and resentment will result from periodic abstinence. The couple was advised by their physician to use the basal temperature method combined with the calendar method. Repeated pregnancies and births ensued. The couple eventually had to resort to three-week periods of abstinence from sexual intercourse. While pregnancy has been avoided for three years, the practice of periodic abstinence from sexual intercourse for such long periods is very difficult for both the husband and wife. The relationship has become tense and mutually damaging. The husband argues that the rhythm method transforms sexual intercourse from a spontaneous expression of spiritual and physical love into a simple release of bodily energy. He is obsessed with sex throughout the long period of abstinence, his marital fidelity is at risk, his disposition toward his wife and children is adversely affected, and he must avoid all affection toward his wife for three weeks at a time. The husband sees periodic abstinence as a diabolical, immoral, and deeply unnatural method of fertility control. The wife is sullen and resentful toward her husband when the time for sexual relations finally arrives. She finds it difficult to respond to her husband's advances after the three-week periods during which he reserves his affection. The wife's dreams and unguarded thoughts are invariably sexual. Periodic abstinence and the Roman Catholic Church are discussed.
Kenya national training manual for community based distributors. Draft.
Session summaries and trainers' notes are presented for the training of participants in sexually transmitted diseases (STD) and infertility. The first session will focus upon STDs and last two hours. The plan dictates a fifteen-minute introduction, a 45-minute lecture, fifteen minutes of brainstorming, fifteen minutes of discussion, and a ten-minute closure. At the end of the session, participants will be able to define the term STD, explain the most common signs and symptoms of STDs, explain how to prevent the spread of STDs, list at least two complications of untreated STDs, and explain how to counsel and refer clients who may have STDs. The second session is on infertility and lasts one hour. There will be a ten-minute introduction, thirty minutes of lecture, ten minutes of evaluation, and a ten-minute summary. At the end of the session, participants will be able to define infertility, state three common causes of infertility for men and women, and explain how to counsel and refer clients for management of infertility.
The author considers religious values which enhance reproductive health and rights. He explains that reproductive health and rights have primary reference to women because they are the willing/unwilling victims of abuses against reproductive health and rights. Women's right to be what they should be in a male dominated society is at the heart of reproductive health and rights. Women argue that society should stop regarding them as mere producers of babies and objects of male enjoyment, and instead uphold them as co-creators of communities which enhance and sustain a full life for everyone. Values influence decisions, while supporting, maintaining, and nurturing social structures and institutions. These values are therefore crucial vehicles of change in relation to forces which negatively affect reproductive health and rights. Positive religious values, the sanctity of life, the wholeness of life, the freedom to be, communalism, negative religious values and sanctions, the ideal woman, marriage for procreation, the weaker sex, and patriarchy are discussed.
Marriage has religious, contractual, and social aspects. Among Muslims, divorce is absolute, not legal separation or annulment of marriage. The marriage tie is completely severed in divorce, but the marriage is nonetheless recognized to have existed in the past. In Islamic law, divorce is the most detested of things allowed by God. Among Muslims, divorce is therefore a last resort. Most Muslims avoid the Shar'ia courts and resort to village or family elders. Divorce is nonetheless very difficult in Islam. Muslims must also account before God upon death and before entering heaven. Dr. Abubakar looks at reproductive health from the viewpoint of marriage and the consequences of marriage. This author offers a complementary religious point of view, then comments upon the lecture given by Rev. Dominguez and Fr. Tiong.
Botswana has considerable land resources per capita, but that land is useless without water. Botswana is therefore already a very heavily populated country when you compare population to available water, with the population already having grown to a point where it is beginning to exceed available water resources. As Minister of Local Government and Lands, Chairman of the Botswana Parliamentary Council on Population and Development, and Treasurer of the All-Africa Parliamentary Council on Population and Development, the author fully understands the serious nature of the population growth problem and the various factors which contribute to it, such as teen pregnancy. Botswana's population will double in size every twenty years at current population growth rates. It is clear that inadequate attention has been given to the ramifications of increasing child survival and decreasing mortality in the context of an average national total fertility rate of seven children born per woman. Women in Botswana are having too many children and too early in the course of their reproductive lives. People must begin recognizing the relationship between early childbearing, population growth, and general development in the interest of national economic development as well as the personal welfare of all Botswanans. Even though some people do not want to face the truth, teens in Botswana are having sex and people are increasingly using contraception. Urgent steps must be made to provide girls, women, boys, and men with sex and health education in the interest of stemming unwanted pregnancies and the tide of HIV infection.
A cse study: the experience of YWCA.
The Young Women's Christian Association (YWCA) is running a Pathfinder-funded program to help educate teenage mothers who have dropped out of school. The program is working to ensure that these mothers are educated at least up to the level of Junior College. Teenage mothers from impoverished families are first identified, then encouraged to continue their studies at the YWCA. Each morning the mothers and their babies are brought from their homes to the YWCA, where the babies are cared for while their mothers study in class. The author described at the conference the poor, desperate conditions in which the young women live, and the changes realized by participants after some time at the center. Fathers of the babies have been allowed to visit, but they are not encouraged to do so. It is hoped that in the future fathers will be officially invited to participate. The program is not residential because of the desire to involve the teenage mothers' families in the project. The Pathfinder funding is not for an indefinite period. It has been suggested that a parallel program be established at the YMCA in which men would counsel the fathers of the young children while the teenage mothers pursue their education.
A suggestion was made to amend recommendation 13 in the main report which calls for pregnant girls to be readmitted into the same school from which they dropped out. The recommendation should also mention boys, for secondary school regulations demand that boys who have impregnated a girl be expelled for one year. Mothers should be counseled in clinics on how to talk with both their boys and girls. The Ministry of Finance and Development Planning should be included in recommendation 9 calling for the evaluation of youth programs to make them more development oriented. One speaker expressed her desire for greater parental involvement in the development of the family life education curriculum. In that vein, Curriculum Consultancy Committees are being set up to gather reactions from a cross section of society on family life education. It was suggested that family life education begin by teaching chastity. Moreover, community groups could possibly talk to children about family life education. Finally, policymakers and children should be involved in conferences where recommendations are made with regard to teen sexuality and pregnancy.
"Enter-educate." Reaching youth with messages of sexual responsibility.
Messages about sexual relationships, the prevention of pregnancy and disease, education, the empowerment of women, and concern for the environment are increasingly being disseminated to audiences of all ages through the use of entertainment. Ideas are presented in this Enter-Educate approach through popular, enjoyable entertainment in the form of songs, dramas, soap operas, variety shows, and other folk media. This approach can be adapted to be acceptable and effective in all cultures. Yafaman is one such example. It is a drama written and acted by high school students in Cote d'Ivoire which depicts the story of a school girl who learns that her older, married boyfriend is no longer interested in her when she becomes pregnant. After winning the annual national drama contest, Yafaman was televised and broadcast widely in schools and on national networks in francophone Africa. The video has also been dubbed in English for wider use. Popular music has delivered effective messages of sexual responsibility to young adults in Latin America and the Philippines. The US Agency for International Development-funded Population Communication Services project at the Johns Hopkins University supports 36 major Enter-Educate television series and specials, nine radio dramas, three songs, and nine music videos. Other organizations are expanding or experimenting with work in this area. The authors discuss the theoretical basis for Enter-Educate projects and explain that the approach works because it is pervasive, popular, personal, passionate, persuasive, practical, profitable, and proven effective.
Why, too many people? A world program.
Demographic projections indicate that global population is likely to double in size to 10 billion in the next 40-50 years. Global resources are already being depleted and the population of India is likely to exceed that of China in a relatively few years. The poor are moving to cities en masse. The author's book "Too Many People" is an attempt to analyze the factors which are responsible for the potentially catastrophic population explosion worldwide. The author believes that a major effort now may prevent the catastrophic extinction of many species when poverty and an increasing population lead to famine and aggression. The conflicts and strife in Somalia and Rwanda are examples of what the future may hold for populations worldwide. He suggests that people in the West consume fewer irreplaceable resources and provide help to poor countries, especially with regard to women's education and the provision of contraceptives. The author's main proposal is that under the auspices of the UN a laboratory for population studies be established in a large city where scientists, religious experts, economists, and politicians working for the UN can try to solve complex population problems. This paper discusses world population, whether political regimes can respond to the dangers, whether protection individual rights in liberal democratic societies interferes with the general good of the community, population control as the most urgent task for the UN, and our destiny.
Impact of improved treatment of sexually transmitted disease on HIV infection [letter]
Grosskurth and colleagues report the outcomes of a randomized controlled trial to evaluate the impact of improved treatment of sexually transmitted diseases (STD) on HIV infection. The authors congratulate the research team on the high quality of the design and execution of their study. They are amazed by the reported 43% reduction in the incidence of HIV as a result of the medium-strength intervention. The effect upon other STDs is, however, less apparent. The researchers discussed possible effect modifications of different co-factors, but concluded that bias is negligible or very limited. These authors do not, however, think that the researchers sufficiently consider the implications of the difference in baseline HIV prevalence between intervention and comparison communities. It is important to correct for the initial 14% difference in initial condition since the prevalent cases form the source of subsequent HIV infections. The authors therefore recalculated risk ratios using a correction factor for each of the six matched pair communities. In so doing, the overall estimate of HIV reduction as a result of the intervention would be 33%, probably a better estimate than the original 43%. The confidence interval for the effect was widened by the correction. A more sophisticated analysis should consider the possibility that frequencies changed during the research period, since the HIV epidemic has most likely not yet reached its dynamic equilibrium. The authors stress in closing that a 33% reduction in the frequency of HIV is nonetheless remarkable for this type of intervention.
Impact of improved treatment of sexually transmitted disease on HIV infection [letter]
Grosskurth and colleagues report the outcomes of a randomized controlled trial to evaluate the impact of improved treatment of sexually transmitted diseases (STD) on HIV infection. Their findings will be valuable to public health policy makers. Results from other trials, including mass STD treatment trials, are, however, also needed to complement Grosskurth's efforts. Grosskurth and colleagues have previously suggested that when entire communities are the target of STD treatment intervention, the impact may be greater than interventions which target only symptomatic individuals. The cost analysis of their trial is not available, but World Health Organization guidelines suggest that mass treatment is more cost-effective than early detection programs. At least one community randomized trial is underway in Africa comparing mass STD treatment with a control intervention which includes treatment of symptomatic STDs. The results of mass treatment trials together with the results of that trial will provide a more complete assessment of the utility of STD treatment interventions and will more fully inform public health policy decisions.
Impact of improved treatment of sexually transmitted disease on HIV infection [letter]
Grosskurth and colleagues report the outcomes of a randomized controlled trial to evaluate the impact of improved treatment of sexually transmitted diseases (STD) on HIV infection. If their findings can be generalized, they will be of major importance both in substantiating the hypothesis that infection with STD facilitates the transmission of HIV, and in defining future directions and priorities for the control of HIV. The authors do, however have some concern about the analysis and interpretation of Grosskurth's findings. Grosskurth et al. did not include data on baseline HIV seroprevalence in the logistic regression model that they used to adjust the relative risks of HIV seroconversion; the overall baseline prevalence of HIV was higher in the control than intervention communities. Inclusion of that data would have helped to substantiate that the observed effect was truly a result of the intervention. If the intervention did indeed affect HIV seroconversion rates, the workers suggest that the intervention reduced HIV frequency by shortening the average duration of infection with STDs. The authors, however, find it surprising that the magnitude of the effect upon HIV was greater than upon STD prevalence for all but one of the STD indicators reported. Grosskurth et al. consider other explanations for the reduction in HIV infection rate, including a possible effect of the intervention upon sexual risk behavior. This latter possibility is, however, unlikely given the focus of the intervention and the absence of statistically significant differences between the groups. Efforts must continue to both determine how to best deliver STD care and quantify the attributable risk of STD control. Future trials of similar interventions will have to pay careful attention to the difficulty of measuring the prevalence of STD.
Grosskurth and colleagues reported the outcomes of a randomized controlled trial to evaluate the impact of improved treatment of sexually transmitted diseases (STD) on HIV infection. Subsequent to the publication of study findings, Rygnestad and colleagues drew attention to the greater loss to follow-up because of other reasons in the intervention communities and postulate an extreme scenario in which all those losses occurred in the two roadside communities; they also question whether the treatment of STDs was improved by the intervention. Habbema and de Vlas and Whitaker and Renton pointed out the lack of adjustment in the statistical analysis for the imbalance in HIV prevalence in the intervention and comparison communities at baseline, while several correspondents alluded to the lack of clearly demonstrated effect upon STD prevalences. O'Reilly and colleagues drew attention to the lack of an intervention effect upon sexual behavior and condom use during the two years of intervention in the communities. Grosskurth et al. respond to this critique of their research. In closing, they repeat their view that AIDS control programs need to combine effective behavioral interventions with improved STD treatment services to have the maximum impact upon the spread of HIV. Moreover, adequate public health services for the diagnosis and treatment of STDs should be regarded as a basic right.
Planned Parenthood v Casey [letter]
The author takes issue with a number of positions held by J. Benshoof, author of "Planned Parenthood vs. Casey: The Impact of the New Undue Burden Standard on Reproductive Health Care." Benshoof opposes the parental consent restriction with a number of arguments. While this author agrees that some of these arguments may have merit, he would never treat a minor in nonemergency situations without parental consent. He questions why abortion, an invasive procedure, should be exempt from the requirement of parental consent. Moreover, minors who are seeking an abortion are having unprotected sexual intercourse and are therefore at risk of contracting sexually transmitted diseases. Involving parents is therefore even more important. The author suggests that the potential benefits of parental involvement outweigh the additional hardships with which Benshoof is concerned. Letting a child have an abortion upon request will discourage her from taking responsibility for her action. Knowing that she will have to face her parents in order to secure an abortion may encourage more responsible behavior. The author also disagrees with Benshoof's statement that all women will suffer as a result of the ruling.
M.C.H. -- challenges and issues [editorial]
Mothers and children in any country comprise a large, vulnerable population subgroup. Women have special risks related to child bearing, while children face perils during the course of their overall development. In the attempt to address the myriad health needs of women and children, maternal and child health (MCH) services have been bolstered in India during 1992-93 by the government introduction of the National Child Survival and Safe Motherhood Program. Available data in India indicate a dramatic decline in the rate of maternal mortality over the past three decades, but the level of mortality nonetheless remains alarmingly high. Approximately 70% of maternal deaths could, however, be avoided were deliveries conducted by skilled and trained personnel in clean environments. Like the rate of maternal mortality, the rate of infant mortality has declined significantly, but remains high. Low birth weight, premature birth, infections, birth injuries, and congenital malformations are the major causes of infant death. The main problems currently affecting MCH in India are malnutrition, infection, and the consequences of unregulated fertility. Continuing population growth is undermining India's natural resource base and jeopardizing the agricultural economy upon which most Indians depend for their livelihood. Moreover, social problems such as female foeticide, female infanticide, neglect of female children, lack of awareness, and the inadequate availability and use of MCH services compound the effect of the major medical MCH problems in the country.
Health and human development [editorial]
Participants at the 1988 World Conference on Medical Education in Edinburgh, Scotland, resolved to make the training of physicians more relevant to the needs of the majority in their own societies. The majority of the disadvantaged suffer from morbidity caused by malnutrition, low-quality water supplies, unsanitary conditions, inadequate housing, and illiteracy. It is with regard to these factors that greater interaction is needed between the medical profession and the non-medical education, research, and extension system on the one hand and social infrastructures on the other. The interactions may not be in general terms, but in terms of specific ethnic groups in which they happen to practice. Researchers and experts in the field of social science must make a concerted effort to provide a realistic baseline of information to the medical profession about the ethno-psycho-social environment of a given niche. The masses are apathetic, tired, and generally do not trust governmental medical functionaries. These feelings derive largely from poor people's necessary dependence upon poor facilities, practitioners' inhuman attitudes toward the sick, unclean surroundings, the widespread prevalence of unethical practices, excessive delays, and other negative factors. People who can afford to secure care in the private sector. The author comments on infant mortality, the concept of human development, social development, and population growth.
Controversy erupts in Brazil over penis nicknames.
Commissioned by the Brazilian health ministry to conduct a publicity campaign designed to encourage the use of condoms, the Master Communication and Marketing company conducted a survey in which it collected dozens of nicknames for the penis. The television component of the campaign involves an actor who holds a heart-to-heart conversation with his penis, recommending that it use condoms and showing it, with a candle, how to do so. "Braulio" was chosen as the name for the penis. Braulio, however, is a common men's name in Brazil. Shortly after the launch of the campaign, men named Braulio staged numerous protests against the use of their name. The Health Minister subsequently suspended the campaign on September 23, 1995, to allow selection of an alternate name for the penis. The campaign has resumed, this time using eight impersonal expressions such as "partner" and "him" to identify the penis, and is planned to run for three months despite the controversy. A journalist formerly named Braulio has officially changed his name to avoid being mocked, a lawyer in Sao Paulo named Braulio will continue to head a suit against the government filed by a group of Braulios alleging moral damage, and the Catholic Church criticizes the bluntness of the campaign, which mentions oral and anal sex on the radio. Nonetheless, a health ministry poll of almost 1000 people found that 80% supported the campaign. The coordinator of the Program of Sexually Transmitted Diseases insists that the blunt language is necessary to reach the lower-income, less-educated masculine population. Official figures indicate that 80% of the slightly more than 71,000 registered AIDS cases in Brazil are among men aged 19-35 years, and it is among men aged 20-40 years that HIV is spreading most rapidly. The health ministry has been bombarded with alternate nicknames for the penis since the initial uproar, enough to fill a book. The article points out that the nicknames vary according to region.
The author was, until 1994, Team Leader of the Polio Eradication Initiative in the Western Pacific Regional Office of the World Health Organization (WHO). He is now Director of the WHO Global Program for Vaccines and Immunization. Global efforts against polio have caused the estimated number of cases to decline from an estimated 400,000 in 1980 to just over 100,000 in 1993. Of 213 countries under surveillance, 145 reported zero cases in 1993. A great deal of confidence therefore exists that polio will be eradicated by the year 2000. Polio cannot, however, be eradicated anywhere until it is eradicated everywhere. There are 68 countries in which wild polio virus remains in circulation. The continued survival of polio is fostered by a lack of commitment to eradication by some donor nations and poverty, weak health infrastructure, and internal conflict in others. The author explains why it is important to eradicate polio by 2000. Eradicating polio is a three-stage process and the world is ready to launch the final assault in that process. Significant momentum has been built against polio and all effort must be made to keep it until polio is truly wiped out. If polio is only reduced to very low levels and not really eradicated, there is a very real potential for a serious epidemic early in the next century. Such an epidemic will be expensive in both financial and human terms, and only make it more difficult to foster support for another eradication attempt. The surveillance systems and large quantities of vaccines needed in the final stage of the war against polio may seem expensive in the short term, but the investment is more than worth it over the long run.
Vitamin A was discovered in 1913. Long known that the lack of vitamin A can cause stunting, infection, and blindness in animals, it was not known until recently that vitamin A supplementation can reduce child mortality by 25-33% in many developing countries. It was first reported in 1974 that vitamin A deficiency is a major cause of blindness among children of the developing world. Also in that year, a research project was launched in Indonesia to find out more about vitamin A deficiency and what levels of deficiency were associated with xerophthalmia. The study unexpectedly revealed that malnourished children with adequate vitamin A were less likely to die than well-nourished children who were deficient in vitamin A. A follow-up study in Indonesia found that child mortality was reduced by 33% in villages where children received vitamin A capsules every six months compared to villages in which there had been no intervention. The medical and research establishment eventually accepted these findings as valid, with the WHO and UNICEF making vitamin A supplementation a routine part of measles treatment and the elimination of vitamin A deficiency becoming one of the goals adopted by the World Summit of Children held in 1990. Increasing vitamin A intake can be achieved by improving diets, fortifying common foods, and distributing vitamin A capsules. Ministries of health around the world have now sanctioned vitamin A supplementation. Official recommendations, however, usually endorse supplementation only when there is evidence of severe deficiency, while the evidence suggests that supplementation can significantly reduce mortality even among populations with mild vitamin A deficiency.
A vasectomy involves cutting a man's vas deferens, the two tubes which carry sperm to the urethra, and sealing the ends. In so doing, the man loses his fertility. Vasectomy is therefore the most permanent of male contraceptive options and should not be chosen unless a man is certain that he does not want to bear another child. Surgical procedures designed to reverse vasectomy usually cost approximately $5000, have a success rate of only around 50%, and are available in only certain states. For men who have completed the reproductive phase of their life, vasectomy may be a viable option for contraception. The procedure is quick, simple, safe, highly effective, and relatively inexpensive. Many doctors, urologists, outpatient clinics, and some family planning organizations offer vasectomy, and most health plans help pay. Eight million American men, 20% of those over age 35 years, have undergone the procedure. Neither male sex drive, functioning, physical sensation, nor circulation of hormones is affected by vasectomy. Since sperm constitutes only a small percentage of seminal fluid, even the amount of semen ejaculated following vasectomy remains virtually unchanged. The author is a 36 year old, married man with two children who opted for vasectomy after four years of contemplation. He describes his rationale for and experience with the procedure.
A theoretical exploration of the interactions between migration and household formation.
The author explores the role of spatial mobility during the transition period from adolescence to adulthood in contemporary Spain. Specific topics of interest are leaving the parental household, union formation, and childbearing. Life events of different careers are concentrated during this period and their coordination is particularly determinant of the individual's ultimate social situation. The author focuses upon the determinants and mechanisms involved in the interaction between household formation and migration of individuals, outlining a general analytical framework which interprets the relations among life course careers and on the processes influencing decision making. That framework specifies a suitable context in which to study specific interactions between migration and household formation. A set of working hypotheses concerning that relationship is then formulated in the second part of the paper. Some of the hypotheses will be explored and tested in future research applying event history models. Individual-level data from the 1991 Sociodemographic Survey on the 1940-41, 1950-51, and 1960-61 Spanish birth cohorts will be used.
A perinatal ethics committee on abortion: process and outcome in thirty-one cases.
The US Supreme Court's June 1992 decision to uphold most of Pennsylvania's law restricting access to abortion confirms that while abortion is still permitted in the US, it is being increasingly regulated. Individual institutions may, however, find ways to permit access to abortion. One hospital formed a mandatory, prospective perinatal ethics committee (PEC) in May 1987 to develop clinical guidelines with which to consider and decide requests by physicians for their patients seeking abortions. The authors obtained the consent of this PEC to study its membership, processes, case outcomes, and clinical decision making. Understanding PEC processes and outcomes may help other institutions to decide whether to institute similar mechanisms. Specifically, the investigators determined the backgrounds and abortion-related beliefs of PEC members and obstetric and gynecology department members, whether the PEC affects the number of abortions performed, how PEC members decide in individual cases, and whether requesting physicians find the PEC helpful. All eleven PEC members and 58 of the 65 medical staff ob/gyn physicians returned background surveys. Study results are presented. Overall, the PEC appeared to function as an affirming regulatory body for second-trimester, medically-indicated terminations and for certain personal choice terminations. Institutional interests were well-served by the PEC and with the assurance of informed consent, the interests of some patients were also well served.
HIV infection, risk behaviors, and depressive symptoms among Puerto Rican sex workers.
Findings are reported from a study of the association between depressive symptoms and HIV infection and risk behaviors among 127 prostitutes in Puerto Rico, a US territory with a very high incidence of HIV infection among women, especially prostitutes. The participants were aged 18-60 years (mean age, 32 years), recruited from three brothels and four street locations from across the island. Blood tests were conducted to determine the prevalence of infection with HIV and syphilis and interviews conducted learn about their risk behavior during the preceding six months. 70% of the women could be considered highly depressive, with depressive symptoms observed among 91.4% of HIV-infected women. The prevalence of depressive symptoms did not differ significantly across age or educational level, although a far higher percentage of street prostitutes were depressed than prostitutes who worked in brothels. 40% reported inconsistent condom use with clients during vaginal and oral sex. The risk of high depressive symptoms was eight times higher for these women compared to women who engaged in protected sex. Participants who tested positive for syphilis also had higher levels of depressive symptoms than those with negative results. The use of IV drugs was also strongly associated with a high level of depressive symptoms.
Information, education and communication. Developments and trends in population IEC.
One primary goal of information, education, and communication (IEC) programs is to enhance the ability of couples and individuals to decide freely and responsibly the number and spacing of their children. The other goal is to raise awareness and understanding about the relevance of population-related issues to all levels of decision making, whether personal, national, or international. Access to information on population growth and population size, the health benefits of family planning, family planning methods, the dangers of sexually transmitted diseases, and overconsumption and waste empowers people to more effectively participate in the decision-making process in their communities and countries. Effective IEC efforts should use a range of communication channels, although electronic media is playing an increasingly important role worldwide in disseminating messages. Targeting specific audiences such as men, adolescents, and young couples is crucial to the success of IEC programs. In all cases, however, the design of information programs should involve the target audiences, especially in the cases of men and young people. Good interpersonal communication and counselling skills are at the heart of successful IEC programs, particularly within the context of family planning and other health care services.
Sexual practices of the sex workers in a red light area of Calcutta.
The authors conducted a study in Rambagan, the northern part of Calcutta, India, during May-July 1993 to gather information on the profile of female prostitutes and their clients, their socioeconomic backgrounds, and their sexual practices. There are more than 420 prostitutes in this red light district. The prostitutes and their clients were both of low socioeconomic status. 80% of the women originate from the rural areas of West Bengal, while the rest are either migrants from Bangladesh or neighboring Indian states. Approximately 70% are Hindu and the rest are Muslim. Almost 78% had been in the profession for ten years or more, with poverty cited as the main reason for their employment as prostitutes, some women were brought/tricked into it. The clients of transient prostitutes generally do not use condoms, and prostitutes who are resident in the area tend to have less poor clients. It was determined from responses of 100 female prostitutes to self-monitoring sexual practice cards that more than 89% were involved in penile-vaginal sexual intercourse, with only 32% of such practice protected by a condom. Slightly more than 10% and 0.4% reported practicing oral sex and anal sex, respectively. Only 11% of anal sex episodes were protected with a condom.
Moving from AIDS to symptomatic HIV infection [editorial]
Approximately 3000 cases of AIDS have been diagnosed in South Africa since 1982, and many thousands more are infected with HIV. With competing demands for limited health resources, it is easy to adopt a defeatist attitude in the face of HIV and AIDS. The authors recommend focusing greater effort upon managing HIV disease instead of focussing too narrowly upon AIDS. Combatting early HIV-related disease would be more acceptable to the community and would benefit the population overall. Moreover, interventions could be incorporated into existing health services more easily than the alternative of providing tertiary services, specialist care, and expensive technology for treating AIDS patients. World Health Organization guidelines have been published to help all levels of health services in developing countries adopt this strategy.