This study assesses compliance with two different iron-supplementation regimens among pregnant women attending a prenatal clinic in Ilula village, Iringa Region, Tanzania. In one group, each woman received 120 mg of a conventional (Con) iron supplement per day for 12 weeks. In the other group, each woman received 50 mg of a gastric delivery system (GDS) iron supplement per day, also for 12 weeks. Each pill bottle was equipped for one month with a special reader that recorded each time the bottle was opened and closed and the time and date. Adherence was reported daily during the first month of supplementation and at follow-ups at 8 and 12 weeks of supplementation. Hemoglobin concentration was measured at the 21-26 week entry point and after 12 weeks of supplementation. The women were asked to recall side effects after 12 weeks of supplementation. 97 of 176 women completed the 12-week supplementation period. The 87 women who had complete measures of adherence and a subsample of 27 women with anemia were used in the analysis. The GDS group had fewer side effects. 61% of the GDS group and 42% of the Con group complied fully with the regimen. Adherence was lower in both groups among women who had side effects, but among these adherence was greater in the GDS group. At 12 weeks, GDS group women in the subsample had a significantly higher hemoglobin concentration than the Con group. Multivariate analysis revealed that among the subsample the link between adherence and hemoglobin concentration was insignificant. Women in the Con group that had the highest adherence had a hemoglobin concentration similar to that of the GDS group. Findings suggest that there were other determinants of adherence. For populations with a higher prevalence of anemia, a larger amount of iron supplementation and better compliance may be needed to reach a similar hematologic response.
Tanzania registers declines in levels of impaired fertility.
This article summarizes Larsen's findings based on an analysis of data from the 1973 Tanzania Demographic Survey and the 1991-92 Tanzania Demographic and Health Survey on fertility and subfertility. The rates of childlessness in Tanzania declined among women aged 30-49 years from 10-11% to 3%. The effects of infertility on the total fertility rate (TFR) varied among Tanzania's 20 regions. In regions where TFR was over 6.8 children per woman in 1973, fertility declined. The range in decline was from 25% in Mbeya to 6% in Kagera. Fertility also declined in some regions with low contraceptive prevalence. Fertility declined 3% in Mara and 25% in Kilimanjaro. In most regions, TFR remained the same or increased, even in the three regions with increased contraceptive prevalence. Larsen suggests that these changes may be due to decreases in childlessness and subfertility. Three regions with low fertility in 1973 experienced further fertility decline in 1991-92. In Dar es Salaam, TFR was 4.7 in 1973 and 4.1 in 1991-92, and contraceptive prevalence was 11% in 1973. In Mtwara, TFR declined from 5.2 to 3.9, and childlessness and infertility were among the highest in 1973. Larsen suggests that fertility decline in these regions may be due to high rates of sexually transmitted diseases (STDs). In regions with both fertility decline and high contraceptive prevalence, fertility transition may be underway. Larsen mentions that rural levels of childlessness declined over time, and that variations between regions may be due to variability in STD prevalence. Declines in childlessness and subfertility may be due to improvements in malaria and STD treatment and treatment of pregnancy complications. Childlessness among urban women declined from 14% to 5%. In 1973 childlessness was high in the Tabora plateau, lake basin, and coastal regions. By 1991-92, subfertility in coastal regions remained high and actually increased among women aged 25-29 years.
This article presents findings from a study of the effects of different regimens of misoprostol on abortion success and side effects in trials conducted in the US. Study participants included 58 women aged 18-45 years, with pregnancies that were under 10 weeks. Women with complications were excluded. Abortion success means a complete passage of gestational tissue without the need for curettage. During the first phase, all 26 women who were assigned to the three groups received 200 mcg of misoprostol vaginally. Misoprostol was administered up to five times at the same dosage at 8-hour intervals, until gestational tissue was expelled. Each woman received either no other treatment, two 10 mg tablets of tamoxifen immediately after the administration of misoprostol, or a laminaria placed in the cervical opening immediately before administration of misoprostol. Abortion success was 50% among the first group of women, 64% among the second group of women, and 60% among the third group of women. During the second phase, 3 women in the first group, 4 in the second group, and 5 in the third group received 400 mcg of misoprostol initially and then 200 mcg doses at 8-hour intervals thereafter. Treatment was the same as in the first phase by group. The success rates were 100%, 25%, and 80%, respectively, among the groups. During the third phase, 15 women received an initial dose of 400 mcg of misoprostol and subsequent doses of 200 mcg every 4 hours. No one received more than four subsequent doses. Abortion success was 60%. During the fourth phase, 5 women received 400 mcg vaginally initially and every 8 hours, and a single oral dose initially of 400 mcg. 3 out of 5 women successfully aborted. The mean time to expulsion for all phases was 9.9 hours. All successful abortions with misoprostol alone and 61% of the abortions with combination regimens occurred within 24 hours of the initial dose. It is suggested that a combination of regimens of misoprostol and methotrexate be tried 24 hours before a scheduled suction abortion.
Networks, support groups, and domestic violence.
This article discusses recent preliminary research findings on domestic violence against women in Calcutta, India, during 1994-95 and other evidence from around the world. The Beijing Conference on Women affirmed that physical, sexual, and psychological abuse of women occurs regardless of income, class, or culture. The author found from interviews with 47 abused Indian women from a mixture of backgrounds that middle-class women were the most private and difficult to interview. Findings from interviews suggest that women can resist or challenge the abuse by men, and resolution is the end to abuse. The research aimed to identify factors that enhanced resistance and resolution. Over 66% of abused women responded by informing others or crying or offering resistance. Single women and mothers are vulnerable due to stereotyping and economic insecurity. Women's groups recommend formation of shelters for abused women, income generation programs, and training projects, but funding is frequently limited for such activities. Some abused women are unaware of their rights or do not seek help from agencies. Illiteracy interferes with exchanges of pertinent information. Women in the Indian study did not accept violence as part of marriage. 70% of the women stated that after reporting the violence there was resolution. For sexual violence, resolution did not occur, and Indian law does not treat marital rape as a criminal offense. Most of the abused Indian women had contacts with governmental or other organizations. It appears that outside support is important to resolution and nonviolent relationships. Employment that is home-based isolates women and may not be useful as a resource for achieving resolution. Groups need to focus on capacity-building.
Dealing with hidden issues: trafficked women in Nepal.
This article discusses approaches to dealing with prostitution in Nepal and exportation of women prostitutes to Asia and the Middle East. It is estimated that over 200,000 Nepalese women are in Indian brothels, and tens of thousands are exported each year to other countries and forced either into prostitution or other oppressive conditions. In Nepal, women prostitutes are rejected as wives or daughters, regardless of the reasons involved. Women Acting Together for Change (WATCH) organized a national public hearing in June 1995 on these issues. During the hearing, 11 women and one man shared their views about being forced into prostitution, the ineffectiveness of the law, and social rejection. Participants at this forum questioned the legal practice of human rights and decided that law was a hindrance. Government representatives on the "listening bench" responded defensively and argued that prostitutes were unwilling to use the law, but agreed that the government should punish traffickers and commit politically to ending the trafficking in women. Roundtable discussions among concerned people after a day of hearings decided to initiate a nationwide coalition against the trafficking in women. The alliance would consist of 17 people and include nongovernmental representatives, lawyers, women who testified, representatives of the National Planning Council, and representatives from women's groups. The sex trade is viewed as a part of the national economy and a very profitable enterprise. Extreme poverty and few employment options are strong incentives for the continuation of prostitution. Patriarchal norms reinforce the view of women as born for the sexual pleasure of men. Nepal's national economy and policies have contributed to family poverty and to migration to other countries where women are exploited. The forum revealed schisms in the government commitment to Article 20 of the constitution.
The right to protection from sexual assault: the Indian anti-rape campaign.
This article reveals a viewpoint that emphasizes some dilemmas among Indian feminist practice, women's sexuality in legal terms, and case law in India. The Indian Women's Movement (IWM) was successful in 1983 in adding a legal amendment on rape and child abuse. The case that mobilized women to change the law occurred in 1980 when a court acquitted two policemen who were charged with raping and molesting a 16-year-old tribal girl. The Bombay High Court overturned the judgement and convicted both policemen. The case was appealed, and the policemen successfully argued that rape did not occur because the girl did not protest and was sexually experienced anyway. In 1980 the Forum Against Rape was formed to mobilize public support and to lobby the State for reform of the law on rape. The campaign focused on custodial rape and political repression, rape as civil rights issue, and rape as a women's issue. There was a distancing between the victim, who occupied a lower caste and class position, and her defenders in the women's groups. The campaign appealed to both the appropriate judgement of the State and the denial that the State was an effective vehicle for change. The campaign did not directly address incest and marital rape or domestic violence within families. The legislature debated the issue of legal change during 1982. The debate revealed deep divisions about sexuality and women's status. It was argued that chaste women were not rape victims, and unchaste women were of a socially inferior caste and class. It was argued that there should be a ban on child marriage rather than spousal rape laws. Child rape is a legal issue only when the perpetrator is outside the family. Rape was discussed as an act of lust and not violence. In 1992, a woman promoting an end to child marriage was raped and the men were acquitted. It was argued that the law was out-of-date and in need of revision.
Reproductive health in Europe. In every country -- for every age group [editorial]
This editorial (September 1996 issue of "Entre Nous") presents the view that reproductive health is appropriate for all stages of the life cycle. Europe comprises about 50 different countries and 850 million people. Reproductive health concerns vary between regions and countries. The World Health Organization definition indicates that reproductive health refers to a state of complete physical, mental, and social well-being. Reproductive health implies that people are able to have a responsible, satisfying, and safe sex life. This means access to effective, affordable, and acceptable methods of fertility regulation, health services for safe pregnancies and deliveries, treatment of reproductive diseases and cancers, and care during and after menopause. This issue of the magazine includes a variety of perspectives on reproductive health. There is an article on the rise of sexually transmitted diseases in the Newly Independent States of the former USSR. Other articles address the health needs of older women in European developed countries, changes in contraceptive needs as women age, and the suffering of women due to reproductive health problems. The world focus on maternal and child health draws attention away from a holistic or comprehensive perspective. Although many women in developing countries suffer from reproductive tract infections, little attention is given to these common problems that have serious social and health implications. Dr. Nafis Sadik affirms the importance of women's empowerment and couples' and individuals' rights to decide freely and responsibly the number and spacing of children and to have the access and means to act. The principle of reproductive health is important for all women, all people, and all nations.
Reproductive health in Europe. Different problems need different solutions.
This article presents an interview with Dr. Gayane Dolian concerning reproductive health issues in Europe. Dr. Dolian describes reproductive health as having many aspects, like the petals of a flower. The center of the flower is the key area of emphasis within each country. For example, the Russian Federation must concentrate on moving from abortion to contraception. In Moldova, almost 80% of sexually transmitted diseases occur among adolescents aged 16-21 years. Western nations with a sizeable population aged over 40 years need to focus on the contraceptive needs of older women. Reproductive health is both a national priority and an international problem. Multilateral agencies carry tremendous responsibility for information exchanges between developed and developing countries. On one level there is a need for technical exchanges of information and training on safe and effective abortifacients. Also, the general public needs appropriate sex education materials. Countries need the funds to duplicate several hundreds of thousands of sex education materials. Handynet is a recent European project that provides a database accessible throughout Europe on national programs and assistance for the disabled. Multinational agencies are storehouses of information that can be useful to individual health workers. A healthy population means healthy workers. The Newly Independent States (NIS) of the former USSR and war-torn countries are particularly in need of reproductive health information and services. The most important issues are appropriate and sufficient information, primary health care services for all areas of reproductive health, and youth services and information. The NIS are underdeveloped and in great need of information services.
Family planning and lifestyles in Germany.
This article presents a discussion of issues related to reproductive health, family planning, and life styles in Germany. The Federal Republic of Germany assumes all are knowledgeable about contraception. Sex education is compulsory in school and a 1995 Federal Act assures the right to information and advice relating to sex education, prevention, and family planning. The act establishes a Federal Center for Health Education and funds the establishment of advisory centers. Pills are the most widely used contraceptive method, followed by condoms. Women can choose from a wide variety of methods. Women under 20 years of age can obtain free information and contraceptives. Women over the age of 20 receive free medical consultations and free IUDs, if they are receiving social assistance. 66% of all pregnancies are planned, and the abortion rate is 104/1000 live births in the older German states and 495/1000 live births in the newer German states. It is apparent that women without partners or women who desire a pregnancy are the ones not preventing unplanned pregnancies. In 1994, contraceptive use was greatest among women aged 21-29 years. Contraceptive use was lower in the younger and older age groups. Adolescents aged under 20 years who gave birth as single mothers included 40.5% in older German states and 86.9% in the new ones in 1991. Almost 75% of women aged 16-65 years who were single and without a partner used no protection. 79% of single women with a steady partner used contraception. There are many life style differences between women in the East and West with regard to linking work and motherhood. Improvements in reproductive health should enable women, regardless of their age, to have greater choices.
Striking improvement in public health and MCH.
This news brief identifies some achievements in maternal and child health in China during 1991-95. Maternal mortality declined from 94.70/100,000 people in 1990 to 64.80/100,000 in 1995. Infant mortality declined from 50.19/1000 to 37.79/1000. Child mortality declined from 61.00/1000 to 46.75/1000. The incidence of birth defects declined from 105.23/10,000 to 90.60/10,000. The proportion of breast-fed babies aged under 4 months in urban areas increased from 23.60% to 47.50%. 46.60% of rural babies were delivered at hospitals in 1995. The life expectancy of women reached 71.0 years in 1995. Other accomplishments include greater prevention of tetanus infections among newborns and declines in the incidence of common childhood diseases. The international program for "Strengthening Maternal and Child Health Care and Family Planning Services in the Grassroots Units of China" was implemented in 305 poor counties that comprised a population of 120 million. The Law on Maternal and Infant Health Care assures improvement in the quality of lives of mothers and children and protection of their health.
A survey on farmers' fertility desires.
This news brief presents findings from a survey of fertility desires among 10,000 farm households in 1400 villages, 140 townships, and 14 counties in Hunan Province, China. Findings reveal that farmers fully support the present national family planning program. Farmers believe that smaller families will contribute to higher incomes and improvement in people's lives. 1.51% of farmers were dissatisfied with the family planning program, and 2.48% desired more children. During 1982 to the present, the average number of births in Huanglongxincum Village, Huanghua Town, Changsha County, declined from 76 to 26 births. The average net per capita income increased from 100 yuan to 3000 yuan. Five couples with only daughters declined the offer of second birth quotas. A woman from Shou Hongsheng, Heliao Township, Zhigiang County, had an only daughter and left with her family for another village in 1991 with the hope of having a second child. Instead the couple prospered, and net annual family income from a specialized fruit production business increased to 40,000 yuan yearly. By 1994, the couple was given permission to have a second child, but the couple turned down the offer. Local provincial family planning officials believe these changes in attitude among farmers are a hopeful sign and the highest award given by the people to the public sector.
Food security and population: AFPPD plan of action for 1996.
This news brief focuses on the forthcoming activities and plans of the Asian Forum of Parliamentarians on Population and Development (AFPPD). The 1996 program of action will be devoted to the linked issues of food security and population growth. AFPPD will be paying attention to the Food and Agriculture Organization's (FAO) Food Summit that is scheduled for November 1996 in Rome, Italy. National committees, regional partners, and international partners will be asked by the AFPPD Executive Committee to focus on food security and population issues in preparation for the World Food Summit. The Chairman of the AFPPD reports that a sufficient supply of food should not be taken for granted and that the environment is in trouble. Parliamentarians must contend with the prospects of the food supply not keeping pace with population growth. There is already evidence of food shortages, particularly among women and children. AFPPD maintains ties to the FAO World Food Summit Secretariat, the FAO Director General's office in Rome, and the FAO Regional Office in Bangkok. Recently officials of these organizations met with AFPPD and were informed about AFPPD's programs. AFPPD was invited to attend the Regional Nongovernmental Organization Meeting on the World Food Summit that was held in Bangkok.
Variation in menarcheal age of Assamese girls.
This study determined the mean age at menarche among 571 Assamese girls who came from various castes (brahmin, kalita, and kaibarta). The sample population also included Muslims and two Mongoloid populations. Evidence from early research suggested that differences in the mean age at menarche occurred between castes and scheduled tribes in Assam, India. Findings from the present study indicate that the mean age at menarche was 12.23 +or- 0.19 years among brahmin girls, 11.96 +or- 0.16 years among kalita, and 11.92 +or- 0.08 years among kaibarta. The decline in age at menarche followed the decline in status among this caste. Among Muslims, the mean age at menarche was 12.10 +or- 0.10 years. Among the Mongoloid group, the mean age at menarche was 11.83 +or- 0.09 years for ahoms and 11.94 +or- 0.12 years for sonowals. There were no statistically significant differences in menarcheal age between caste and tribal groups. Findings suggest a change in the mean age at menarche over time. Age at menarche appeared to decrease among the kaibarta, sonowal, and Muslim groups; it appeared to increase among the brahmin, kalita, and ahom groups. These findings are considered tentative pending further research.
Role of general practitioners in primary health care.
This news brief discusses the important role of general practitioners (GPs) in providing primary health care in India. The Indian Medical Association (IMA) is committed to achieving the goal of "Health for All by the Year 2000." The IMA aims to provide health care to the needy rural population with the help of voluntary organizations, to improve the science and art of medicine, to provide primary health care in communities, and to practice sound medicine. GPs are at the center of the medical community and link the community to hospitals. GPs must become members of the IMA, take refresher and continuing medical education courses, and keep pace with the changing technology. GPs must visit hospitals and make rounds in addition to attending lectures. GPs must be knowledgeable about referrals and provide prompt referrals to medical specialists. Properly trained GPs can serve as supervisors of paramedical staff. The involvement of GPs in the National Health Program will determine its success. Community welfare is dependent upon GPs and their role in prevention and control of communicable diseases and in managing epidemics. Almost 66% of the population relies on the services of GPs. Only 23% seek medical help from government hospitals. It is necessary for all GPs to be involved in the goals of "Health for All." Success will depend upon the provision of primary health care in rural areas by government agencies, nongovernmental organizations, and the huge network of GPs.
Multicultural counseling with teenage fathers: a practical guide.
An unplanned pregnancy represents a developmental crisis for the adolescent male; the teenager's relationships with his own parents, with the mother of his child and her parents, and with his peers are profoundly altered. Although many programs address the medical, educational, and psychological needs of adolescent mothers, adolescent fathers tend to be overlooked and unserved. This handbook seeks to remedy this trend by providing helping professionals with a conceptual framework for responding to the common and unique needs of adolescent fathers from different cultural backgrounds. The book's central thesis is that the therapeutic goal of helping teenage fathers can best be achieved through use of the process and intervention skills embedded in Pedersen's model of multiculturalism. In this model, culture-specific and universalist perspectives are integrated. The chapters in Part I focus on universal counseling considerations, a profile of the teenage father, program development issues, pregnancy resolution, legal issues, and preparation for fatherhood. Part II discusses the particular needs of Black, White, and Hispanic youth as well as the impact of social class, religion, and urban/rural residence. Part III presents three case studies that demonstrate the application of multicultural counseling, and Part IV discusses implications for research, training, and clinical practice.
Maternal and perinatal health in Mali, Togo and Nigeria.
A comparative study of hospital obstetric care in Mali, Nigeria, and Togo revealed the importance of family planning, prenatal care, and the identification of high-risk pregnancies to maternal and perinatal health in African countries. A questionnaire developed and applied in Hesse, Germany (n = 58,430) was administered at district hospitals in Bamako, Mali (n = 1462), Lome, Togo (n = 1002), and Kaduna, Nigeria (n = 1055) in 1990. Mean age at first birth was 19.5 years in Mali, 21.2 years in Togo, and 22.2 years in Nigeria, compared with 26.7 years in Germany. The proportions of mothers having more than 10 prenatal visits were 10.6%, 2.0%, 15.5%, and 72.0%, respectively. Birth was attended by a physician in 58% of cases in Nigeria, compared with only in 12% in Mali and 5% in Togo. The fetal death rate was 28% in Mali, 18% in Togo, 10.8% in Nigeria, and 1.7% in Germany; perinatal mortality rates were 115%, 77%, 68%, and 5.3%, respectively. 21.2% in infants in Togo, 12.4% of those in Mali, and 11.6% of infants in Nigeria were low birth weight. Maternal mortality was highest in Mali (2000/100,000 live births), followed by Nigeria (800/100,000), and Togo (420/100,000). Fetal heart rate recording, ultrasound technology, and neonatal intensive care units were rarely available in the African countries. Recommended are: 1) health education campaigns, disseminated through village meetings and the mass media, on pregnancy care, family planning, and child spacing; 2) upgraded training of midwives and doctors; 3) a mother passport system; and 4) competitions among district hospitals for the best perinatal and maternal health performance. Implementation of these measures would require an organizational structure developed by national societies of obstetrics and gynecology in collaboration with African governments.
A practical guide to the diagnosis and management of amenorrhoea.
Amenorrhea, characterized by anatomical, genetic, and neuroendocrine abnormalities, occurs frequently in adolescents and in 10-20% of women presenting with subfertility. It can be caused by anatomical defects of the genital organs or endocrine dysfunctions. A correct diagnosis, reached through history, physical examination, laboratory data, and imaging, is essential to proper treatment. Amenorrhea resulting from ovarian malfunction, the most common presentation, is associated with four distinct endocrine conditions. Hyperprolactinemic amenorrhea, often linked to a pituitary adenoma, is treated with prolactin-lowering drugs or cyclical progestogen and hormone replacement therapy. Hypogonadotrophic amenorrhea, frequently associated with stress and nutritional deficiency, is generally addressed through counseling and sequential use of estrogen and progestogen. Hypergonadotrophic amenorrhea, the result of ovarian failure, has no curative therapy; however, long-term hypoestrogenicity should be treated with estrogen to prevent an increased risk of osteoporosis and cardiovascular disease and cure symptoms. Finally, in normogonadotrophic amenorrhea, caused by a disturbance in the pattern of pulsatile gonadotropin-releasing hormone, menstrual bleeding can be induced by cyclical progestogen administration or the sequential use of estrogen plus progestogen.
Clinical research conducted in Australia suggests that a progestin-androgen combination depot has potential for hormonal male contraception. The authors' previous research had indicated that 6 200-mg testosterone enanthate pellets implanted subdermally produced substantial reductions over injections in the delivered testosterone dose while maintaining equally effective suppression of spermatogenesis with few metabolic side effects. The present study sought to determine whether lower testosterone doses would maintain efficiency and to assess the efficacy of adding a depot progestin to a suboptimally suppressive depot testosterone dose (6 mg/day). 10 volunteers received either 2 or 4 200-mg testosterone pellets or 4 200-mg pellets plus a single intramuscular injection of 300-mg depot medroxyprogesterone acetate (DMPA). The testosterone implants alone achieved inadequate suppression of spermatogenesis for a male contraceptive; 400 mg of testosterone (3 mg/day) had a negligible effect on sperm output, while 800 mg (6 mg/day) produced azoospermia or severe oligozoospermia in only 4 of 10 men. However, the addition of DMPA markedly increased the extent, but not the rate, of sperm output suppression: azoospermia was achieved in 9 men and oligozoospermia in all 10 subjects, and sperm suppression persisted for 3 months. Epitestosterone concentrations, used as a marker of Leydig cell steroidogenesis, were decreased in a time- and dose-dependent manner, reaching castrate levels in the combined group. Plasma luteinizing hormone and follicle-stimulating hormone levels were suppressed in a dose-dependent fashion by testosterone and further suppressed by the addition of DMPA. Sex hormone-binding globulin levels were decreased by DMPA, but not by either testosterone dose. Prostate-specific antigens and lipids were not significantly altered by any regimen. There were no discontinuations or reports of side effects.
Breast cancer and hormonal contraceptives: further results.
A review of the available epidemiologic evidence suggests that there is little difference between women who have and who have not used combined oral contraceptives (OCs) in terms of the estimated cumulative number of breast cancers diagnosed during the period from starting use up to 20 years after discontinuation. The Collaborative Group on Hormonal Factors in Breast Cancer reviewed data from 54 studies from 26 countries that included at least 100 breast cancer cases. This yielded a total of 53,297 women with breast cancer and 100,239 controls. Overall, 41% of women with breast cancer and 40% of controls without breast cancer had used OCs at some point. The median age at first use was 26 years, the median year at first use was 1968, the median duration of use was 3 years, the median time since first use was 16 years, and the median time since last use was 9 years. Despite heterogeneity in terms of subjects and study designs, there was remarkable consistency in results across the studies. Noted was a small increase in breast cancer diagnosis in current users of combined OCs and in women who stopped use in the past 10 years; this risk disappeared, however, when more than 10 years had elapsed since OC discontinuation. Moreover, the cancers diagnosed in OC users tended to be less advanced clinically than those in non-users. Although there is insufficient information to assess the effects of specific types of estrogens and progestogens, the pattern of risk for progestin-only OCs seems to be similar to that for combined OCs. In need of further investigation is the finding of higher relative risks for recent users who began OC use before 20 years of age than for recent users who began at older ages. Unexpected, and also in need of replication, was a trend toward a reduction in both breast cancer risk and in tumors spreading beyond the breast among subgroups of women whose OC use ceased more than 10 years earlier, especially among women whose OCs contained the highest hormonal doses. Further research is needed to establish whether the associations reported reflect the earlier diagnosis of breast cancer in OC users, the biological effects of hormonal contraceptives, or both these factors.
Oral contraceptives and venous thromboembolism.
In July 1996, seven months after the publication of evidence linking third-generation oral contraceptives (OCs) to an increased risk of venous thromboembolism, the New Zealand Ministry of Health issued guidelines for physicians on this topic. Although all combined OCs increase the odds of thromboembolic events, preparations containing desogestrel or gestodene are associated with a two-fold greater risk than first- or second-generation OCs. In 1995, the UK Committee on the Safety of Medicines advised physicians not to prescribe OCs containing desogestrel or gestodene to women with risk factors for venous thromboembolism and recommended that current users should continue with these preparations only if they could not tolerate other OCs. The New Zealand recommendations are less directive. Doctors are advised that, when initiating OC therapy, they should consider prescribing OCs containing no more than 35 mcg of ethinyl estradiol and a progestogen other than desogestrel or gestodene; it is noted, however, that third-generation OCs may have an additional therapeutic role in specific medical conditions. In New Zealand, about 75% of OC users (compared to 50% in the UK) use these new OCs and about 40 of the 50 expected cases of venous thromboembolism in New Zealand pill users per year will occur in women taking OCs containing desogestrel or gestodene.
The findings of a multicenter clinical trial challenge the practice of estrogen treatment of the prolonged or irregular vaginal bleeding associated with depot medroxyprogesterone acetate (DMPA) contraceptive use. Included in the study were 1035 DMPA users (mean age, 27 years) from Alexandria, Egypt; Bangkok, Thailand; Chiang Mai, Thailand; Jakarta, Indonesia; Karachi, Pakistan; and Manila, Philippines. 456 (44%) of these women experienced a bleeding episode lasting more than 7 days during their first 6 months of DMPA use. Of these, only 278 (61%) requested treatment. These 278 women were randomly allocated to receive 50 mcg of ethinyl estradiol (n = 90), 2.5 mg of estrone sulfate (n = 91), or placebo (n = 97) daily for 14 days. The treatment stopped the bleeding episode for 93% of women in the ethinyl estradiol group, 76% of those in the estrone sulfate group, and 74% of women receiving a placebo. The ethinyl estradiol advantage was marginal, however. On average, women treated with ethinyl estradiol had their bleeding episode shortened by 1 bleeding day and 3 spotting days. Immediately after treatment, women given ethinyl estradiol had less bleeding and spotting days than their counterparts in the 2 other groups, but demonstrated a more unpredictable pattern, including a greater range of lengths of bleeding/spotting-free intervals. Three months after treatment, there were no differences between the 3 groups in vaginal bleeding patterns.
Progestogen-only pills and bleeding disturbances.
Although the progestogen-only minipill decreases side effects such as dizziness, nausea, headaches, and breast tenderness associated with combined oral contraceptives, this advantage is outweighed by disturbances of menstrual flow. 1/3 - 1/2 of minipill users experience prolonged menstruation, and up to 70% report breakthrough bleeding or spotting in 1 or more cycles. These menstruation disorders are the most frequently cited reason for method discontinuation. In some studies, under 50% of mini-pill users continued method use for 12 months. Morphometric studies of endometrial biopsies from progestogen-only pill users suggest that the endometrial response is variable and unpredictable, including irregular secretory endometrium and a lack of or suppressed proliferation. Other studies have found increases in the total and dilated veins at the endometrial-myometrial junction in minipill users. New strategies to improve cycle control would enhance acceptance of this excellent second line contraceptive method.
Endometrial vasculature in Norplant users.
Enhanced understanding of steroid control of the endometrial microvasculature, microvascular heterogeneity, and microvascular fragility is essential to controlling the disrupted, prolonged, and irregular vaginal bleeding associated with progestin-only contraceptives. A World Health Organization study involving 191 Indonesian women with 3-12 months of exposure to Norplant implants yielded important information on these aspects. The endometrium was consistently thinner (0.4 mm) in Norplant users compared with Australian controls (5.8 mm). Other histologic features characteristic of the endometrium in Norplant users included a basalis-type appearance and minimal functionalis, signs of hemorrhage, dilatation and congestion of subepithelial vessels, spindle-shaped periglandular cells, and breaks and signs of re-epithelialization in the surface epithelium. Steroid control of the vasculature can operate through numerous direct and indirect mechanisms, with up to 30 genes relevant to vascular function having consensus estrogen response elements in their promoter regions. The vasoactive effects of progestins are less well documented, but appear to be independent of their effects on the other tissue compartments. The vasculature varies considerably from vessel to vessel, and localized rupture of vessels appears responsible for breakthrough bleeding. It is hypothesized that exogenous progestin administration perturbs one or more steps of the normal angiogenic process, producing a situation in which parameters such as basement membrane breakdown or endothelial cell adhesion molecule expression are altered, leaving the vessels in a permanently weakened state.
Endometrial angiogenic response in Norplant users.
A study of 40 Norplant acceptors and 30 controls from Jakarta, Indonesia, demonstrated that use of this contraceptive method reduces angiogenic activity in the endometrium. The endothelial cell migratory activity toward endometrial explants from controls was significantly higher than explants from Norplant users (p < 0.001). There was no significant association between the endothelial migration score and peripheral hormonal concentrations or the free levonorgestrel index in Norplant users. Plasma estradiol concentrations in Norplant users fluctuated from 20.00 to 453.54 pg/ml, and there was a nonsignificant trend for lower estradiol concentrations to be associated with amenorrhea. The plasma concentration of levonorgestrel was 0.81 +or- 0.07 nmol/l at 6.20 +or- 0.33 months' duration of Norplant use. There was no difference in the endometrial angiogenic activity in the endometrium on the basis of the presence of prolonged or irregular bleeding/spotting. Of interest was the finding that the 4 Norplant acceptors with an endothelial cell migration score of 1.0 or above had the lowest free levonorgestrel index. This suggests the possibility that the free levonorgestrel index could be used to predict a better endometrial angiogenic response in Norplant users.
Menstrual bleeding patterns in Chinese women using the Norplant subdermal implant.
A 5-year investigation of 306 Norplant acceptors from China indicates that the menstrual cycle disturbances associated with this contraceptive method are chiefly related to changes in the total number of bleeding days. The numbers of bleeding/spotting days were 36.6 at observation point 1 (1-90 days), 34.9 at point 2 (91-180 days), 31.1 at point 3 (181-270 days), and 30.3 at point 4 (271-360 days), while the number of spotting days was 21.5, 18.7, 15.0, and 13.4 days, respectively. Also observed over the 4 first-year reference points was a significant decrease in the average duration of the bleeding/spotting episodes (15.4, 12.5, 11.6, and 10.4 days, respectively). The percentage of women displaying a normal menstrual pattern increased from 7.8% at the onset of use to 21% by the end of the first year and 40% by the end of the fourth year. The gross cumulative termination rate for menstrual problems was only 3%. Norplant discontinuers were significantly more likely than women who continued method use to experience prolonged bleeding.
Management of irregular uterine bleeding and spotting associated with Norplant.
A review of the literature suggests that estrogen, progesterone, and nonsteroidal anti-inflammatory agents have the potential to ameliorate the prolonged bleeding associated with Norplant use. The feasibility of such treatment was investigated in both a pilot study and a multicenter trial. In the pilot study, bleeding episodes were stopped within 5 days (average, 3.1 days) in 8 of the 10 Norplant acceptors with irregular bleeding who received 20 mcg of ethinyl estradiol for 10 days. On the basis of this finding, 44 Norplant users from 5 US sites were administered 20 mcg of ethinyl estradiol for 10 days, 800 mg of ibuprofen 3 times a day for 5 days, or a placebo. Interim analysis of data from the multicenter trial suggests that 1 of these regimens (unknown at this point due to the double-blind nature of the study) produces a reduction in the mean number of spotting days, but there is no difference by treatment group in the number of bleeding days. The mean number of spotting days was reduced (0.23 +or- 0.44) in Group A compared to Group C (1.94 +or- 1.34) during the first 5 days of treatment. The overall mean number of bleeding days was 1.34 days in the first 5 days after treatment initiation and 0.82 during the second 5 days of treatment. Completion of the multicenter trial analysis should provide guidelines on ways to improve the menstrual disturbances that are the major barrier to Norplant use.
Endometrial biopsy collection from women receiving Norplant.
Research on the causes of progestogen-induced breakthrough bleeding in Norplant users depends on the availability of endometrial biopsy samples. In this study, 3 biopsy techniques were utilized in 191 Indonesian women with 3-12 months of exposure to Norplant: microhysteroscopy with biopsy forceps (n = 87), Pipelle suction curette (n = 52), and Karman cannula (n = 52). Diagnosable endometrium were obtained in 51%, 42%, and 58% of these procedures, respectively. Use of the microhysteroscope often resulted in the collection of full thickness endometrium, including a small amount of myometrial tissue, but the endometrium was always very thin or absent. In contrast, both the suction curette techniques collected endometrial tissue only. Women from whom successful endometrial biopsies were obtained tended to have significantly more days of endometrial bleeding in the 90 days preceding biopsy (26.5 +or- 2.1 versus 16.2 +or- 1.8) and higher mean peripheral estrogen concentrations in the 2 weeks preceding biopsy (439 +or- 35 versus 289 +or- 33 pmol/l). The fact that the group from which successful biopsies are obtained may not be representative of all Norplant users should be considered in the analysis of clinical research.
Endometrial vasculature in Norplant users: preliminary results from a hysteroscopic study.
Endometrial biopsies collected from Norplant users have revealed an increase in endometrial microvascular density after 3-12 months of use. Moreover, morphologic changes in endometrial capillaries after progestogen exposure have suggested increased vascular fragility. In this study, hysteroscopy, and the attendant imposition of mechanical stress on the endometrium, was used to identify in vivo characteristics of the endometrial vasculature in 34 Norplant acceptors from Australia. A total of 24 women presented for hysteroscopy during a bleeding episode. Superficial vascularity appeared to increase as early as 1 month after Norplant insertion. Women with a relatively avascular endometrial surface experienced less bleeding than those with extensive networks of superficial vessels. Common were areas of dense vascularity adjacent to areas that appeared pale and relatively avascular. Dilated superficial vessels, observed in 1/3 of cases, were associated with more breakthrough bleeding in the previous 30 days. Unexpected was the predominance of petechiae and ecchymoses in the endometrium of Norplant users. Profuse bleeding at deflation and reflation of the uterine cavity was observed in most subjects and was also associated with an increase in breakthrough bleeding. Larger vessels appear to be the site of the breakthrough bleeding. The role of mechanical stress in the initiation of bleeding may be important in spontaneous menstrual bleeding, especially when vessels are made fragile by lack of stromal support due to progestogen-induced endometrial atrophy.
Progesterone receptor in Norplant endometrium.
Research on the effects of levonorgestrel on endometrial progesterone receptors in Norplant users is critical to reducing the menstrual disturbances associated with this contraceptive method. Studies conducted during the normal menstrual cycle have indicated that the concentrations of endometrial progesterone receptor and its mRNA vary in glandular epithelia but remain steady in stromal cells. The endometrium in Norplant users shows an increase in immunoreactive progesterone receptor concentration but a reduction, compared to controls, in progesterone receptor mRNA levels. Overall, the clinical research suggests: 1) there is a differential sensitivity of glandular and stromal progesterone receptors to steroid regulation during the normal menstrual cycle; 2) there appears to be a dissociation between the concentrations of progesterone receptor and its mRNA in Norplant endometrium; and 3) there are significantly more progesterone receptor mRNA and lower plasma estrogen concentrations in Norplant users with amenorrhea than in those with normal menstrual bleeding.
The potential of an estradiol patch (100 mcg/day for 6 weeks) to reduce the menstrual disturbances associated with progestogen-only contraception was investigated in 98 Norplant users. Of the 64 subjects reporting abnormal bleeding, 33 were given an estradiol patch and 31 received a placebo patch; the 34 Norplant users with normal bleeding patterns served as controls. Clinical improvement was recorded in 23 estradiol patch and 13 placebo patch subjects, a nonsignificant difference. Ovarian activity, demonstrated by fluctuating high levels of estrogen, occurred in most Norplant users, but without ovulation. Serum levonorgestrel concentrations ranged from 1000 to 1500 pmol/l, with no significant differences according to group. Sex hormone-binding globulin (SHBG) levels were low (range, 20-50 nmol/l), again with no significant group differences. Both levonorgestrel and SHBG concentrations were steadier in women with normal bleeding patterns. Histology revealed that endometrial specimens from Norplant users were more atrophic than proliferative. Significantly increased mean immunostaining scores of stromal progesterone receptor were noted in Norplant users whose endometrium appeared atrophic. Also observed were low estrogen receptor concentrations in both glandular and stromal compartments. Overall, these findings suggest that progestogen-related bleeding abnormalities are related to the bioavailability of estrogen and progesterone receptors in the endometrium rather than histological changes.
Oestrogen treatment for increased bleeding in Norplant users: preliminary results.
A clinical study conducted in Indonesia confirmed the effectiveness of ethinyl estradiol and ethinyl estradiol plus levonorgestrel for the treatment of the frequent, prolonged, and irregular bleeding associated with Norplant use. The 91 subjects were randomly allocated to receive, for 3 weeks, 50 mcg of ethinyl estradiol, a combined pill containing 30 mcg of ethinyl estradiol and 150 mcg of levonorgestrel, or a placebo. To date, 48 subjects have completed a 90-day post-treatment menstrual diary. Among this subgroup, only ethinyl estradiol alone reduced significantly (p < 0.02) the number of bleeding/spotting days during the 21-day treatment period. In the 90 days after treatment, both ethinyl estradiol and the combined pill significantly (p < 0.05) reduced bleeding/spotting compared to the 90 days preceding treatment; moreover, the length of each bleeding/spotting episode was significantly (p < 0.05) shorter. Although 84 women completed 2 biopsies (before treatment and at day 14 or 21), adequate endometrial tissue at both time points was obtained from only 33 women. Histopathologic analysis revealed no obvious effect of either ethinyl estradiol or the combination pill on endometrium exposed to the levonorgestrel subdermal implant for an average of 8 months.
All endometrial epithelium contain the cytoskeletal intermediate filaments cytokeratins 8, 18, and 19. The aim of this study was to observe changes in the expressions of these cytokeratins in endometrial epithelial cells from Indonesian women receiving norethindrone enanthate and to compare them with the patterns of expression reported for Norplant users. Study subjects received 2 norethindrone enanthate injections (150 mg) spaced 8 weeks apart. Regardless of bleeding pattern or histopathologic finding, epithelial tissues from these 7 women stained either strongly or intensely for cytokeratin, including isolated epithelial fragments from unclassified biopsies. Surface and glandular epithelia from norethindrone enanthate users consisted of a single layer of high columnar cells, with no obvious differences between proliferative-like and secretory-like endometria. In contrast, surface epithelial tissue from 37 Norplant users showed weaker immunostaining and epithelial cells were rounded and stratified. No relationship between cytokeratin expression and breakthrough bleeding pattern was detected. These findings suggest that norethindrone enanthate and Norplant act differently on endometrial epithelial cytokeratin, with women receiving the former contraceptive agent showing a cytokeratin distribution similar to that seen in the normal menstrual cycle. The capability of norethindrone enanthate to preserve epithelial integrity may have implications for reducing the incidence of progestogen-related breakthrough bleeding.
A review of recent research indicates that three forms of abnormal uterine bleeding, ovulatory and anovulatory dysfunctional uterine bleeding and progestogen-related breakthrough bleeding, are associated with different local endometrial molecular mechanisms. Moreover, the wide variety of local substances that control endometrial breakdown and repair are altered by circulating concentrations of exogenous and endogenous steroid hormones. Ovulatory dysfunctional uterine bleeding is associated with a series of vascular and hemostatic disturbances that all appear to contribute to increased loss of blood and tissue fluid at menstruation. Anovulatory dysfunctional uterine bleeding is associated with obvious disturbances of endometrial histology, vascular morphology, and fragility, with variable and increased blood flow. Progestogen-related breakthrough bleeding is associated with a multitude of morphological and functional endometrial changes that appear to relate predominantly to a patchy capillary origin for the bleeding. It remains unclear whether there is a single but different underlying mechanism responsible for these multiple abnormalities in each of the three clinical situations. A greater understanding of these mechanisms has the potential to increase use of effective contraception since menstruation disorders are the most frequent cause of method discontinuation.
Occasional condom use and HIV risk reduction.
The emphasis of acquired immunodeficiency syndrome (AIDS) prevention programs on consistent condom use has tended to obscure the benefits of occasional condom use for individuals who are unable or willing to use a condom every time. Mathematical model-based estimates of the probability of human immunodeficiency virus (HIV) transmission indicate that occasional condom use can significantly reduce the threat of infection, especially during the long asymptomatic period between initial infection and the development of AIDS. In the Bernoulli-process model, each sexual contact with an infected partner is treated as an independent trial capable of transmitting HIV. Although this model could be improved by the incorporation of additional terms reflecting variability or heterogeneity in infectivity, it confirms that the probability of seroconversion decreases in a dose-response fashion with the proportion of condom use. Relative risk reduction estimates can be reduced by approximately 50% by using 90% effective condoms for 50-70% of all sexual contacts. However, if the infectivity is very high, as in the case of receptive anal intercourse with a recently infected partner, condoms provide relatively little protection even when used consistently. Although consistent condom use should remain the ideal, AIDS prevention efforts that stress harm reduction rather than absolutism may be more effective.
Interpreting HIV seroprevalence data from pregnant women.
On the basis of the assumption that human immunodeficiency virus (HIV) seroprevalence among pregnant women is representative of all women in the general population, serosurveillance of pregnant women with unlinked anonymous testing has become a standard estimation technique. However, the ratio of prevalence in pregnant women to that in all women is influenced by HIV-related risk behaviors (e.g., condom usage, rate of partner change, migration, socioeconomic status, knowledge of HIV-positive status, and presence of other sexually transmitted diseases) that are different for pregnant and nonpregnant women as well as by differences in fertility levels between infected and uninfected women. Moreover, this approach neglects potential sources of bias, including age, geographical location, culture, and dominant mode of HIV transmission. Proposed, to overcome these complexities, is a model that incorporates the identification of risk factors, estimation of their effect, the proportion of the population exposed to each of these features, and the HIV prevalence in pregnant women to estimate the prevalence in the female population in specific populations. Since both fertility and most HIV risk factors are associated with age, the model is stratified by age. Also reflected in the model are the three modes of HIV transmission: heterosexual, injecting drug use, and transfer of infected blood products. Taking as its inputs population-specific data on the HIV and fertility risks for the relevant features, as well as the size of the groups exposed to them, the model can produce estimates of the HIV prevalence due to heterosexual transmission for that population.
Fertility options after vasectomy: a cost-effectiveness analysis.
Calculations of cost per delivery for vasectomy reversal versus sperm retrieval-intracytoplasmic sperm injection (ICSI) under a wide variety of initial assumptions clearly indicate that vasectomy reversal is associated with lower costs per delivery and higher delivery rates. The data for the models on average postvasectomy infertility costs were derived from 6 specialized medical centers in the US in 1994; only men with female partners 39 years or younger were included. The overall vasectomy reversal pregnancy rate was 52%, with an estimated live delivery rate of 47%; for sperm retrieval and ICSI procedures, the mean weighted delivery rate per attempt was 33%. The average cost per delivery for vasectomy reversal (including pretreatment evaluation, surgeon's fee, anesthesia, ambulatory charges, complication costs, lost work costs, and delivery costs weighted for the number of procedures performed at each center) was US $25,475 (95% confidence interval, $19,609-31,339). In contrast, the cost per delivery after sperm retrieval and ICSI was US $72,521 (95% confidence interval, $63,357-81,685), with an average of $73,146 for percutaneous or testicular sperm retrieval and $71,896 for surgical epididymal sperm retrieval. Overall inpatient charges for delivery of a singleton gestation were $9845 ($37,947 for twin gestations and $109,765 for triplet gestations). Unless microsurgical epididymal sperm aspiration results improve dramatically or ICSI procedural costs and multiple gestation rates decrease, vasectomy reversal will remain the indicated treatment for men interested in fertility restoration after vasectomy.
Psychosocial risk factors for HIV infection.
The associations between high-risk sexual practices and measures of psychosocial functioning were investigated, for the study reported in this doctoral dissertation, in a convenience sample of 21 human immunodeficiency virus (HIV)-positive and 22 HIV-negative homosexual men 18-60 years of age from Montreal, Canada, matched for age and age at first intercourse. About 25% of men in both groups had engaged in unprotected oral and anal intercourse with a partner known to be HIV-infected. Overall, 17 (30%) subjects could be diagnosed as alcoholic according to the Michigan Alcoholism Screening Test (MAST). Moreover, both groups reported a high incidence of use of alcohol, marijuana, inhalants, or cocaine in association with sexual behavior. MAST scores were significantly correlated with lifetime condom use, while social support was significantly associated with the lifetime number of homosexual partners. Clinical levels of anxiety and depression were within the normal range in both groups, as were measures of self-esteem in interpersonal situations and risk-taking personality attributes. Only 2 factors, lifetime number of sexual partners and the percentage of 1-time partners, differentiated HIV-positive and HIV-negative men; the former group scored higher on both measures. Regression analyses revealed a significant negative association between MAST scores and social support and a positive relationship between social support and CD-4 cell count.
Although adolescent sexuality has been the focus of a substantial body of research, the instruments used in many of these studies lack methodological rigor. Few studies publish their data collection instruments or report measures of reliability and validity. The purpose of the study reported in this master's thesis was the development and psychometric testing of a self-administered questionnaire to measure adolescent sexual behavior and contraceptive use. The draft questionnaire was assessed for content validity by 5 experts and examined for its readability. Then it was pretested with 25 Canadian students in grades 10-12 before it was administered to 59 additional students. One month later, the instrument was re-administered to 54 of these students. Item-item correlations between the test and retest indicate that 42 out of 48 items had significant reliability correlation coefficients over 1 month. Unclear directions, a small number of respondents who had engaged in anal sex, and a lack of interest in answering the same questions twice may have affected the stability reliability of these items. Although some open-ended questions were included to allow teens to define their own frame of reference, these items often produced inappropriate or nonspecific responses. The reliability of responses about sexual activity in the recent and distant past tended to reflect the degree of importance respondents placed on the sexual event, the response format, and the clarity of the question. Among the recommendations to improve the instrument are more close-ended formats on sexual history items; restriction of contraceptive methods listed to condoms, oral contraceptives, rhythm, and withdrawal; and simplification of instructions for those who have never had sexual intercourse.
Does the use of contraception reduce the risk of pregnancy-induced hypertension?
During 1988-1994 in Spain, data on 113 primigravidae with pregnancy-induced hypertension were compared with data on 109 age- and parity-matched controls to examine the effect of exposure to spermatozoa on the risk of developing pregnancy-induced hypertension. Both cases and controls delivered at the Hospital Clinic of the University of Barcelona in Spain. Duration of unprotected sexual intercourse was about 50% shorter in cases than controls (2.3 vs. 4.7 months; p < 0.0001), regardless of previous contraceptive method used. In women having no previous exposure to spermatozoa, women with pregnancy-induced hypertension had reduced exposure to spermatozoa (i.e., unprotected sexual intercourse) than the controls (2.8 vs. 4.7 months; p < 0.01). In women who had used oral contraceptives (OCs), cases had a significantly shorter duration of unprotected sexual intercourse than controls (2.1 vs. 4.7 months; p < 0.001). Duration of exposure to father's spermatozoa with condoms had no effect on pregnancy-induced hypertension. Women with pregnancy-induced hypertension were more likely to conceive during the first month of unprotected sexual intercourse than the healthy women (48.6% vs. 25.6%; p < 0.001). They were also more likely to conceive during the first three months of unprotected sexual intercourse than controls (85.8% vs. 54.1%; p < 0.00001). This was especially true for women with preeclampsia (91.5% vs. 54.1%; p < 0.0001) and when compared to those with gestational hypertension (79.6% vs. 54.1%; p < 0.01). These findings do not support the belief that OCs protect against pregnancy-induced hypertension. They suggest that increased exposure to father's spermatozoa reduces the risk of pregnancy-induced hypertension. In conclusion, use of contraception to reduce the risk of pregnancy-induced hypertension is not a likely viable public health option.
Clinical profile and risk factors for oral candidosis in sick newborns.
During February-September 1992, all 650 infants admitted to the neonatal intensive care unit of the University College of Medical Sciences and G.T.B. Hospital were screened for oral thrush. A case control study was conducted to determine risk factors for oral candidiasis in newborns. The rate of oral candidiasis in this population was 3.2% (20 cases). The most common pathogen was Candida albicans (50%). All but 1 oral thrush case had acute pseudomembranous candidiasis. 75% of oral thrush cases were asymptomatic. Mean age of onset was 10.4 days (median, 9.5 days). Clotrimazole solution was applied to oral lesions of all oral thrush cases. The multiple logistic regression revealed that birth asphyxia was the only significant factor responsible for oral thrush in newborns (odds ratio = 8.09; p = 0.0226). These findings show that the most important perinatal event associated with oral thrush in newborns was birth asphyxia.
During October 1989-April 1990 at two large hospitals in Kinshasa, Zaire, 342 HIV-infected women were enrolled in a prospective study designed to estimate the time of mother-to-child transmission of HIV to breast-feeding infants. The women delivered 323 live-born infants (including 7 sets of twins) and 8 stillbirths. The infants were monitored, on average, for 18 months. HIV serodiagnostic tests used included polymerase chain reaction (PCR), HIV culture, or ELISA. 69 (26%) of the 261 infants with sufficient data for determination of HIV status tested positive for HIV. Among the HIV-infected infants, 23% acquired HIV during the intrauterine period, 65% during the intrapartum/early postpartum period, and 12% during the late postpartum period. The estimated risk was 6% for intrauterine transmission, 18% for intrapartum/early postpartum transmission, and 4% for late postpartum transmission. It is suggested that breast feeding was the risk factor for late postpartum transmission of HIV. These findings show that most vertical transmission of HIV occurs during labor and delivery or in the early postpartum period. Nevertheless, there is a considerable risk of HIV transmission related to breast feeding during the postpartum period.
Oral contraceptives and primary liver cancer: temporal trends in three countries.
Researchers used incidence data on primary liver cancer in Japan, Sweden, and the US and mortality data from the same countries to determine whether or not there is a temporal association between the introduction of oral contraceptives (OCs) and the incidence of, and mortality from, primary liver cancer. An examination of the vital statistics from the three countries did not reveal a temporal association between the introduction of OCs and primary liver cancer. In fact, primary liver cancer incidence and mortality rates were not significantly different between cohorts of women exposed to OCs and women who could not have used OC users. Trends in the incidence and mortality rates of primary liver cancer among women and men were similar. Various explanations may account for the observed lack of association between OC use and primary liver cancer. For example, OC users may face no increased risk of primary liver cancer and the studies that found a large risk were biased. These findings suggest that, if indeed OCs increase the risk of liver cancer, the public health impact seems negligible.
The study described in this doctoral dissertation was intended to characterize the risk of HIV infection among blood donors, quantify the risk of HIV contamination in the blood supply, and assist the development of effective strategies to defer blood donors at highest risk of HIV infection. Data on blood donors in Zimbabwe were taken from the published literature, a survey, a longitudinal cohort study and from blood donor records. The modeling techniques included multiple and conditional logistic regression, Poisson regression, CART analysis, decision analysis, and cost-effectiveness analysis. Identified risk factors for HIV seropositivity among adult first-time blood donors were worksite and community hall recruitment, age greater than 22.5 years, married, occupation as a driver, high density and non-urban residence, history of a sexually transmitted disease (STD), and condom use (a marker for high-risk behaviors). Among repeat donors, the risk factors for HIV seroconversion included worksite and St. George Clinic recruitment, age 20-45 years, unemployment, high density and non-urban residence, weight loss between blood donations, and lapsed donor status. Among male factory-recruited donors in Harare, the risk factors for HIV seropositivity were first time and lapsed donor status, age greater than 25 years, married, having paid for sex, multiple sex partners, beer hall visiting, and condom use with a non-primary partner. Risk factors for HIV seroconversion in the same population included age less than 25, single, pending marriage or divorce, genital ulcer disease, and condom use with a non-primary partner. Potential sources of HIV contamination in the Zimbabwean blood supply were laboratory false negatives, window period donations, and human error. Based on these findings, risk factor deferral strategies are proposed for each group studied. For example, among first-time adult donors in Harare, Zimbabwe, workers in an HIV diagnostic laboratory should defer donors older than 22.5 years who use a condom with a non-primary partner or were recruited at a worksite with a history of STD in last 10 years or who live far from their partners.
For the study described in this doctoral dissertation, during April 1993-March 1994 at health facilities in Chiredzi district, Masvingo province, Zimbabwe, maternal blood samples and cord blood samples were collected from 277 parturient women 15-49 years old. The purpose was to determine the antibody prevalence rates of Plasmodium falciparum, HIV-1, and HTLV-I/II in these women and their neonates. The P. falciparum parasite rate was 1.08%. The ELISA positivity rates for IgG, IgM, and IgE were greater in maternal blood than in cord blood (50.2% vs. 24.9%, 91.2% vs. 14.9%, and 22.7% vs. 2.7%, respectively; p < 0.001). Cord antibody rates tended to be independent of maternal antibodies. P. falciparum IgG rates were associated with parity only when parity was categorized into parity 1 and parity 2 or greater (p = 0.0035). The immunoblot positivity rates for P. falciparum IgG, IgM, and IgE were not consistently greater in maternal blood than in cord blood (78.1% vs. 72.5%, 39.6% vs. 14.3%, and 1.33% vs. 1.33%, respectively). Matched maternal and cord sera with very strong to strong IgG immunoblot reactivities were nearly homologous for each pair. The antigen complexes in the positive IgG immunoblots 195- to 170-, 91- to -75, and 48-kDa were the most prevalent and strongest complexes. 33% of the maternal sera had both IgM and IgG antibodies. 34.9% of mothers were confirmed HIV-1 seropositive. Women 31-35 years old had the highest HIV-1 seropositive rate (54.5% vs. 33.3-50.6%). 87% of parturients were positive for HTLV-I/II by ELISA, while the Western blot found no HTLV-I/II infection in 48.4% and an indeterminant finding in the remaining 56.2%. This suggests early HTLV-I/II infection. Among matched pairs, HIV-1 negative cases were more likely to have P. falciparum IgG antibody reactivity than HIV-1 positive cases (91.7% vs. 49.1%; p < 0.001), suggesting that HIV-1 effects immunosuppression of P. falciparum IgG antibodies.
In Australia, endometrial biopsy data on 11 women 18-40 years old from Sydney, who had accepted the contraceptive implant Norplant, were compared with similar data on 20 controls from Melbourne who used no contraception, and endometrial biopsy data before Norplant insertion were compared with similar data 3-6 months after Norplant insertion. The aim was to examine the distribution and staining pattern of endometrial microvascular basement membranes (BMs) in biopsies of these women. The BM components considered were collagen IV (CIV), laminin, and heparan sulphate proteoglycan (HSPG). It was hypothesized that a reduction in the amount of BM material around endometrial vessels in Norplant users might effect increased capillary fragility. Vascular BM immunostaining in the Norplant biopsies was similar to that in the mid-late secretory phase of the normal cycle. HSPG was present in only about 40% of vessels with CIV and laminin immunoreactivity. Reduced staining of all BM components was the case in the menstrual biopsies. Regional variability in staining intensity was present in several biopsies. Endometrial biopsies of Norplant users had areas of distinct, decidual-like stromal immunostaining for CIV and laminin. These findings did not identify a mechanism for progestogen-induced breakthrough bleeding. Other techniques could provide information on changes in the integrity of FM components that might effect BM strength.
An assessment of health and family planning needs in rural Chittagong. Volume 1.
In the rural subdistricts (thanas) of Anowara, Boalkhali, Lohagora, Rangunia, and Sitakunda in Chittagong district, Bangladesh, a multistage operations research (OR) study was conducted to assess management factors that influence the accessibility and use of health services and maternal-child health/family planning (MCH-FP) services, and to help local program managers in developing an action plan for program improvement. The contraceptive prevalence rate (CPR) ranged from 35% to 47%. About 50% of married women of reproductive age (MWRA) wanted no more children. More than 75% of nonusers planned to use contraception in the future. Clients had limited awareness about satellite clinics and health and family welfare centers, explaining the low attendance rates (4-17% and 30-50% of MWRA, respectively). In the previous 2 months, family welfare assistants (FWAs) or field workers from a nongovernmental organization (NGO) had visited less than 20% of MWRA at their homes. CPR increased greatly with contacts with FWAs or NGO workers. 70-90% of MWRA attended immunization sites or had received the tetanus toxoid shots. In all 5 thanas, the vacancy rate for FWAs and health assistants was high. At satellite clinics, 50% of clients sought curative services for themselves or their children. Another 50% sought MCH-FP services. These findings suggest that strengthening field activities will further improve the use of health and MCH-FP services. Based on these findings, participants in a January 1996 district approach workshop in Chittagong were advised to focus on improving client-worker contact and the management of fixed-site service centers. Workshop participants also identified responsibilities for managers at various program levels to achieve improvements and a time frame for completion of various activities.
Perinatal outcome in pregnancy induced hypertension.
During December 1989-May 1991 in India, a prospective study was conducted of 140 pregnant women with hypertension admitted to Kamla Nehru Hospital in Shimla to examine pregnancy outcomes. These women represented 4.1% of all pregnant women admitted to this hospital during the study period. 52.8% of the 140 women were primigravidae. The mean diastolic blood pressure was 99.9 mmHg. The mean arterial pressure was 113.7 mmHg. 21 (14%) of the 149 infants (9 being twins) born to these women died, for a perinatal mortality rate (PMR) of 140/1000 births. 13 of the perinatal deaths were stillbirths, for a stillbirth rate of 8.7%. PMR increased as blood pressure increased: 9.5% for 140/90-149/94; 38% for 150/95-159/109; and 52.3% for 160/110 and above. Low birth weight (=or- 2000 g) infants comprised 17.4% of all births. All perinatal deaths had increased serum uric acid levels (>4.5 mg%). PMR was highest for serum uric acid levels of 7.6-8.5 mg% (28.5% vs. 9.5-23.8%). Based on these findings, obstetricians are advised to regularly check the blood pressure and serum uric acid levels of pregnant women in order to reduce hypertension-related PMR.
In India, data on 50 newborns delivered vaginally and data on 50 other newborns delivered by cesarean section for cephalopelvic disproportion were analyzed to compare the maternal and cord blood levels of immunoglobulin G (IgG) and immunoglobulin M (IgM). The mothers were 21-33 years old. Hemoglobin levels ranged between 10 and 12 g/dl. For cord blood, normal delivery cases had a higher IgG level than cesarean section cases (1653 vs. 898.3 mg/dl). For maternal blood, however, the IgG level was not significantly different (1310 mg/dl for vaginal and 1275 mg/dl for cesarean section). Seven of the 50 mothers who delivered by cesarean section had a severe fever. All their newborns had higher IgG levels than other cesarean section cases and vaginal delivery cases (1060 vs. 896 mg/dl). IgM maternal and cord blood levels were not significantly different between the two groups. These findings suggest a need for prophylactic measures to prevent complication of neonatal sepsis.
Hypokalemia in a pediatric intensive care unit.
Data were analyzed on 290 children admitted consecutively to the pediatric intensive care unit (PICU) of the Postgraduate Institute of Medical Education and Research in Chandigarh, India, in 1993 to examine the frequency, severity, risk factors, and mortality of hypokalemia (<3.5 mEq/l serum potassium) and the efficacy of treatment. 43 (14.8%) children had 54 episodes of hypokalemia. Most (68.6%) episodes were moderate. Predisposing factors were the nature of primary disease (renal disease 19%, septicemia 19%, acute diarrhea 14%, and heart disease with congestive failure and meningoencephalitis 12% each), malnutrition (weight for age <80% in 72%), and treatment with drugs (diuretics 20%, beta-agonists 13%, and corticosteroids 11%). Diagnoses most common in hypokalemia cases were acute renal failure (25%), septicemia (22.8%), and acute severe bronchial asthma (20%). The most important predisposing factor for hypokalemia prior to hospitalization was poor oral intake (i.e., inability to replace adequate potassium) (27%). All 43 children received 4-6 mEq potassium/100 ml of intravenous fluids. Clinicians administered an infusion of 0.3 mEq potassium/kg/hour to 7 children (9 episodes) who had ECG changes of hypokalemia until the ECG became normal. Potassium levels returned to normal in all 9 episodes requiring rapid correction and in 40 of 45 episodes requiring slow correction. PICU patients with hypokalemia were more likely to die than PICU patients with no hypokalemia (25.6% vs. 10.9%; p < 0.05; odds ratio = 2.34). Hypokalemia patients who received slow correction therapy were more likely to die than those who received rapid correction therapy (31% vs 0; p < 0.05). Mortality was lower in PICU patients whose hypokalemia was corrected than in PICU patients whose hypokalemia was not corrected (13.5% vs. 100%; p < 0.05). Based on these findings, regular monitoring and rapid correction are recommended to improve the outcome of hypokalemia.
Nutritional adequacy of boys in orphanages.
In India, nutritionists gathered information on dietary intake, measured the diet, and calculated nutritional composition of the diet of 118 boys, 4-12 years old, living in all the orphanages in Udaipur, to determine the adequacy of their diet. The orphans consumed inadequate amounts of all food stuffs. For example, the boys consumed 76.2-91.5% of recommended intake for cereals, 30% for pulses, less than 50% for milk, and 30-45% for fats and oils. They consumed almost no leafy vegetables (0/75 g for 4-6 year olds; 1.5/75 g for 7-9 year olds; and 0.8/100 g for 10-12 year olds), but they consumed more than the recommended intake of other vegetables. The orphans were not provided fruits, meat, fish, or eggs. Only those 4-6 years old had adequate intake of protein. Energy and calcium intakes were significantly low in all age groups (p < 0.01, except for calcium intake in 4-6 year olds [p < 0.05]). In all age groups, phosphorous intake was adequate while iron intake was significantly lower than the recommended daily intake (p < 0.01). Beta-carotene intake was insufficient in all age groups (p < 0.01). In fact, beta-carotene intake in 7-9 year olds did not even reach 20% of the recommended daily intake. Only the 4-6 year olds had adequate intake of niacin. Vitamin C intake was 30% of recommended levels. These findings show that these school age orphans had inadequate intake of almost all nutrients due to a daily diet limited in cereals, pulses, milk and milk products, leafy vegetable, fats and oils, and sugar. The orphanages should include seasonal green vegetables and other low-cost nutritious foods in the diet of orphan boys.
Effect of bathing on temperature of normal neonates [letter]
In Bangalore, India, the department of pediatrics of St. John's Medical College Hospital conducted a study to determine the effect of bathing on the body temperature of 35 healthy, full-term newborns. Nursing trainees bathed the newborns with warm water and dried them with a towel. They then wrapped the clean newborns. The bathing procedure lasted 3-5 minutes. Temperatures were recorded by placing a low reading mercury-in-glass thermometer in the top of the left underarm area. They held the left arm against the newborn's side for 3 minutes. They recorded axillary temperatures 30 minutes before the bath, immediately after the bath, and 60 minutes after the bath. Hypothermia was defined as axillary temperature below 36.5 degrees Celsius and severe hypothermia as below 35 degrees Celsius. The babies tended to be uncovered before bathing. This study aimed to address the belief that bathing causes heat loss in newborns.
From data to decision making in health: the evolution of a health management information system.
This book focuses on self-assessment and action related to monitoring and supervision of a health management information system (MIS). MIS is intended to address the problem of overburdened health workers collecting quantities of useless or unused information as well as the scarcity of vital data available for analysis or managerial planning. The case study is detailed of the transition from a traditional reporting system to MIS in three regions of Ghana. The first chapter addresses reasons for implementing MIS. Chapter 2 describes the project design, including process and objectives. Chapter 3 explores the tools used for planning and data collection as well as those for self-assessment and reporting. Perhaps the most important step of the MIS process is addressed in Chapter 4: the development and introduction of self-assessment tools, including 45 essential indicators that can be graphed easily at any level of the system. The graphs serve to stimulate discussion during regular management team meetings at that level. Chapter 5 looks at the achievements to date and major project outputs. The last chapter examines obstacles and answers to a series of critical questions for designing, developing, and implementing an MIS. The annexes cover self-assessment tools: instructions for using the tools and examples of completed self-assessment tools (primary health care coverage assessment and primary health care: continuity/quality of care assessment).
In terms of medical liability, fears of the clinician and of the patient about the IUD tend to be based on impressions rather than on study data and facts. Clinicians need to understand common situations that may end in legal action and how to prevent litigation. Only 1% of US women use the IUD compared to 19% in Germany and 26% in Sweden. A 1990 California study reveals that clinicians refuse to recommend the Copper T 380A IUD to female patients because of fear of liability (40%) and issues related to medical safety (30%). Between 1982 and 1988 (the peak period of liability battles related to the Dalkon Shield), IUD use fell by 66% from 2.2 to 0.7 million. Only 10% of past IUD lawsuits in the US alleged physician liability, the remaining cases were against the manufacturer for product liability. The lawsuits brought about IUD regulations that ensure clinical safety and efficacy of IUDs. As a result of these lawsuits, the manufacturer of the progesterone-releasing IUD developed a new package insert and a patient information booklet that required a signed consent form prior to IUD insertion. Since 1988, there has been only one lawsuit filed against the manufacturer of the Copper T 380A. The case involved a broken IUD in utero, resulting in partial perforation. IUD users have maintained favorable attitudes toward the IUD during 1985-1991. Common problems that can lead to lawsuits include failure to document warning discussions, failure to use detailed labeling provided by the manufacturer, use of inappropriate statements or statements not based on fact, change of medical records after the fact, and criticism of manufacturers or other health care providers. Some keys to preventing litigation about IUDs and other prescription products are: know the drugs/product; know the product design inserts; use detailed patient information leaflets and informed content; and carefully document discussions with the patient concerning warnings, side effects, and any product information materials given to the patient. Physicians should maintain a concerned, caring attitude with the patient and a nonjudgmental relationship with the patient and colleagues.
An economic model was developed to compare the effectiveness and costs per person of 15 contraceptive methods (tubal ligation, vasectomy, oral contraceptives, implants, injectables, progesterone-releasing IUD, Copper T 380A IUD, diaphragm, male condom, female condom, sponge, spermicides, cervical cap, withdrawal, and periodic abstinence). An assumption of the model was uninterrupted contraceptive use for 1, 2, 3, 4, or 5 years of all sexually active women of reproductive age in the US. Number of pregnancies avoided (difference between number of expected pregnancies if no contraception is used and number of expected pregnancies during perfect use of a specific method) was the primary outcome measure for each method. The model included costs of side effects and unplanned pregnancy. It assumed managed payment costs. Over the 5-year period, each contraceptive method was significantly more effective and less expensive than no use. At 1 year in the managed payment model, the least expensive contraceptive was the injectable contraceptive, while the most expensive model was tubal ligation. Beginning at 2 years and throughout 5 years, however, the Copper T 380A IUD was the least expensive method (at 5-years; $540 vs. $764-$5730). When the model combined number of pregnancies avoided and 5-year savings for each method and for no contraceptive use (at 5 years, 4.25 pregnancies at a cost of $14,663), the researchers found the most relatively cost-effective methods to be the Copper T 380A IUD ($14,122 in savings, 4.229 pregnancies avoided), vasectomy ($13,899 in savings, 4.248 pregnancies avoided), and the contraceptive implant ($13,813 in savings, 4.234 pregnancies avoided). In conclusion, contraceptives save health care resources. This analysis reminds clinicians that up-front acquisition costs for contraceptives are inaccurate and unreliable predictors of total costs of competing contraceptive methods.
National Iodine Deficiency Disorders Control Programme in India.
In India, 167 million people are at risk of iodine deficiency disorders (IDDs). 54.4 million people have a goiter. About 8.8 million people have IDD-related mental/motor handicaps. IDD is a problem in every state and union territory. It is a major public health problem in 211 of the 245 districts surveyed. Even though IDDs cannot be cured, they can be easily prevented. Daily consumption of iodized/iodated salt is the most effective and inexpensive way to prevent IDD. In 1962, the government of India implemented the National Goitre Control Programme, now called the National Iodine Deficiency Disorders Control Programme (NIDDCP). In 1982, the government made a policy decision to iodate all edible salt in India by 1992. During 1994-1995, India's private sector produced 34 lakh metric tons of iodated salt per year. The government expects iodated salt production to increase to 50 lakh metric tons in the near future. Iodated salt is transported on the railways under a priority category that is second only to defense. In 19 states and 6 union territories, the sale of noniodated salt has been completely banned. The remaining state governments have been urged to ban the sale of noniodated salt and to include iodated salt under the public distribution system. Each State Health Directorate has been advised to set up an IDD Control Cell. The biochemistry division of the National Institute of Communicable Diseases has a national reference laboratory for monitoring of IDD, and it also trains medical and paramedical personnel. District health officers in all endemic states have test kits to conduct on-the-spot qualitative testing to ensure quality control of iodated salt at the consumption level. NIDDCP provides IDD surveys, health education, and publicity campaigns. Its information, education, and campaign activities include video films, posters, and radio/TV spots.
Contraceptive use and AIDS protective sexual behaviors in the era of AIDS.
For the study described in this doctoral dissertation, data on 402 college students (172 males and 230 females) were analyzed to better understand the variables influencing HIV/AIDS-protective sexual behaviors. Students who had never been sexually active answered questions somewhat differently than students who had sexual experience. Thus, the analysis included only participants who had had vaginal intercourse in the previous six months. Many variables, both individually and in combination, are associated with contraceptive and HIV/AIDS-protective behavior. Social network influences from family, friends, and partners were associated with effective HIV/AIDS-protective sexual behavior. Religiosity and its accompanying beliefs and self-efficacy were among the various factors related to protective behavior against AIDS, sexually transmitted diseases, and pregnancy. Substance abuse was among the factors associated with risk behavior. The dissertation maintains that information alone on prevention of HIV/AIDS and unwanted pregnancy is not sufficient to change behavior. Needed are interventions that also address self-efficacy, beliefs, social networks, and sex attitudes.
For the study outlined in this doctoral dissertation, in Abia State, Nigeria, focus groups and interviews were conducted with female adolescents, women, and parents, all members of the Afikpo Ibo ethnic group, to examine the effects of social change on adolescent sexual norms and behaviors, especially changes in the patterns of sexual socialization. Traditionally, adolescents tended not to be sexually active outside of marriage, and out-of-wedlock pregnancies were rare. Societal mechanisms regulated adolescent pregnancy and sexual activity. They included early marriage, process of rites of passage (e.g., circumcision) or social management of sexualization, cultural responses to biological developments, punishment for pregnancy out-of-wedlock, and rewards for pregnancy within marriage. In modern Afikpo society, sexual activity begins quite early, knowledge about family planning methods is low, and, among girls who know about these methods, family planning use is low. Thus, the rates of out-of-wedlock pregnancies, of abortion, and of maternal mortality among adolescent females are high. Modernization has ushered in the breakdown of the societal mechanisms controlling sexual socialization. Nothing has replaced the social management of sexualization (i.e., rites of passage). The family is now expected to teach sexual behavior. Girls are now being prepared for careers outside the family and outside the community rather than merely to become wives and mothers. Yet, they receive very little information about preventing pregnancy and are faced with reproductive risks. Based on these findings, it is recommended that schools institute effective family life/sex education and not suspend pregnant students.
For the study detailed in this doctoral dissertation, data from 533 freshmen students attending Appalachian University were analyzed to examine gender differences in the cognitive determinants of condom use decision making. The questionnaire used was based on Ajzen's Theory of Planned Behavior. This model accounted for 66% of the variability in intention to use a condom at next intercourse for all students, for females, and for males. When the analysis was focused on females, the gender variables were not statistically significant. For males, communication about condoms as women's work and stage of the relationship were significant gender variables. This difference also existed in other analyses, suggesting that males consider themselves as having sexual intercourse in a variety of relationships, while females may have a more narrow picture of the type of sexual relationship. Condom use was less likely as the length of a sexual relationship increased. Males who considered condom use to be men's work and who had higher levels of perceived control over condom use were more likely to intend to use a condom than their counterparts. The fact that different models were needed to explain condom use intent for females and for males suggests that decision making is subtly different for males and for females. Health educators can use these findings to appropriately tailor interventions for female and male subgroups.
Empowering women for development through nonformal education: the case of Lesotho.
For the study described in this doctoral dissertation, interviews were conducted with 20 Lesotho women who were living in the outskirts of Maseru or near the urban area of Mohale's Hoek, had received informal business education for at least two years, and had attended at least two business training courses offered by the Institute of Extra Mural Studies. The purpose was to examine the compatibility of combining informal education and the empowerment approach and whether this combination could result in changing the present status of Basotho women. All the women were engaged in business on a full-time basis. They generated income for the family. The women were very aware of their subordination both in the home and in the patriarchal society. Men's control and their exercise of power on women frustrated the women. They considered this treatment by men to be humiliating to them as people, as parents, and as leaders. They have run up against discriminating laws as they conducted their business. In terms of cognitive, psychological, and political empowerment, the women exhibited low to moderate levels of empowerment. On the other hand, they had significantly higher levels of economic empowerment, suggesting that the business training programs were successful. Women who attended the women-only programs (which did not have a deliberate empowerment content but had a component on how to collectivize to influence a desired change) exhibited higher levels of political empowerment than their counterparts. This suggests that a deliberate empowerment content can improve levels of empowerment. These findings indicate that informal education for empowerment can serve as a vehicle through which women can join together to effect social change and thus achieve their rights to participate as equals in the development process.
Development strategies for rural women of Pakistan.
The Aga Khan Rural Support Program (AKRSP) in the northern province of Sindh in Pakistan was studied for this doctoral dissertation on how the implementation of such a project could improve conditions for women. The program consists of support packages targeted to women's organizations: training (e.g., field demonstrations), provision of credit, and input management techniques. A time-series and cross-section regression analysis were used to evaluate AKRSP. The time-series analysis or estimation of the model aimed to measure the relative effects of the various support packages on women's income by examining the years 1983-2010. The cross-section analysis compared the project districts (Gilgit, Chitral, and Baltistan) with the control districts (Mirpurkhas, Sanghar, and Nawabshah). The level of income of the village (men) and women organizations' members in the project areas increased significantly during 1983-1993. It was projected to increase thereafter. The support packages off-set the structural constraints and cultural disadvantages facing women in Sindh. Women's organizations were a crucial element for negotiating for collective loans, credits, training, and other services. The greater economic independence in the project areas has given rise to a nuclear family system and to women having more decision-making power in investments, expenditures, and consumption. Young girls have become interested in formal education and aspire to be mainly teachers or nurses. Due to the similar conditions of women in both the project and control areas, the AKRSP strategies would likely be successful in the larger and more populous Sindh province and other underdeveloped rural areas.
Women and health education in rural Tanzania: lessons in empowerment.
This doctoral dissertation describes a 12-month community health course in central Tanzania that focused on AIDS prevention. The students were 9 women 18-36 years old. An ethnographic process and continuous evaluation allowed assessment of various participatory and experiential learning activities. As needs emerged, curriculum components were introduced. The traditional health curriculum (environmental sanitation, nutrition, maternal-child health, neighborhood survey techniques) was expanded by adding AIDS prevention, germ theory, economic literacy, gender awareness, and the basics of teaching. The most effective participatory teaching methods included health campaigns, discussion groups, and popular theater. Peer counseling was not a successful participatory teaching method. Role play helped students simulate future teaching situations. The students gained leadership ability, political awareness, and knowledge about health. The economic crisis facing Tanzania effected low hopes of gainful employment, however. Macroeconomic policies of international financial institutions were connected to the declining conditions in health and education at the microlevel. This action research suggests that the curriculum components and instructional innovations that were developed can be used throughout the college system.
A case study of education for street children in Nairobi, Kenya and implications for future policy.
This doctoral dissertation describes field research conducted in Kenya in the summer of 1993 and reviews the literature to examine educational policy issues related to street children in Nairobi and how future policy might address these children's needs. There are 500,000 street children in Kenya. Kenya's policy of universal primary education in the early 1960s caused rapid expansion of the formal educational system. Since the government did not have the funding to support schools, it relied heavily on the community-funded Harambee schools to expand the formal system of schooling. Kenya still has a dualistic Harambee and formal educational system complete with inadequacies in internal and external efficiency. The system has supported a more literate work force as well as contributed to development problems. Many squatter settlements in Nairobi have emerged as a result of urbanization and industrialization. The economic difficulties suffered by persons living in these settlements and inequities in the educational system have sparked rising numbers of street children. Locally organized groups, religious organizations, and nongovernmental organizations (e.g., Undugu Society of Kenya) provide most educational services to these children. Economic development in Kenya is a step towards addressing the educational needs of street children. Kenya must also take steps to achieve the goals of Basic Education for All it had set for itself. The dissertation examines policies and programs for street children in India, Nepal, the Sudan, Mali, Angola, Zambia, Mozambique, and Brazil to identify policy options for Kenya. Seven policy points are recommended for Kenya. One policy point is revision of laws regarding children's rights, labor, and education. Other points concern government funding and infrastructure, existing service providers, public awareness, system of delivery of educational services, and inadequacies.
[Tuberculosis in patients infected with HIV in Ho Chi Minh City]
During 1993-1995 in Vietnam, 65 HIV-infected patients were treated who had been admitted to Pham Ngoc Thach Hospital in Ho Chi Minh City. 95% of these HIV-infected patients were male. The mean age of all 65 HIV-infected patients was 40 years. 71% were drug users for more than 5 years. 47 HIV-infected patients were diagnosed with tuberculosis. 85% of these cases had pulmonary tuberculosis. Koch bacilli were detected in 30 of 40 samples tested. 12 HIV-infected cases had pneumonia. Two had tumors. For all 65 cases, mortality was high during the first 2 weeks of hospitalization (23%). No HIV-infected patient during this period had the opportunistic infections common in AIDS cases: Pneumocystis carinii pneumonia, cytomegalovirus infection, or Kaposi's sarcoma. The lack of opportunistic infections may be explained in part by the lack of available diagnostic tools.
Preinsertion patient counseling and follow-up.
Patient education prior to IUD insertion is the foundation of informed consent. It helps protect women's health and provides a means for effective patient self-care and clinician follow-up. Patient education strategies include the private practice model; individual counseling; written materials, videotapes, and other communication media; and a combination strategy. The provider can schedule a follow-up appointment for IUD insertion. Information the potential IUD user needs includes efficacy, risks and benefits, cost, contraceptive mode of action, immediate return to fertility, postremoval pregnancy rates, predictable and rare side effects, risk factors of sexually transmitted diseases of the client and her partner, and the insertion procedure. The postremoval pregnancy rates for the Copper T 380A IUD are 54.4% at 3 months, 70.3% at 6 months, and 91.1% at 12 months. For the progesterone-releasing IUD, they are 49% at 3 months and 75% at 12 months. Predictable side effects of the Copper T 380A IUD are increased menstrual blood flow and painful periods (nonsteroidal anti-inflammatory drugs can manage the pain). Rare events for both IUD types include expulsion and uterine perforation. Unlike the Copper T 380A IUD, the progesterone-releasing IUD is associated with a reduction in menstrual blood (about 40% decrease) and in dysmenorrhea. On the other hand, bleeding and spotting episodes are more common. Essential elements of informed consent documentation include a separate form signed by the patient and a witness and documentation of this informed consent process in the client's chart. After IUD insertion, the physician needs to inform the IUD user that pregnancy protection is immediate, that she should check for the presence or absence of the IUD strings, and about warning signs requiring a follow-up appointment (e.g., unusual pain or bleeding). This article provides guidelines for management of missing strings, delayed menses, unusual pain or bleeding, discharge and pain, pelvic infection, and actinomyces infection.
IUD insertion and removal techniques.
Clinicians need to undergo appropriate training in IUD insertion and removal. Experience and skill improve patient outcomes. The copper IUD should not be inserted until pregnancy can be reliably excluded. The progesterone-releasing IUD should be inserted during the latter part of the menstrual period or 1-2 days thereafter. Unlike the copper IUD, it should not be inserted in the immediate postabortion or postpartum periods. Both IUD types come in a sterile package. After performing the bimanual examination to determine the size and position of the uterus, the clinician should clean the cervix and upper vagina with an antiseptic solution. Before tenaculum placement, the clinician may apply a topical antiseptic to the cervix or use a paracervical block to prevent any potential discomfort. The tenaculum should be placed at the anterior cervix if the uterus is not greatly retropositioned. The clinician should not insert an IUD if the uterine depth is less than 6 cm or more than 9 cm. Before loading the IUD, the clinician should put on sterile gloves. Upon stabilization of the IUD at the top of the tubing, the clinician needs to move the flange to the point indicating the depth of the uterus and the plane in which the arms of the IUD will open in the case of the copper IUD or to verify that the number of the inserter matches the uterine depth. After the copper IUD arms are released, the clinician should gently move the insertion tube upwardly until resistance of the fundus is felt. In the case of the copper IUD, the solid rod needs to be removed first and then the insertion tube. The clinician should cut the copper IUD threads to 2.5-4 cm beyond the cervical os or assure that the shorter thread is the difference between 9 cm and the uterine depth. A uterine dressing or a ring forceps can be used to gently remove the IUD. This article addresses difficult IUD removals and uterine perforation. Perforations occur almost always during insertion. IUD expulsions are most likely in the first 12 months after insertion. The clinician may use antibiotic prophylaxis in women with prosthetic heart valves or a history of endocarditis.
Researchers conducted a prospective cohort analysis of 427 children 1-23 months old treated for diarrhea at the Diarrhoea Treatment Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) to examine their outcomes soon after hospital discharge and factors associated with the risk of death. 77% were younger than 1 year (median 8 months). Family size ranged from 2 to 13. 30 (7%) children died within 6 weeks after discharge. Two more children had died by 12 weeks of discharge. More than 60% of deaths occurred within the first 2 weeks of discharge. 69% of deaths occurred in infants no more than six months old. 22% of the dead children were admitted to the ICDDR,B hospital before death. 31% went to other hospitals. 28% went to a private practitioner. 22% were not seen by any practitioner before death. The logistic regression analysis found the significant risk factors associated with child death after hospital discharge to be age younger than 6 months (relative risk [RR] = 4.57), no breast feeding (RR =2.35), lack of immunization (RR = 1.6), malnutrition (RR = 2.97 for <85% of length-for-age median), no maternal education (RR = 2.12), and female gender (RR = 1.73). The primary causes of death of the 32 children followed up to 12 weeks after discharge from the hospital were diarrhea (69%) and acute respiratory infection (31%). The key associated causes of death were malnutrition (41%) and low birth weight (31%). These findings suggest the need for health workers to pay special attention to and follow up on hospitalized children, particularly young infants. They should focus their efforts on the week of discharge.
Feeding practices of mothers during childhood diarrhoea in a rural area of Nigeria.
In Nigeria, focus group discussions and interviews were conducted with mothers living in the Ife South local government region of Osun State so researchers could identify feeding patterns during home management of the locally recognized types of diarrheal illnesses and the rationale behind them. 335 randomly selected women were interviewed. There were about 14 varieties of diarrhea types. The most frequent type mentioned was described as frequent watery stool in large quantity. More than 60% of mothers decreased fluid intake during diarrhea episodes. The mothers perceived raw corn starch as an antidiarrheal agent. Raw corn starch was fed across all diarrheal illnesses. Bread, raw cassava meal or corn starch, and yam were commonly given in cases of watery diarrhea. Mothers avoided giving rice and sweet or sugary foods. They thought sugar caused frequent, watery stool or any type of stool with blood. Eating groundnuts was believed to cause diarrhea to deteriorate into any type of stool with blood. A common belief in the Yoruba community was that beans tend to worsen diarrhea. Raw cassava given in cases of watery diarrhea is significant, since a cassava-salt solution is efficacious and safe as a home management of childhood diarrhea. Cultural beliefs and not maternal education appeared to be the major determinant of the choice of particular foods. Based on these findings, community-based educational interventions need to consider the cultural beliefs and aim to correct the local perceptions of the causes of illness and to improve dietary patterns.
Public health departments providing sexually transmitted disease services.
In 1995, the Alan Guttmacher Institute surveyed 1437 local public health departments that provide sexually transmitted disease (STD) services to determine the range of STD services. They had around 2 million clients annually. These agencies comprised 50% of all local public health departments in the US. Further analysis was limited to 587 randomly selected agencies. The health department clients tended to have incomes less than 250% of the poverty level (83%) and to be women (60%) and non-Hispanic Whites or Blacks (55% and 35%, respectively). 36% of clients were teenagers. 30% were 20-24 years old. Among clients screened for STDs, 23% had chlamydia, 13% had gonorrhea, 3% had early-stage syphilis, 18% had another STD, and 43% had no STD. 99% and 93% of all public STD control programs provided testing and treatment for gonorrhea and syphilis, respectively. 97% treated chlamydia but only 82% tested for chlamydia. 14% of all agencies always provided STD services in separate sessions. They tended to be in metropolitan areas, to serve many clients, to see about as many men as women, and to provide little contraceptive care. 37% of all agencies always integrated STD services and other health care. They tend to have small STD caseloads, to provide STD services mostly to women, and to offer contraceptive methods other than male condoms. 49% used a mix of separate STD sessions and sessions in which STD services were integrated with other services. Individuals in need of STD testing and/or treatment who lived in sparsely populated areas appeared to have a limited choice of accessible clinic-based or private providers.
Update on contraception 2: post-coital and barrier methods.
In the UK, postcoital contraception is underutilized and not promoted adequately. Four high-dose pills (Ovran 50) taken in 2 doses 12 hours apart comprise the Yuzpe regimen. The pills need to be taken within 72 hours of unprotected intercourse. The failure rate of the Yuzpe regimen lies between 2% and 4%. Women over the age of 35 and women who suffer from focal migraine can safely use the morning-after pill. Depending on what part of the cycle this pill is taken, the pill delays ovulation or prevents implantation. In the case of failure, women need to be informed that there is no observed risk of abnormality in infants born to women who have used the emergency pill. Postcoital insertion of the IUD is more effective than the Yuzpe regimen. It can be inserted up to 5 days after the earliest predicted date of ovulation. The IUD prevents implantation. Two progestational-only postcoital regimens (20 Microval and 25 Microval) can be used in cases where the Yuzpe regimen and the IUD are contraindicated. Two doses of 25 Microval can be initiated within 48 hours of unprotected intercourse. The failure rates for the progestational-methods are similar to those of the Yuzpe regimen. RU-486 is more effective than the standard postcoital regimen and causes less nausea. It is not yet licensed as a postcoital contraceptive, however. Diaphragms and cervical caps have higher failure rates than previously believed (10 and 18/100 women-years, respectively). The contraceptive sponge Today is no longer on the market. Its failure rate was 25/100 women-years. Polyurethane condoms may soon be available. Their advantages over latex condoms include: not damaged by oil-based lubricants, less susceptible to heat and humidity, and as strong and perhaps more acceptable since they are thinner. Key advantages of the female condom are: under woman's control, inserted before intercourse, and protection against AIDS. Its failure rate is 15/100 women-years.
Infant feeding patterns on Mauritius island, 1991.
In 1991, a Contraceptive Prevalence Survey (CPS) was conducted among 5262 women 15-44 years old living on Mauritius Island. Some researchers focused on data of the 2263 children younger than 5 to examine infant feeding practices and compared the 1991 data with the data from the 1985 CPS. The incidence of breast feeding decreased from 86% in 1985 to 72% in 1991. Yet, duration of breast feeding remained the same (13.6 months). The proportion of ever-married women working outside the home increased from 22% to 41%. Working outside the home explained only part of the decline in breast feeding, however. The incidence of breast feeding fell among all categories of employment status. Semi-urban women had a relatively high incidence of breast feeding (86%), while rural women had the lowest incidence (68%). Only 16% of infants 0-3 months old were exclusively breast fed. About 60% of all infants 0-3 months old received infant formula as well as breast milk. 97% of them bottle fed. About 30% received water. The proportion of children receiving infant formula via a bottle remained high (late in 1st year = 83%; 2nd year = 42%; and 3rd year = 21%). The mean number of breast feedings per day was 7.7 in the first 2 months and decreased modestly to 4.5 for the last 6 months of the second year. These findings show a decline in breast feeding and early supplementation on the island. These infant feeding patterns may indicate future declines in breast feeding for other African and Asian countries. Breast feeding, particularly exclusive breast feeding, needs to be actively promoted in Mauritius. Policies should be implemented that make breast feeding easier for working mothers: promotion of expressing breast milk, child care facilities near the work place, and multiple breaks in the workday for breast feeding.
For the study described in this doctoral dissertation, interviews, observations, health and eye examinations, and anthropometric measurements were conducted among 889 sick children in Nepal in order to study the effect of vitamin A supplementation on the severity of diarrhea and acute respiratory infections (ARI) and factors that affect the severity of diarrhea and ARI. All the children lived at sites participating in the Nepal Vitamin A Child Survival Project. 2.4% of all children had had diarrhea during the second year of the project team's visit. 5.9% had suffered from severe ARI. Children with xerophthalmia were more likely to have diarrhea with dehydration and diarrhea of 5 days or more than children with no xerophthalmia (relative risk [RR] = 2.38 and 1.98, respectively; p < 0.05). Two capsules of vitamin A (2 x 200,000 IU retinol plus 40 IU vitamin E) significantly reduced the risk of diarrhea with dehydration by 54% and the risk of diarrhea for 5 days or more by 64% (p < 0.05). Risk factors for diarrhea with dehydration and diarrhea for 5 days or more included pre-monsoon season (April-May) (RR = 22.3 and 8, respectively), no market in area (RR = 0.18 and 0.62 for market in area, respectively), cholera epidemic (RR = 4.8 and 3.03, respectively), maternal illiteracy (RR = 0.99 and 0.37, respectively), stunting and wasting (diarrhea with dehydration only, RR = 2.02), and young age (<5 years old) (diarrhea with dehydration only, RR = 3.08-5) (p < 0.05 for all factors). Children who received vitamin A supplementation were less likely to develop severe ARI than the controls (RR = 0.14; p < 0.05) but not moderate ARI. Children with xerophthalmia were more likely to develop moderate ARI than children with no xerophthalmia (RR = 4.55; p < 0.05) but not severe ARI. Significant risk factors for ARI were season (June-July for severe ARI, RR = 18.09), age in months (severe ARI, RR = 1.03), and a market in the area (moderate ARI, RR = 2.62). These findings show that high-dose vitamin A supplementation should be conducted in Nepal and other countries where diarrhea is a major cause of death. Further research on vitamin A's effect on ARI is needed.
In the US, health and welfare officials in the 1920s and 1930s were concerned about maternal and infant deaths and believed that alcoholism, prostitution, and poverty were inherited. In the next decades, contraception, sexual sterilization, and abortion dominated public health and welfare programs. Policy makers nationwide regarded North Carolina as a model of public commitment to reproductive health. Historians have considered state-sponsored sterilization as embracing state control over female reproduction. They have described liberal legislation on abortion and birth control as granting reproductive control to women. Their views have put these technologies at opposite ends of the political spectrum. There was indeed tension between progressive contraceptive policies and coercive policies of population control. This doctoral dissertation describes a simultaneous analysis of birth control, sterilization, and abortion in public health and welfare. The analysis found that the history is more complicated and intertwined than has been interpreted by many historians. All these contraceptive technologies sometimes enhanced yet sometimes limited women's reproductive freedom. They have also supported the dual purposes of improving women's and children's health and controlling the sexual and reproductive behavior of poor women. During the 20th century, four groups determined the nature and delivery of reproductive policies. Social scientists, including eugenic theorists, presented theories about the origins and characteristics of poverty and recommended solutions (e.g., reproductive control will eliminate poverty). Health and welfare officials and philanthropists who supported birth control and sterilization programs in North Carolina also contributed to the shape of public policy and the nature of reproductive services. State and county health officials who implemented public health and welfare policies affected the delivery of reproductive services. The clients of these programs influenced the implementation of birth control and sterilization programs, the policy making process, and theories on causes and treatments of poverty.
Condom use among Norplant users and oral contraceptive users.
In September 1991 in Florida, interviews were conducted with 1539 Norplant users and oral contraceptive (OC) users attending family planning clinics of county public health departments and community health centers in Duval, Lee, Palm Beach, and Hillsborough counties. There were 715 women (391 Norplant users and 118 OC users) available for the follow-up interview 6-12 months after the initial interview. The data are analyzed for this doctoral dissertation to compare self-reported condom use among Norplant users and OC users and to examine sociodemographic and sexually transmitted disease (STD) risk factors associated with STD/HIV. Most women (75% for Norplant users and 66% for OC users) did not currently use condoms (i.e., in last 4 weeks) with their main sex partner. 9% of Norplant users and 10% of OC users always used condoms. This low prevalence of consistent dual method use indicates a low perception of STD/HIV risk. 16% of Norplant users and 17% of OC users had at least 1 STD/HIV risk factor. 4% and 3%, respectively, had more than 1 sexual partner. Among women with no STD/HIV risk factor, Norplant users were less likely to use condoms than were OC users (24% vs. 37%; p < 0.05). Among those who had an STD/HIV infection and those with multiple sex partners, Norplant users were more likely to use condoms than OC users (44% vs. 20%; p < 0.01 and 27% vs. 0; p < 0.05, respectively). In both groups, condom users tended to be young (especially teenagers), single, non-White, and poor (income, <$9600). These findings indicate a need for family planning workers to counsel women using long-acting contraceptives that these methods do not protect against STDs/HIV and that they should also use condoms if they are at risk of STDs/HIV.
A survey was conducted among 89 family planning providers working at 24 family planning clinics funded by the federal Title X program and the Office of Family Planning (OFP) in Los Angeles County, California, to examine their knowledge, attitudes, and beliefs toward emergency contraceptive pills (ECPs). The family planning providers included program administrators, clinicians, and health educators. The ECP policy allowed providers to give information about ECPs to clients in 64% of the clinics. 49% of all clinics had no restrictions on who can receive this information. At 52% of clinics, information on ECPs was given only to clients who asked for it. 62% dispensed ECPs. 27% provided ECPs to anyone, 38% to rape victims, 42% to contraceptive failure cases, and 40% to unprotected intercourse cases. Reasons why the clinics with no ECP policy had no such policy were: no approval for ECP by the US Food and Drug Administration, no Title X approval, and no OFP approval. Health educators and nurse practitioners were most likely to provide information on ECPs (51% and 70%, respectively). The most common action when ECPs were requested was appointment (63%). Most family planning providers thought that ECPs should be offered (74%) and would feel comfortable providing information on and distributing ECPs to all women (69% and 61%, respectively). More than 75% had heard about ECPs. Yet, more than 50% had poor knowledge about ECPs. They were more likely to know the number of hours ECPs could be taken after unprotected intercourse than which oral contraceptives could be used (64% vs. 30%). Attitudes toward abortion and pregnant teens had a significant association with which populations should, according to the family planning providers, be informed about ECPs. The belief that women's knowledge about ECPs would increase the incidence of unprotected intercourse was significantly correlated with the providers' comfort level with offering ECPs to clients.
For this doctoral dissertation, data were analyzed on 4718 Brazilian children younger than 5 and living in the northeastern states of Maranhao, Piaui, Pernambuco, and Paraiba to determine the frequency and determinants of acute lower respiratory infections (ALRI) among counties with various levels of economic development and in children from various levels of poverty. 19% of the children lived in the counties with the lowest level of economic development, while 46% lived in those with the highest level of economic development. Children living in the low economically developed counties were more likely to have ALRI than those living in the most economically developed counties (14% vs. 8%; prevalence odds ratio [POR] = 1.84). The prevalence of ALRI increased as the socioeconomic status decreased (high 6%, middle 9%, and low 13%; p < 0.001 for linear trend). Poverty had a higher association with ALRI in the low economically developed counties than in the high economically developed counties (POR, 10.8 vs. 1.34). Malnutrition, crowding, or use of wood or coal as cooking fuel did not explain this effect. These findings show that economic development has a strong influence on the effect of poverty on ALRI risk in young children. In effect, the community has a powerful effect on ALRI risk.
At the Calcutta National Medical Hospital in India, data were compared on 40 abortion seekers of gestational age 13-20 weeks treated with a synthetic prostaglandin E2 derivative (PGE2) (500 mcg intramuscular [IM] injection) with data on 40 abortion seekers of the same gestational age treated with 15-methyl PGF2alpha (250 mcg IM injection). The objective was to determine a safe and effective method for terminating midtrimester pregnancy. 97.5% of cases in both groups aborted within 20 hours of treatment. Complete abortion was higher in the PGE2 group than in the PGF2alpha group (70% vs. 60%). Women of the shorter gestational age (i.e., 13-16 weeks) had a higher success rate (100% vs. 95% for 17-20 weeks) and a shorter induction-abortion interval time (IAT) (14.28-14.42 vs. 16.42-17.21 hours). Multiparous women were more likely to have a successful abortion than nulliparous women (100% vs. 95%) and to have a shorter IAT (14.01-14.58 vs. 18.3-18.49 hours). The PGF2alpha group was more likely to experience the side effects of vomiting and diarrhea than the PGE2 group (100% vs. 27.5% and 97.5% vs. 12.5%, respectively). These findings suggest that both synthetic prostaglandins were effective in inducing second trimester abortion via IM injection but PGE2 was more tolerable.
During March-April 1992 in Vietnam, a cross sectional survey of 1132 mothers with children younger than 5 was conducted in Tien Hai district of Thai Binh Province to examine utilization of reproductive health services (family planning, prenatal care, and delivery services) in the Red River Delta during 1987-1992 and the socioeconomic determinants for utilization of health services. 70% used family planning methods, especially the IUD (61.6% vs. 0.1-7% for other methods). Health services rarely offered other methods. 91% of the 1662 pregnancies in the previous 5 years ended in delivery, 4% in miscarriage, and 5% in induced abortion. Most abortions were performed in the third pregnancy or later. Current use of the IUD was associated only with number of children alive (odds ratio [OR] = 4.8 for 2 children and 7.97 for =or+ 3 children). 70% of mothers did not receive any prenatal care during their last pregnancy. Only 5% received 3 check-ups. Only 13% received 2 tetanus toxoid vaccinations. Women who were pregnant for the first time were more likely to have received prenatal care and more tetanus toxoid vaccinations. 85% of primiparous women who received at least 2 prenatal check-ups also received 2 tetanus toxoid vaccinations. Mothers with fewer deliveries, higher education, and who were of the Buddhist faith or had no religion used prenatal care services more often than their counterparts. 37% delivered their last child at home. A health professional did not attend 25% of all deliveries. Fewer deliveries (i.e., low parity), higher education, Buddhism/no religion, and adequate caloric intake were associated with delivery attended by health professionals. These findings show that reproductive health care services must be strengthened in Vietnam, and that health workers must improve efforts to reach women not using the reproductive health services available.
Lack of interaction between orlistat and oral contraceptives.
In the Netherlands, a double-blind, randomized, placebo-controlled, two-way crossover study was conducted to determine whether administration of the inhibitor of gastrointestinal lipases, Orlistat, concomitantly with combined oral contraceptives (OCs) inhibits the ovulation-suppressing action of OCs. The 20 subjects, 20-27 years old, were healthy and had a body mass index between 22 and 27 kg m-2. All subjects completed the study. Most adverse events were mild and related to the pharmacological effect of Orlistat (fatty or oily stool, flatus with discharge, or abdominal pain). The geometric means of time-averaged serum concentrations in the cycles with Orlistat and the placebo and the 1-sided 95% confidence region for the mean in the cycle with Orlistat were 0.147, 0.145, and less than 0.176 mcg l-1 for progesterone and 1.92, 2.03, and less than 2.23 IU l-1 for luteinizing hormone (LH), respectively. These figures were well below the peak concentrations during normal ovulation (>3 mcg l-1 for progesterone and >30 IU l-1 for LH). The plasma concentration of Orlistat was either close to the limit of quantification (1 mcg l-1) or below this limit. These findings suggest that Orlistat had no effect on the ovulation-suppression capabilities of the OCs.
Transmission of HIV-1 in breast milk.
The first recorded case of HIV-1 transmission via breast milk occurred in 1985. 1985 was also the year HIV-1 was first isolated in breast milk. In developed countries, many hospitals' special neonatal units no longer operated breast milk banks. National policies advised HIV-1 infected mothers to feed their babies breast milk substitutes. They advised pregnant women with HIV-1 risk factors to undergo voluntary HIV-1 testing so interventions could be taken to prevent HIV-1 transmission to their infants if the mothers were indeed HIV-1 positive. Routine HIV-1 testing without pretest counseling poses an ethical dilemma. In developing countries, universal breast feeding is still the policy. Limited resources in developing countries precludes them from voluntary or mandatory HIV-1 testing and administering zidovudine (AZT) treatment before and after the birth. Further, there are no inexpensive and readily available options to breast feeding in developing countries. The risk to the baby of not receiving breast milk outweighs the risk of HIV-1 infection. In 1992, the World Health Organization and UNICEF admitted that breast feeding poses a significant risk of HIV-1 transmission. The mother-to-infant HIV-1 transmission rate is higher in developing countries than developed countries (20-39% vs. 12.9-30%). Breast feeding perhaps explains the difference in risk. HIV-1 transmission to the infant is associated with a maternal CD4 lymphocyte count less than 700/mcl, maternal CD4/CD8 ratio less than 0.5, and p24 antigenemia. Both lymphocytes and cell free fractions of breast milk have been found to have HIV-1. Colostrum has a higher concentration of cells and immunoglobulins than breast milk. Anti-HIV-IgA and IgM are found in breast milk, indicating that HIV is in the mammary glands. Cracked nipples, breast abscesses, and sores in the infant's mouth may increase the risk of HIV-1 transmission. In conclusion, no realistic alternative to breast feeding exists in developing countries. If the mother is known to be HIV-1 positive, the HIV-1 transmission risk to the baby is significant.
Retroviral vaccines: challenges for the developing world.
The two major foci of HIV-1 infection in Asia, Thailand and India, have separate HIV-1 epidemics related to distinct HIV-subtypes. By the late 1980s or early 1990s, there were two distinct HIV-1 epidemics in India. One epidemic, particularly in Manipur region, was typical of intravenous (IV) drug-associated epidemics and was likely due to subtype B. The other has the patterns of a typical sexually transmitted disease and was likely due to subtype C. The two epidemics in Thailand follow a similar delineation to those in India. Yet, unlike India, a new HIV-1 has emerged, HIV-1 E, in both epidemics. Subtypes C and E viruses from Asia are associated with efficient heterosexual transmission. These HIV-1 subtypes grow considerably better in Langerhans' cells (highly prevalent in tissues of the vagina, cervix, and penis foreskin and almost absent from the rectum) than does HIV-1 subtype B. HIV-1 B viruses appear to have lost their affinity for efficient heterosexual transmission through mutation, suggesting that HIV-1 B can be maintained in groups where transmission by vaginal sex is not needed (i.e., high density of contacts with homosexuals and/or IV drug users). A homogeneous, heterosexual population with the highest incidence of new HIV-1 infections, which is exposed to the same viral subtype or strain, is the ideal test population for designing and testing an HIV-1 vaccine. The ideal HIV-1 test vaccine is the polymerized envelope antigen gp120. The safety of live attenuated HIV vaccines is doubtful. It appears that HIV-2infection provides some protection against HIV-1 infection (cross-reactivity immunity). In conclusion, trials of HIV-1 vaccines are needed but should use HIV-1 C or E strains that spread rapidly by vaginal sex. These strains can be isolated from vaginal fluids with tropism for Langerhans' cells.
Epidemiology of HIV and AIDS in the Asia-Pacific region.
The Asia-Pacific region has about 55% of the world's population, yet it has reported less than 3% of the world's reported AIDS cases. A 1996 World Health Organization data review found that 22% of the estimated 21.8 million HIV-infected people were from the Asia-Pacific region, suggesting that this region is at an early stage of the HIV/AIDS epidemic. Substantial underreporting of AIDS cases in some countries is likely. Among countries with more than 500 reported AIDS cases, since 1990, the AIDS incidence rates are falling in New Zealand and stabilizing in Australia but increasing in Thailand, India, and Burma. India has the highest estimated number of HIV-infected people (1.75 million) in the Asia-Pacific region. This number far exceeds the total estimates for North America, Australia, and Europe combined. China has only an estimated 10,000 cases of HIV infection, most of whom live in Yunnan province. HIV-1 incidence studies indicate that HIV-1 spread rapidly among intravenous (IV) drug users and sex workers in Thailand during the late 1980s. The HIV-1 seroconversion rate in these groups peaked at 50/100 person-years but now lies between 5 and 20/100 py. A decline in HIV incidence has been noted in Thai military conscripts. Several waves of HIV-1 infection have struck Thailand: IV drug users, sex workers, male clients, female partners of infected men, and infants of infected women. HIV-1 appears to be spreading in India, Burma, and Cambodia the same way it did in Thailand. The leading mode of HIV transmission is homosexual intercourse in Australia, New Zealand, and the French Pacific Territories. In southern China, Malaysia, and Vietnam, it is IV drug use. Heterosexual intercourse unrelated to sex workers is the primary mode of HIV-1 transmission in Papua New Guinea. HIV incidence rates are low in the Philippines and Indonesia. There have been various HIV-1 subtypes identified in the region (e.g., India has 4 subtypes to date). The first reported HIV-2 case was in India in 1990. HIV-2 is spreading rapidly there. Most persons infected with HIV-2 in India are also infected with HIV-1. An HIV/AIDS epidemic of the same scale as that in sub-Saharan Africa is expected.
Challenge and response: HIV in Asia and the Pacific.
In the Asia-Pacific region, almost 5000 people become infected with HIV every day. The leading mode of HIV transmission is heterosexual intercourse. Sharing of injecting equipment among drug users is also a major mode of HIV transmission. Myanmar is the epicenter of the HIV epidemic in Asia. The political tensions there interfere with attempts to curb the spread of HIV in-country and to neighboring countries. The lack of effective cross-border programs has resulted in an explosive situation in China's south Yunnan province, especially among drug abusers. In many countries in the region, the blood supply is unsafe. Thailand is the only country politically committed to curbing HIV transmission. Government-facilitated massive education programs and other interventions preceded a decline in the overall rate of sexually transmitted diseases (STDs) in Thailand. Key strategies in Thailand include detailed epidemiologic studies to determine the incidence and prevalence of HIV infection nationwide, promotion of safer sex practices in commercial sex establishments (e.g., 100% condom campaign), and official willingness to work with nongovernmental organizations. The government of India has not responded appropriately to the HIV/AIDS epidemic and the outcome has been disastrous. India will likely soon have more HIV-infected people than any other Asia-Pacific country. Preventive programs may spare western Pacific countries, where HIV incidence is low. Obstacles to tackling the HIV epidemic include poverty, poor facilities for the treatment of STDs, failure to address discrimination against those infected with HIV, and problems associated with the very low status of women. Many years of national development can be lost to the HIV epidemic. Australia has model HIV prevention and control policies and can help its Asia-Pacific neighbors fight HIV/AIDS. Health professionals in only Thailand, Australia, and New Zealand are prepared for the future AIDS caseload. Australia offers clinical programs for the region's health professionals. Greater political commitment is needed in the region to minimize the HIV/AIDS epidemic.
Secondary prevention health behavior on cervical cancer in Korea: Papanicolaou smear screening test.
For the study detailed in this doctoral dissertation, secondary data were analyzed on 1489 women, 20-59 years old, taken from the 1992 Korean Health Behavior Survey, who were selected from the 1990 census to determine their sociodemographic characteristics and variables that predict Pap test utilization. A follow-up survey was conducted in 1995 of 424 of these women. Unlike the first survey, this survey included questions about barriers to Pap test utilization. Pap tests were more common in 1995 than 1992 (36% vs. 27.9%). In 1992, variables that significantly and independently predicted Pap test utilization included age (30-49 years vs. 20-29 and 50-59 years), marital status (married and others vs. single), educational status (middle and high school vs primary and no school), usual source of care (vs no source of care), health check-up (vs no health check-up), perceived household economic status (high and middle vs low), and presence of chronic disease (vs no chronic disease). There were fewer significant independent predictor variables in 1995, however. In terms of women's lifetime experience of the Pap test, predictor variables were age, marital status, health check-up, and usual source of care. Among suspended users and regular users of the Pap test, the only significant independent predictor was health check-up. The physician factor (physician's attitude, communication skill, and recommendation) posed a significant barrier to initiating the Pap test (odds ratio [OR ] = 2.321; p = 0.001). The personal factor (busy schedules, previous experience, perceived ineligibility, and forgetfulness) was less likely to be a barrier for women who discontinued Pap test utilization than for current users (OR = 0.640; p = 0.0350). The personal factor played a significant role in Pap smear utilization among women who had regular Pap smears when compared to women who had not had regular Pap smears (OR = 1.799; p = 0.0132). Neither the characteristics of the Pap smear itself and the procedure nor the cultural factor were significant barriers to Pap test utilization.
Seroprevalence, incidence and risk factors for HIV infection among men in a rural area in Malawi.
For the study described in this doctoral dissertation, data were analyzed from the published and unpublished literature to determine current and future trends of the HIV/AIDS epidemic, particularly among adults, in sub-Saharan Africa (SSA), the key risk factors for HIV infection, and the role of risk factors in the demographic and geographic distribution of HIV infection in SSA. By June 1995, about 35% of all reported AIDS cases were from SSA. At least 8 million of the 12 million HIV-infected persons in the world live in Africa. East and Central Africa have the highest HIV prevalence and incidence rates in SSA. HIV is spreading into the general population and to rural areas, mainly through sexual intercourse. Leading risk factors for HIV infection among SSA adults are older age, multiple sex partners, sexually transmitted diseases, blood transfusion, lack of condom use, and circumcision. Continuous monitoring of HIV prevalence and incidence rates, comprehensive STD control, and health education are needed in SSA. A prospective cohort study was also conducted of male workers 18-65 years old at the Sugar Corporation of Malawi during 1994-1995 to determine HIV prevalence and incidence rates and to identify risk factors for HIV infection among these men. The purpose was also to identify a population for potential HIV vaccine field trials in Malawi. The HIV prevalence rate was 24.5%. The HIV incidence rate over a 1-year period was 10.7% per person-semester, the highest ever recorded among heterosexual men in SSA. Risk factors for HIV prevalence were marital status (married vs. single), high educational level, self-reported STDs, syphilis, history of multiple partners, and recent hospitalization. Risk factors for HIV seroconversion among the workers in Malawi included young age (<40 years), STDs, and history of multiple sex partners. These findings show that intervention programs that target youth, before or early in their sexually active stages, are needed in Malawi.
Hospital mergers and reproductive health care.
In the US, when one of the two hospitals involved in a merger is a Catholic hospital, comprehensive reproductive health care tends to suffer. The Catholic Church forbids its hospitals from providing and making direct referrals for many reproductive health services (i.e., reversible contraception, infertility treatments, male and female sterilization, abortion, condoms for HIV prevention, and emergency contraception). These mergers are especially severe in small towns and rural areas. Several groups have formed to address this hidden crisis. In Troy, New York, a settlement was reached about 12 months after a law suit was filed against the conditions of a merger between a Catholic hospital and a nonsectarian hospital. After a long fight, the settlement essentially guaranteed that patients who are dependent on religious institutions obtain the contraceptive and sterilization services they need and want, but abortion services and referrals continued to be denied. The state of Montana considered the impact of a merger of a Catholic institution and a nonsectarian institution, yet continued availability of all reproductive health services was not guaranteed. The American Civil Liberties Union asked the Federal Trade Commission (FTC) to investigate the merger's impact on reproductive health care, since the merger created a monopoly on acute care in Great Falls. FTC took no action. Key factors to provision of reproductive health services other than abortion in cases of mergers between a Catholic hospital and a nonsectarian hospital include the type of association the two hospitals enter into, the local bishop's willingness to accept a creative solution, and the willingness of the state to consider the implications of such a merger and take steps to guarantee the continued availability of services. State reproductive health care advocacy groups (e.g., MergerWatch in New York) are increasing public awareness of the risks these mergers pose and helping residents ensure that reproductive health services remain available. Pressures to reduce costs will likely require Catholic hospitals to continue to merge with nonsectarian hospitals.
Health care of adolescents [editorial]
Few countries have specific services and programs to cater to adolescents. The curative health sector does not address many health issues of adolescents (e.g., substance abuse, sex behavior, and psychosocial adjustment problems). National health statistics tend to be poor sources of epidemiologic data about adolescent health. Key health- and behavior-related problems of adolescents include diseases particular to adolescents (e.g., growth disorders), diseases and behaviors that affect youth disproportionately (e.g., injuries), health problems that begin in childhood but become more problematic during adolescence (e.g., epilepsy), health behaviors and diseases with major effects on future health (e.g., smoking), and pediatric illnesses that also affect adolescents (e.g., diarrhea). There is a gross underestimation of the health needs of youth. In the US, 20% of adolescents have at least 1 serious health problem. In the UK, the most common reasons for consulting a general practitioner are respiratory illness, infective and parasitic diseases, nervous system disorders, and skin conditions. The main reasons for hospital admissions are induced abortion for girls and trauma for boys. The first requirement for developing relevant services and programs for adolescents is collecting epidemiologic data. Qualitative studies play an important role as well. For example, they can identify youths' anxieties. Adolescents should be included in planning data collection and implementation of adolescent-centered programs. In 1993, 83% of the world's 10-19 year olds lived in developing countries. By 2020, they will comprise 87%. Debt servicing is draining resources from developing countries to developed countries and, as a result, cutting health budgets in many developing countries. Youth-centered programs are unlikely in these countries. School health services can reach many adolescents, even drop-outs. They should include youth participation in service provision and integration of counseling/health education with the science and biology curriculum.
Health care in-depth. Tuberculosis and HIV.
Tuberculosis (TB) probably did not become a problem in sub-Saharan Africa (SSA) until around the 1850s. Poverty, inadequate TB control activities, and the HIV epidemic contribute to SSA having the world's highest TB case notification rate. HIV infection is responsible for a marked increase in TB in 15-45 year olds. In some parts of SSA, up to 70% of TB patients have HIV infection. A healthy immune system controls infection with Mycobacterium tuberculosis and prevents progression to TB but does not rid the body of dormant TB bacilli. HIV infection lowers immunity, therefore increasing susceptibility to TB. 25% of new TB cases each year in SSA are attributable to HIV infection. TB is the leading cause of death in HIV-infected individuals in SSA. The median CD4 count in HIV-infected adult TB patients is 200-250. Many persons in late stage HIV infection with TB are sputum smear negative. HIV-infected persons are more likely to have disseminated and extrapulmonary TB than HIV-negative persons. HIV infection sometimes reduces the skin test response to tuberculin. It is best to avoid anti-TB treatment as a diagnostic test for TB. Clinicians should not treat HIV-infected TB patients with thiacetazone but rather ethambutol. Thiacetazone can induce a severe, and sometimes fatal, skin reaction in HIV-infected persons. Many National TB Programs recommend ethambutol in place of streptomycin due to the problems associated with inadequate sterilization of needles and syringes and the pain associated with streptomycin injections in wasted HIV-infected TB patients. HIV-infected TB patients are more likely to die within 12 months after anti-TB treatment has begun than HIV-negative patients. Active TB may boost HIV replication. The World Health Organization does not yet recommend widespread isoniazid preventive therapy for HIV-positive persons in high TB prevalence countries.
Tuberculosis prevention: where do we go from here?
The Karonga (Malawi) Prevention Trial revealed that repeat BCG vaccinations did not protect against pulmonary tuberculosis (TB) but appeared to provide some protection against glandular TB. They increased protection against leprosy. In fact, a single BCG vaccination conferred 50% protection against leprosy and a repeat BCG vaccination increased protection by another 50%. This trial's findings confirm the need for maintaining BCG vaccination programs in countries where leprosy is a public health problem, for individuals at high risk of leprosy (i.e., contacts of leprosy cases), and because BCG provides some protection against severe forms of TB (i.e., miliary disease and TB meningitis). An alternative TB vaccine needs to be developed, however. The protective efficacy of BCG against pulmonary TB is higher at latitudes far from the equator (80% in northern Europe vs. 0% in India and Malawi). It appears that the immunologic effects of environmental mycobacteria compromise BCG's protective effect against pulmonary TB. There is heterologous immunity between various mycobacterial infections. Low-level delayed-type hypersensitivity (DTH) to tuberculin in non-BCG vaccinated people reflects exposure to environmental mycobacteria. These people are at lower risk of TB than are people with either no DTH or strong DTH to tuberculin. Intradermal exposure to different mycobacteria provides varying degrees of protection against TB in guinea pigs. The warmer and the wetter the environment, the more widespread is colonization by mycobacteria. An area of future research is mapping the distribution of environmental mycobacteria, correlating it with the pattern of DTH responses to tuberculin, and then laboratory work to isolate relevant antigens of the mycobacteria. Another approach is identifying mycobacterial antigens that elicit protective immune responses in vitro so researchers can then identify which antigens and responses are associated with patterns of DTH known to reflect low risk of TB and which response patterns are elicited by BCG against leprosy but not TB antigens. New vaccines are not on the imminent horizon, however.
TB control programmes: the challenges for Africa.
Governmental neglect of tuberculosis (TB), inadequately managed and inaccurately designed TB control programs, population growth, and the HIV epidemic account for the resurgence of TB in sub-Saharan Africa. The World Health Organization and the International Union against TB and Lung Disease have developed a TB control strategy that aims to reduce mortality, morbidity, and transmission of TB. It aims for an 85% cure rate among detected new cases of smear-positive TB and a 70% rate of detecting existing smear-positive TB cases. The strategy involves the provision of short-course chemotherapy (SCC) to all identified smear-positive TB cases through directly observed treatment (DOTS). SCC treatment regimens for smear-positive pulmonary TB recommended for sub-Saharan African countries are: initial phase = daily administration over 2 months of streptomycin, rifampicin, isoniazid, and pyrazinamide; continuation phase = 3 doses over 4 months of isoniazid and rifampicin or daily administration of thiacetazone and isoniazid or of ethambutol and isoniazid. A TB control policy must be implemented to bring about effective TB control. The essential elements of this policy include political commitment, case detection through passive case-finding, SCC, a regular supply of essential drugs, and a monitoring and evaluation system. Political commitment involves establishing a National TB Control Program to be integrated into the existing health structure. Increased awareness of TB in the community and among health workers and a reference laboratory are needed to make case finding successful. A distribution and logistics system is needed to ensure uninterrupted intake of drugs throughout treatment. These regimens have been very successful and cost-effective but pose several disadvantages (e.g., heavy workload of recommended 3 sputum smear tests). A simplified approach involves 1 initial sputum smear for 6 months; 6-months, intermittent rifampicin-based therapy, 100% DOTS throughout entire treatment course, and ascertainment of treatment completion rates and mortality rates in all patients.
In the heart of darkness: sleeping sickness in Zaire.
Human African trypanosomiasis (HAT) control programs existed during the colonial era in the Belgian Congo. HAT cases peaked in 1930 at 33,562. They declined gradually to about 1000 cases in 1959. The civil war that erupted after Zaire's independence in 1960 crippled the public health system. During 1960-1967, no active case finding was conducted and notification of HAT cases fell greatly. Mismanagement and corruption maintained a severe social and economic crisis after the civil war. At the end of the 1980s, the number of new HAT cases began to increase from the relatively stable numbers of 4000-6000 during 1969-1981 to almost 10,000. Socioeconomic conditions deteriorated quickly in the 1990s. The withdrawal of foreign aid in 1991 devastated many governmental health facilities that had been dependent on these funds. In much of Zaire, Catholic and Protestant missions were the only health care providers. The breakdown of the health system contributed to epidemics of Ebola fever, dysentery, the plague, and cholera. The specialized mobile teams providing trypanocidal drugs to HAT patients could no longer operate, resulting in drug shortages and thousands of deaths. The teams were somewhat remobilized during 1993-1994, when some foreign aid was again available. A return to neglected areas in 1994 found the HAT prevalence to be 15.4/1000 in the Equator region. In Kimbanzi, Bandundu region, it was 718/1000 among 241 persons examined. Had the teams not arrived when they did, the entire village of Kimbanzi could have disappeared within 1-2 years. The high prevalence rates in neglected areas were the highest rates recorded this century. The neglect brought about an increase in the number of infectious people, an increase in transmission, and a higher cost and toxicity of treatment due to an increase in late-stage HAT cases. The estimated true total incidence of HAT in Zaire in 1994 was about 34,400 new cases. The number of HAT deaths in 1994 was probably at least 80 times higher than that of Ebola deaths in 1995. Proper HAT control methods need to be fully funded and implemented to control this curable disease.
This review of studies published since 1985 on the metabolic effects of triphasic levonorgestrel in oral contraceptives (OCs) reveals that triphasic levonorgestrel tends not to affect lipid metabolism. Specifically, it does not significantly change the level of the lipids associated with increased vascular risk (low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), and lipid ratios). Overall, triphasic levonorgestrel OCs do not affect triglycerides, while other OCs increase the level of triglycerides. They also have a lower effect on lipid metabolism than do monophasic levonorgestrel OCs. About 50% of the studies suggest that triphasic levonorgestrel OCs do not affect carbohydrate metabolism, while the remaining studies suggest that they cause a significant increase in carbohydrates. Some studies found that triphasic levonorgestrel OCs impair glucose tolerance. Studies on the effect of triphasic levonorgestrel on hemostasis are less numerous than those on lipid and carbohydrate metabolism. Unlike all combined monophasic OCs, triphasic levonorgestrel OCs appear to have a balanced effect on hemostasis. In fact, they stimulate both the coagulant and anti-coagulant-fibrinolytic pathways. Many of the researchers who found statistically significant metabolic interactions found that the changes fell within the normal clinical range and therefore did not increase the risk of cardiovascular disease. Triphasic levonorgestrel OCs tend to have less of a metabolic effect than its monophasic counterpart and a metabolic effect similar to other low-dose OCs.
Some priorities in maximizing access to and quality of contraceptive services.
USAID and its cooperating agencies have developed the maximizing access and quality initiative (MAQ) to help family planning providers in developing countries meet client need by supporting access to improved, practical, quality services. Programmatic research is identifying a range of practical, low-cost interventions that contribute to greater user satisfaction and improved contraceptive use. Successful interventions include contraceptive method choice, counseling on method side effects, client focus, and reduction of medical barriers. There is a need for new, more dynamic counseling models instead of reliance on the medical model. Providers need to learn to determine the client's life situation and health status and to help clients consider these factors as they choose a method. Medical barriers to family planning use are contraindications, eligibility, process hurdles, provider bias, regulations, and side effects management. The MAQ initiative has a guidance document on procedural steps for delivering contraceptive methods. MAQ and the World Health Organization have developed a new system for contraceptive eligibility criteria and checklists to help community-based workers safely deliver oral contraceptives.
The use of lactational amenorrhea as a fertility regulating method.
Lactational amenorrhea has a contraceptive effect during at least the first six months postpartum when mothers fully or nearly fully breast feed. Women practicing the lactational amenorrhea method (LAM) need to know the factors related to the return of fertility. The longer the duration of fully or nearly fully breast feeding, the longer the duration of amenorrhea and anovulation. Suckling inhibits secretion of follicle stimulating hormone and luteinizing hormone, which thereby suppresses ovulation. No cases of ovulation have been found before the 56th day postpartum in fully or nearly fully breast feeding women. It appears that ovulation and a normal corpus luteum function often precede the first menses. The three criteria that must be met simultaneously for correct LAM use include: no return of menses, no regular supplementation of breast milk, and no more than six months postpartum. Another or complementary contraceptive method must be practiced immediately when any of these criteria is no longer met if the LAM client wishes to avoid pregnancy. LAM is more than 99% effective at preventing pregnancy. Family planning, maternal and child health, or primary health care programs should incorporate LAM as one of several family planning choices. They should offer various methods appropriate for breast feeding mothers. Informed voluntary choice is important. Family planning providers must be trained in the provision of LAM and all other family planning options and in counseling. The December 1995 Second Bellagio Conference proposed a practical definition of the return of fertility: the occurrence, after day 56 postpartum, of two consecutive days of bleeding/spotting or of the woman's perception that her menses has returned, whichever of the two comes first. It also found that it may be possible to expand LAM beyond six months postpartum. A study found that the pregnancy rate for lactating amenorrheic women at 12 months postpartum was 1.12%.
[Integration of STD services. "All are part of the same service"]
Two projects have succeeded at integrating sexually transmitted disease (STD) services at the primary health care level. The first operates in Mwanza district in Tanzania. Nurses use the syndromic approach to diagnose STDs and prescribe treatment. They provide health education to STD patients while also distributing condoms and cards for partner contacts. Health workers attend a three-week seminar on diagnosing and treating the most common STDs. The first week is in a classroom. The remaining two weeks consist of practical training in a health center providing STD services. The project began at the main hospital in Mwanza and has since expanded to rural areas. Monthly supervisory visits to each health center ensure the drug supply. The project focuses on the symptoms of urethral infection, vaginal infection, and genital ulcers. Education programs and public awareness promote and popularize risk reduction sex behavior and improve utilization of health services. The other project (Sonagachi) serves sex workers and their clients in Calcutta, India. It integrates STD services with a primary health center. Since its inception in 1992, STDs have fallen and HIV prevalence has not changed. Sex workers involved in the Sonagachi project are more likely to use condoms with clients than those not involved in the project (>50% vs. 20%). Community participation is the key to the success of the Sonagachi project. More than 65 former or current sex workers serve as peer educators. They have attended a six-week training program. They make home visits to sex workers to talk about sexual health, to distribute condoms, to show them how to use condoms, and to encourage them to attend the health center. Peer educators are proud of their work and say that their work gives them confidence and dignity. The peer educators with the most experience become peer educator trainers.
The World Health Organization estimates that more than 1 million children are infected with HIV worldwide. More than 50% of HIV infected children in developing countries die before they reach 12 months old. The lives of many other children who do not suffer from HIV themselves are affected by it because family members have AIDS. Families with adult members with AIDS become more poor and are under more stress because the adults lose their income or are too sick to be involved in agricultural activities. Women can be both HIV infected and in charge of caring for family members with AIDS or for the young children. Often, children must quit school to look for work in order to provide family needs. More than 5 million children will lose their mothers or both parents to AIDS between 1995 and 2000. Grandparents, aunts, or uncles care for the orphans but they are not in the position to pay for the extra food or school. Orphans can lose their rights to inherit family land or homes. Without an education, professional training, and family support, orphans face the risk of becoming street children. These children are especially vulnerable and often become sexually active at a young age, exposing them to HIV. AIDS control programs must find solutions to the needs and problems of children as well as those of adults. The programs must continue to focus on HIV prevention, guarantee access to primary health care for women and children, support children and other family members caring for sick parents, make sure that older children benefit from sexual education, provide the means to prevent HIV infection, and care for more orphans and for older people who can no longer count on their children for their major needs.
[Integration of STD services. How to reach and involve men and women]
In Kenya, a sexually transmitted disease (STD) program implemented in 10 medical centers in Nairobi allows nurses to diagnose syphilis based on symptoms, have blood tests conducted to confirm syphilis, prescribe treatment, and provide counseling. About 5% of pregnant women in Kenya have syphilis but do not know that they are infected or are afraid to seek sexually transmitted disease treatment in health centers. This program tests all pregnant women for syphilis during the prenatal examination. Once syphilis is confirmed, the nurse educates the pregnant woman about syphilis and tells her that syphilis poses a risk to her baby and that she can be treated for syphilis. The nurse must also emphasize the need to treat the pregnant woman's sexual partner. Even though most women agree that the partner must be informed, many fear that the partner will react violently. Each pregnant woman with syphilis receives several partner notification cards asking the partner to go to a health center. The card does not mention syphilis. Once at the center, the man is told that his partner has syphilis. He is told that syphilis can affect the baby. Usually, the men are concerned about the baby. The men receive education on condom use and sexual practices because they have more control and initiative in sexual activity matters. Even though the men and women are advised to abstain from sexual intercourse for a week after treatment, some men have difficulty following this advice. The nurse discusses options relevant to both sexes (e.g., condom use with all partners). It is difficult for women to propose condom use because these decisions are to be made by the men. Women can learn how to use a condom and how to persuade her partner to use the condom. Some women sleep in a separate room or return to their family if their partner insists on sexual intercourse. Almost all pregnant women involved in the project were successfully treated and their partners were informed. More than 50% of the partners were successfully treated. The nurses are pleased with the program.
In September 1993 in Gabon, 192 pregnant women 14-48 years old attending 2 maternal and child health centers in Libreville were recruited into a study designed to identify risk factors, clinical signs and symptoms, and the prevalence of sexually transmitted diseases (STDs) (particularly chlamydia and gonorrhea) and to compare different algorithms used to screen for STDs. 20% had used a condom. Only 4.2% used a condom regularly. STD etiologic agents were Trichomonas vaginalis (14.6%), Chlamydia trachomatis (10.8%), Candida albicans (8.9%), Treponema pallidum (4.7%), Neisseria gonorrhoeae (3.6%), and HIV (2%). 13.5% had cervicitis caused by gonorrhea or C. trachomatis. 21.9% had vaginitis. The researchers then evaluated various diagnostic strategies or algorithms. No matter what type of examination used (medical interview; simple clinical examination, or clinical examination with speculum), the combined use of scores that included risk factors and clinical signs and symptoms yielded a better sensitivity and specificity than hierarchical algorithms. They also were easier to perform. In conclusion, this method may make STD screening more effective, and thus it may prevent maternal and perinatal complications.
Effect of post-coital contraceptive methods on the endometrium and the menstrual cycle.
In Stockholm, Sweden, data on 16 women who received either 0.1 mg ethinyl estradiol (EE) and 1.5 mg levonorgestrel (Yuzpe regimen) or 600 mg danazol (8 women in each group) on cycle day (CD) 12 in the treatment cycle were compared with data on 16 other women who received the same treatment doses on the second day after the luteinizing hormone surge (LH+2) (8 women in each group). In all groups, the women received the doses twice during a 12-hour interval. The aim was to study the effect of the 2 postcoital contraceptive regimens on ovarian function when administered before ovulation and on endometrial morphology when administered immediately after ovulation. After treatment with the Yuzpe regimen and the EE/danazol regimen on CD 12, the mean area under the curve for LH was much lower than in the control cycles (p =or+ 0.01). There was no detectable LH peak in 3 women in the Yuzpe group and in 4 women in the EE/danazol group. Among the remaining women, the LH surge was postponed (CD 16-39 for Yuzpe group and CD 13-24 for EE/danazol group). The Yuzpe regimen as well as the EE/danazol regimen at LH+2 did not significantly affect hormone levels. Most women on the Yuzpe regimen at LH+2 experienced impaired luteal function. In the Yuzpe regimen group, endometrium development changed significantly (p < 0.05) with a dissociation in maturation of glandular and stromal components. Yet, this change was not enough to characterize the endometrium as out-of-phase and therefore was not enough to prevent pregnancy. EE/danazol had no apparent effect on endometrium development. These findings suggest that inhibition or delay of ovulation and suppressed corpus luteum function are the contraceptive effect of the postcoital Yuzpe regimen and EE/danazol. The Yuzpe regimen-associated direct effect on the endometrium is limited.
During April-December 1992 in Pakistan, interviews were conducted with 67 general practitioners (GPs) and 27 pediatricians practicing in Karachi to examine their knowledge and attitude towards use of oral rehydration solution (ORS), management of acute watery diarrhea in children, and factors for their prescribing antidiarrheals. All but 1 GP and 1 pediatrician believed ORS reduces diarrhea morbidity. 50% of all physicians considered ORS to be palatable. 55.3% thought that children younger than 5 accept ORS. Yet, only 20.27% believed that parents accept ORS as the only treatment for acute watery diarrhea. GPs were more likely to prescribe antibiotics, anti-amebics, anti-emetics, and kaolin compounds than were pediatricians (50-80% vs. 11-55%). Most GPs and pediatricians claimed that they did not prescribe antimotility drugs, which are used as antidiarrheals (88% and 96%, respectively). Medical representatives of various drug companies have visited most of these physicians to show them attractive pamphlets touting the efficacy of drugs in treating diarrhea. These pamphlets can be the only source of current information for most physicians practicing privately. Leading reasons for prescribing antidiarrheals included parental pressure (80% for GPs and 64% for pediatricians) and use as placebo (67% and 90%, respectively). GPs were much more likely than pediatricians to prescribe antidiarrheals because they thought the antidiarrheals were necessary (44% vs. 10%). The entire health care delivery system (which should aim to abolish competition between various physicians) should be reorganized to provide financial incentives for private practicing physicians, and to promote continuous education for these physicians. Increased health education among the public about safety, efficacy, and lack of necessity of drugs is needed to reduce parental pressure on physicians to prescribe drugs unnecessarily and irrationally.
Outbreaks of cholera in Kathmandu valley in Nepal.
During July-September (the rainy season in Nepal) 1994, various agar media were used to perform bacterial cultures of the stool of 694 children, 7 months - 14 years old, who had watery diarrhea and were attending the ORT (Oral Rehydration Therapy) Center of the National Kanti Children's Hospital in Kathmandu, to identify the pathogens responsible for this seasonal epidemic of acute gastroenteritis. A field survey to collect water samples was also conducted in various areas with a high patient population to identify pathogens contaminating water sources. Vibrio cholerae were isolated from the stool of 287 of the children, 284 of which were 01 biotype, El Tor Ogawa. The sensitivity test revealed considerable sensitivities to tetracycline, ciprofloxacin, and gentamicin and poor sensitivities to nalidixic acid, cotrimoxazol, ampicillin, and cephalexin among the 28 cholera patients tested. Cotrimoxazol is used widely to treat acute gastroenteritis in Nepal. The most common symptoms among cholera cases were vomiting, diarrhea, and dehydration. About 50% of patients had continuous watery stool that resembled rice water. 2% of cholera cases died. The other children received ORT, intravenous drip infusion of Ringer's lactate solution, and oral tetracycline for 5 days. Younger children had higher cholera morbidity than older children (p < 0.03). Several clusters of gastroenteritis cases lived in the densely-populated periurban areas of the Kathmandu valley along the river. V. cholerae were isolated from the river and canals flowing through these patient clusters. Other enterobacteria identified included pathogenic Escherichia coli (216), non-pathogenic E. coli (119), E. coli species (38), Klebsiella species (21), and Shigella (3).
Perinatal mortality -- a hospital based study.
During August 1992-July 1993, data on 5082 consecutive deliveries in Medical College Hospital in Kottayam, Kerala State, India, were analyzed to determine the perinatal mortality rate (PMR), the late fetal death rate (LFDR), and early neonatal death rate (ENDR) as well as the risk factors for perinatal mortality. Infants weighing less than 1000 g and born before 28 weeks gestation were excluded from the analysis. There were 195 perinatal deaths for a PMR of 38.5/1000 births. Of these 195 perinatal deaths, 102 were late fetal deaths and 93 were early neonatal deaths. The LFDR stood at 20.1/1000 and the ENDR at 18.3/1000. Perinatal deaths were most common in males and in newborns of primigravidae women. Most perinatal deaths occurred in low birth weight infants (LFD = 86% and END = 80%) and in preterm infants (LFD = 90% and END = 78%). Leading causes of LFD included maceration (47%), perinatal hypoxia (41.2%), and congenital anomalies (11.7%). Leading causes of END were perinatal hypoxia (43%), bacterial infections (16%), congenital anomalies (15%), and hyaline membrane disease (15%). 90% of perinatal death cases had had risk factors during the antenatal period (e.g., pregnancy-induced hypertension, antepartum hemorrhage, and cord complications). These findings emphasize the need for health workers to identify high risk factors before pregnancy, during gestation, and intranatally so they can provide appropriate care. Appropriate care will reduce the incidence of prematurity and low birth weight infants. Pediatricians and obstetricians need to work together to reduce perinatal deaths.
Socio-economic influences on gender inequalities in child health in rural Bangladesh.
During February 1989-June 1990 in Bangladesh, local field assistants collected data on 1366 children 2-6 years old, attending maternal and child health clinics operated by a nongovernmental organization, and living in 13 villages in Jamalpur District situated on the banks of the Jamuna River. The field assistants made home visits to record child morbidity every 2 weeks and to measure child height and weight once a month. During January-April 1989, this area suffered from extensive food shortages due to a prolonged drought and one of the worst floods recorded in Bangladesh. Gender bias was not apparent in farming and trading/employee households. In landless households (i.e., fathers' occupation was laborer), girls were significantly shorter and less heavy than boys (p < 0.001), however. During a natural disaster, fathers' occupation significantly interacted with sex (p < 0.05). Specifically, children who were both female and living in a landless household were more likely to have poor nutritional status than children who were female and living in a farming or trading/employee household and children who were male and living in a landless household. This interaction was not apparent as local conditions improved. Over the 16 months following the natural disaster, landless girls grew significantly more in height-for-age and weight-for-age than landless boys (p < 0.001). In other words, these girls experienced more catch-up growth than the boys. At the end of the study, nutritional status varied only according to socioeconomic status but not according to gender. These findings suggest that gender bias within this population depends on changes in food availability and the rural economy. Thus, child nutrition programs should target landless girls, who are at highest risk of gender discrimination and malnutrition during economic adversity.
In Denmark, 48 chlamydia-positive heterosexual patients of the department of genitourinary medicine at Bispebjerg Hospital completed a questionnaire designed to evaluate the reasons for inconsistent or incorrect use of condoms. 24 patients were male and 24 were female. 50% did not use condoms because of decreased pleasure of sex, irritation due to coitus interruptus, or unromantic feelings. Women were more likely than men not to use condoms with a regular sex partner (17% vs. 4%). 21% of women and 29% of men claimed that alcohol drinking was an important factor in not using condoms. Low self-esteem was a factor among women only. Not having brought a condom to the risk situation was a factor for 17% overall. Use of other contraceptive methods was the reason for not using condoms for 15% of patients. 9 of the 11 patients who forgot to use a condom (even though it was available), did not care, or did not consider themselves to be at risk of a sexually transmitted disease were men. 3 patients said that they contracted chlamydia because the condom broke, slipped off, or did not fit. These findings identify various areas that need to be addressed to increase condom use to prevent chlamydia.
Since the HIV p24 antigen appears a few weeks before the HIV antibody, researchers conducted a study to determine whether the HIV antigen test Abbott HIV AG-1 would identify recently HIV-infected female sex workers in Singapore whose infection might be missed if only HIV antibody tests were used. During April 1993-April 1994, blood samples were taken from 1000 female sex workers newly enrolled in the Department of STD (sexually transmitted disease) Control of Singapore General Hospital to test for the HIV p24 antigen. Results of the Abbott HIV AG-1 test were compared with 3 HIV antibody tests (Abbott recombinant HIV-1/HIV-2 3rd generation enzyme immunoassay [EIA] test, the Fujirebio Serodia-HIV particle agglutination [PA] test, and the Diagnostic Biotechnology HIV Blot 2.2 Western blot [WB] test). All 3 HIV antibody tests found 25 female prostitutes to be HIV positive. The EIA and WB tests found 26 women to be HIV positive for a prevalence rate of 2.6%. Only 1 specimen tested positive for HIV antigen. This specimen also tested positive for HIV antibodies. There was no HIV antigen positive specimen that was HIV antibody negative or indeterminate. These findings show that the HIV antigen test did not improve the detection rate of HIV infection in these female sex workers, since there were no HIV antigen specimens that were HIV antibody negative or indeterminate.
As part of the Singapore Ministry of Health's Medical Surveillance Scheme, which requires commercial sex workers (CSWs) to undergo regular screening for sexually transmitted diseases (STD), the National Skin Centre clinic conducted STD screening among CSWs. STD data on CSWs attending the clinic during 1977-1993 were analyzed to examine the changes in STD prevalence among sex workers and the impact of the Medical Scheme on the STD infection rate. The STD infection rates of CSWs who were not in the Medical Scheme (new CSWs and freelance CSWs arrested for illicit prostitution) were compared with those in the Scheme. The STD screening program also provided CSWs access to STD/HIV educational and preventive programs. The gonorrhea infection rate decreased from 9% to 1.7%. The gonorrhea infection rate was lowest in CSWs who were part of the Medical Surveillance Scheme (1992, 2.6% vs. 4.9% for new CSWs and 6.1% for freelance CSWs; 1993, 1.7% vs. 4.3% and 5.8%, respectively). Chlamydia screening was not introduced until 1992. The chlamydia infection rated decreased from 7.4% in July 1992 to 4.2% in December 1993. The 1992-1993 chlamydia infection rate was lowest in CSWs who were part of the Medical Scheme (4.5% vs. 10.2% for new CSWs and 9.6% for freelance CSWs). Similarly, CSWs who were part of the Scheme had the lowest HIV infection rate (1992, 0.04% vs. 0.23% for new CSWs and 2.8% for freelance CSWs; 1993, 0.07% vs. 1.7% and 3.9%, respectively). HIV infection data were first put in to computers in 1992. These findings show that regular STD screening for sex workers effectively control STDs among sex workers.
During July 1993-June 1994 in Bangkok, Thailand, dermatologists examined the skin of 248 HIV-infected patients attending the outpatient clinic or admitted to the medical wards of Siriraj Hospital and performed a CD4+ T-lymphocyte count to determine the prevalence of skin disorders in HIV-infected people and to categorize them into clinical stages. 86% of the patients were male. 140 people were in the asymptomatic group, 27 in the symptomatic group, and 81 in the advanced group (CD4+ <50 cells/sq m). 95% of all HIV-infected patients had at least 1 skin disorder, especially oral candidiasis (34.3%) and pruritic papular eruption (PPE) (32.7%). Other skin disorders included seborrhoeic dermatitis (21%), herpes zoster (16.1%), oral hairy leukoplakia (14.9%), herpes simplex (10.9%), onychomycosis (9.3%), cutaneous ringworm (7.7%), psoriasis (6.5%), and folliculitis (5.6%). No one had Kaposi's sarcoma. 3.2% of all HIV-infected patients had Penicillium maneffei infection, which was limited to only AIDS patients. 9.9% of AIDS patients had Penicilliosis maneffei. Prior to the AIDS epidemic, this infection was unknown to most physicians. AIDS patients were more likely to have at least 3 skin disorders. AIDS patients were more likely to have severe skin lesions than asymptomatic and symptomatic patients (14.8% vs. 9.4% and 7.5%, respectively). Asymptomatic patients had higher prevalence of the frequently seen skin disorders, except cutaneous ringworm, than general patients attending the outpatient clinics (e.g., 3-fold increase for psoriasis, about 25-increase for candidiasis). PPE and oral hairy leukoplakia were unique to HIV infection. This population tended to share a similar pattern of skin manifestations of HIV disease. It is unusual that this population has a high prevalence of PPE and P. maneffei infection and no Kaposi's sarcoma.
Contraceptive options for teenagers.
Birth rates for adolescents vary worldwide (3/1000 teenage women in Japan to 237/1000 in Bangladesh). Many teens engage in sexual intercourse. Most societies consider births to young mothers to be unacceptable. Young childbearing has a great demographic impact. Society should move from controversy, indecision, and debate on adolescent births to action in order to reduce the number of births to young adolescents. Society needs to admit that adolescents are sexually active and to provide teens contraceptive options by increasing access to and availability of all current contraceptives. Each of the current contraceptive options has benefits and drawbacks. The current contraceptive options include combined oral contraceptives (OCs), the injectable contraceptive Depo-Provera, the contraceptive implant Norplant, condoms, vaginal methods or spermicides, the diaphragm or cervical cap, withdrawal, IUDs, and induced abortion. Currently available OCs in high doses could cut the number of unplanned pregnancies by 50% and the number of abortions by about 66% in the US. OCs with low-dose estrogen (e.g., Lo-Ovral or Micro-gynon) can also be used as effective emergency postcoital contraception. Four tablets should be taken within 72 hours after unprotected intercourse, followed by 4 more tablets 12 hours later. The current US political climate explains why OCs are currently not used as emergency contraception. Emergency contraception should be considered a step towards regular contraceptive use. An alternative postcoital contraceptive is insertion of an IUD within 5 days of unprotected intercourse. AIDS and other sexually transmitted diseases (STDs) provide an important and frightening dimension to sexual intercourse between adolescents. In most cases where the choice is between condoms (the most effective means of preventing AIDS and STDs) and OCs (an effective means of preventing pregnancy), providers should promote condoms. If a girl who is at any risk of STD/HIV infection chooses OCs, Norplant, or Depo-Provera, condoms need to be provided and strongly promoted.
Vitamin A deficiency: health, survival, and vision.
This book on vitamin A deficiency not only addresses ocular manifestations but also the broader context of child health and survival. The introduction examines the historical and modern perspectives of vitamin deficiency, what vitamin A is, and the relationship of xerophthalmia (severe vitamin A deficiency) to vitamin A status. The second section of the book discusses consequences of vitamin A deficiency. Chapter 2 looks at mortality associated with moderate to severe deficiency and the fact that vitamin A supplementation reduces preschool-age mortality and measles mortality. Chapter 3 covers infectious morbidity, particularly diarrhea, measles, respiratory disease, urinary tract infection, otitis, and other infections (e.g., HIV). Chapter 4 examines ocular manifestations (xerophthalmia, keratomalacia, night blindness, and conjunctiva). The effect of vitamin A on anemia and iron metabolism and the extent of vitamin A deficiency-associated anemia are discussed in chapter 5. Chapter 6 examines vitamin A's role in growth in animals and children. The third section of the book is dedicated to mechanisms of vitamin A. Chapter 7 looks at contributory and precipitating events (i.e., systemic infections and protein energy malnutrition). Chapter 8 addresses the biochemistry of vitamin A and carotenoids. Chapter 9 examines the relationship between immunocompetence and vitamin A status, particularly lymphoid organs and hematopoiesis, cell-mediated immunity, humoral immunity, effect of vitamin A administration on immune response, and identification of and requirements for immunoregulatory retinoids. The fourth section, chapter 10, is dedicated to treatment of vitamin A deficiency and xerophthalmia. The last section covers assessment and prevention. Chapters 11 and 12 discuss assessment of vitamin A status and epidemiology of deficiency, respectively. The last three chapters examine prevention interventions: dietary interventions, supplementation, and fortification of dietary items with vitamin A.
Correlation of genetic and serologic approaches to HIV-1 subtyping in Thailand.
During September 1993-January 1994 in Bangkok, Thailand, blood samples were taken from 38 HIV-infected subjects, 19-45 years old, 58% of whom were men, who had been referred to the Joint Clinical Research Centre. Their CD4+ T lymphocyte counts were between 6 and 993 cells/mcl (mean, 380 cells/mcl). DNA was extracted from peripheral blood mononuclear cells (PBMC). The aim was to determine HIV-1 subtypes in these subjects and to compare the performance of differential polymerase chain reaction (PCR) and peptide enzyme immunoassay (V3-EIA) using heteroduplex mobility assay (HMA) as the reference standard. It was to be determined whether PCR and V3-EIA, both of which have less rigorous sampling requirements, specimen processing, and logistical and technical requirements of serotyping than HMA, would be useful for screening in the field. HMA identified 84% of subjects as infected with HIV-1 subtype E. The remaining 16% were infected with HIV-1 subtype B. The PCR test achieved 100% concordance with the HMA results. V3-EIA detected HIV-1 in 95% of the subjects. It correctly identified 94% of subtype E HIV-1 infections and all subtype B HIV-1 infections when coupling the antibody-associated V3-EIA with the antigen-limiting V3-EIA, using HMA as the reference standard. The 2 sera that V3-EIA could not type were HIV-1 subtype E as classified by HMA and PCR. These findings suggest that PCR and V3-EIA would be practical as complements to HMA in HIV-1 subtyping in Thailand where subtypes B and E co-circulate.
Evaluation of a confirmatory HIV testing strategy in Thailand not using Western blot [letter]
During December 1993-May 1995 in Thailand, blood samples were taken from 4818 patients admitted to Bamrasnaradura Infectious Disease Hospital in the Bangkok suburb of Nonthaburi to screen for HIV antibodies using particle agglutination (PA) (SERODIA-HIV, Fujirebio Inc. Tokyo, Japan). Researchers aimed to evaluate the World Health Organization (WHO) HIV testing strategy II under field conditions by comparing the PA results with those of the enzyme immunoassay (EIA) and the Western blot (WB). The HIV testing strategy II involves a second screening assay instead of the WB to confirm the results of samples reactive on the first screening test to determine HIV seropositivity in asymptomatic persons in areas with HIV prevalence greater than 10% and in persons with suspected HIV infection. PA detected 1173 (24.3%) HIV-positive specimens. All but 3 (99.7%) specimens were reactive by EIA. All but 1 of the 11730 (99.9%) EIA-reactive specimens were also reactive by WB. The 3 EIA-nonreactive specimens and the 1 EIA-reactive specimen were indeterminate by WB. PA alone had a positive predictive value of 99.7%. EIA as the supplemental test had a positive predictive value of 99.9%. These findings support the WHO alternative testing strategy II as a useful strategy for confirming HIV seropositivity among hospital patients with suspected HIV-related disease in Thailand. Studies of the sensitivity and the negative predictive value of the strategy are needed to determine its utility either to screen blood donors or to assess patients with possible HIV infection.
During October 1993-March 1995, Project Youth Inform sessions were conducted in all 4 polytechnics, 14 junior colleges, 4 centralized institutions, and 8 pre-university centers in Singapore. Project Youth Inform is a comprehensive STD (sexually transmitted disease)/AIDS education program. The School Health Service and the Training and Health Education Department currently administer the project. The 8 components of the program are a focus group discussion with youth, a training seminar for teachers, a lecture/slide presentation by a physician or a nurse a with a question-and-answer session, an education booklet/bookmark, exhibitions on school premises, a video, provisions for anonymous questions, and an evaluation. All the schools require students to attend. In the polytechnics, integration of the program into the health education module achieved better attendance than replacing one of the subjects of the existing curriculum with a health talk (80-84% vs. 56-63%). Replacing a subject with the health talk did not allow time for classroom discussions. Attendance was highest in the junior colleges, pre-university centers, and centralized institutes (90%), all of which integrated the program into the Civics or the General Paper period. Principals, school administrators, and teachers tended to support and welcome implementation of the program on a compulsory basis. 752 engineering students of polytechnics and 248 junior college students studying the arts, business, or science participated in the process evaluation. Most students (74%) thought that the duration of the lecture (40-45 minutes for the talk and 10-15 minutes for questions and answers) was ideal. The least favorable time for the lecture was 1600-1700 h. 78% claimed to have understood the session completely. The leading reasons for not understanding the session were inability to understand the medical or biological terms used and too much information to be absorbed within a short period of time. 86% said that they learned something useful from the session. 41% wanted more sessions.
Hormonal contraception: a cost benefit analysis [editorial]
Contraceptive choices are many in Europe but still limited in Ireland. Condoms have been available only recently in Ireland. Ethical approval is needed for sterilization in several Irish hospitals. Waiting lists for sterilization can be as long as 4 years or closed. Access to emergency contraception is also limited. Improvements in the availability, accessibility, safety, and effectiveness of emergency contraception may reduce the number of abortions sought by Irish women. The combined oral contraceptive (COC) is widely available and approved by almost all health providers. Women using COCs with 30 mcg estrogen face an increased risk of venous thromboembolism, myocardial infarction, cardiovascular accidents, and hypertension. It appears that COCs increases the risk, albeit small, of cervical cancer but confounding variables (e.g., age at first intercourse) may explain this increased risk. On the other hand, COCs are associated with a reduced risk for other conditions. COCs reduce the risk of pregnancy by 99% and the risk of ectopic pregnancy by 90%. They also protect against ovarian cancer (reduction in risk = 40%), pelvic inflammatory disease (50%), fibroids (after 5 years of COC use: 17%), functional ovarian cysts (49-78%), menorrhagia (50%), iron deficiency anemia (50%), benign breast disease (40%), and dysmenorrhea (40%). The research has not yet confirmed an increased risk of breast cancer or choriocarcinoma among COC users. The progesterone-only OC is safe for older smokers and lactating women. Other progesterone-only contraceptives include the contraceptive implant Norplant, the levonorgestrel-releasing IUD, and high-dose progestogen tablets (e.g., Neogest) used as postcoital contraception.
Prioritization in perinatal care [letter]
During August 1988-July 1989 at J.J. Hospital in Bombay, India, interviews were conducted with the mothers of 1622 newborns. The aim was to determine risk factors for perinatal death in order to assign priorities in perinatal care. There were 121 perinatal deaths. Factors significantly associated with perinatal death and with high attributable risk (AR) were poor housing (odds ratio [OR] = 1.2, AR = 18.6), low income (OR = 1.3, AR = 27), illiteracy (OR = 1.9, AR = 22.8), working mother (OR = 1.1, AR = 7.8), mother doing hard physical labor (OR = 1.27, AR = 6.8), short stature of mother (OR = 1.05, AR = 13.8), pregnancy-induced hypertension (OR = 1.44, AR = 10), prolonged rupture of the membranes (OR = 1.23, AR = 15.3), and low birth weight (OR = 1.7, AR = 24.7). Factors associated with a high OR and high AR were history of induction of labor (OR = 4.5, AR = 33), abnormal presentation (OR = 8.1, AR = 5.6), abnormal fetal heart rate (OR = 15, AR = 6.8), antepartum hemorrhage (OR = 4, AR = 5.3), prematurity (OR = 4.6, AR = 24.6), being small for gestational age (OR = 5.03, AR = 6.8), and respiratory distress (OR = 34.6, AR = 15.9). Factors associated with a high OR and a low AR were congenital malformations (OR = 4.15, AR = 0.49), low Apgar score (OR = 26.5, AR = 4.3), and hypothermia (OR = 38.7, AR = 0.69). Factors associated with a low OR included multiparity (OR = 1.6), multiple pregnancy (OR = 1.4), unfavorable maternal age (OR = 0.67), severe anemia (OR = 0.63), operative delivery (OR = 0.39), meconium passage (OR = 0.97), and prolonged labor (OR = 0.99). Socioeconomic factors had a somewhat higher risk of perinatal death than obstetric and neonatal factors. The AR of clinical conditions associated with low socioeconomic status (e.g., prolonged rupture of membrane) was high, suggesting the need for long term preventive intervention. Obstetric factors associated with perinatal asphyxia (e.g., abnormal presentation) had high OR and high AR, indicating the need to properly manage these conditions during labor.
In Senegal, after the ECOLONG Agreement of a group of women from Ziguinchor and Grand Medine regions, a Forum of Community Work on AIDS was held on August 27, 1995, at Tonghor beach. At this time of year, the beach was favorable for leisure and for meeting people from different areas of Dakar's suburbs, including Yoff zone. The fundamental objective of the forum was for women to inform themselves about the dangers of AIDS while providing support and creating different messages for different areas. Launching a message does not only involve giving the definition of AIDS and the modes of HIV transmission and prevention. Determination and imagination are essential to capturing the public's interest. Everyone working together allows the anti-AIDS message to reach a larger public.
Practical experiences in obtaining informed consent for a vaccine trial in rural Africa.
The feasibility of obtaining informed consent from individuals in developing countries, in contrast to the usual practice of working through trusted community leaders, was confirmed in the course of a vaccination campaign in rural Senegal. During 1990-95, the Institut Francais de Recherche Scientifique pour le Developpement en Cooperation (OSTROM) conducted a randomized, double-blind trial of the efficacy of a diphtheria-tetanus-acellular pertussis vaccine versus a whole-cell diphtheria-tetanus-pertussis (DPT) vaccine. Infants were randomly assigned to receive 3 doses of 1 of these vaccines. From August 1992 onward, mothers received extensive information on the research at community meetings and were given the option to refuse to participate (i.e., to receive DPT). Although some mothers wanted to choose 1 of the vaccines for their children or at least be informed of which vaccine was administered, the double-blind concept was explained to them by making comparisons with agricultural research on seed varieties and fertilizers. In a pre-intervention pilot study of individual informed consent, 50 of 55 mothers consented to their children's inclusion in the trial, indicating that they trusted the research team. The 5 refusals were considered to be informed, because mothers chose the better-known vaccine. Of the 13,555 residents of Niakhar, 2607 (19.2%) attended informational meetings on the research. In the May 1990-June 1992 period, before introduction of the individual informed consent process, mothers of 46 (7.4%) of 620 eligible children refused vaccination (defined as not taking one's child to the clinic). From August 1992-August 1994, after the policy change, the overall rate of refusal of the first dose was only 4.9% (107 of 2163 eligible children). Mothers were aware of deaths among local children due to measles and pertussis and viewed vaccination as providing a benefit that outweighed any risks.
Towards better counselling. Keeping confidences. Training activities.
Presented are two training exercises for health personnel who counsel individuals about the results of blood tests for human immunodeficiency virus (HIV). The first exercise is preceded by remarks on the importance of trust and confidentiality in the clinical encounter. Then, participants are divided into pairs and instructed to think of a person they trust and to list 10 characteristics of that person. These attributes are compiled for the entire group. Next, small groups of 3-4 participants discuss the following questions: What do you need to say and do when you are counseling someone to help them have confidence in you? What do you need to do to enable them to keep trusting you? What might happen when confidentiality is broken? What are the benefits of maintaining confidentiality? Finally, the small groups are given case scenarios of breaches of client confidentiality and asked to imagine both how they would feel in such a situation and how it could have been prevented. The second exercise seeks to increase counselors' understanding of clients' risk-taking behaviors and their ability to suspend personal judgment by having them describe incidents from their own lives when they took a risk related to sex, relationships, or money.
Testing positive. Counselling blood donors.
In 1993, Zimbabwe's blood service revised its notification system to protect the confidentiality of blood donors found to be positive for human immunodeficiency virus (HIV) or another sexually transmitted disease (STD). In the past, such donors were referred back to their physicians, many of whom were unable or unwilling to discuss STDs; other donors had no personal physician. Now, donors who test positive for HIV, syphilis, or gonorrhea are informed by mail they have an unspecified infection and offered follow-up and counseling services from an organization or doctor (who also receive letters) of their choice. However, some nongovernmental organizations to which infected donors are referred report that less than half present for counseling. Common reasons include a reluctance to go to a site perceived as an AIDS center, fears of an HIV diagnosis, concerns about encountering a counselor they know personally, difficulties related to travel or limited clinic hours, and problems with the postal service. Still in need of clarification is Zimbabwe's policy toward young blood donors. Many countries seek out school-age donors because of their presumed lower risk of infection; however, when these young people test positive, ethical dilemmas emerge about parental notification and consent for counseling. Finally, to reduce the misuse of blood donation services for HIV testing, measures are needed to improve the availability of HIV screening.
Safe blood and safer sex. Education and counselling.
Education and counseling services aimed at blood donors have the potential not only to increase the safety of the blood supply, but also to promote safer sexual behavior. Public education campaigns should emphasize the social responsibility aspect of blood donation, including stories about lives saved with blood transfusions, and stress the need for donors to act responsibly by not putting others at risk of human immunodeficiency virus (HIV). When people first come to the blood collection center or mobile van, it is helpful to give a talk or show a video about the blood collection process. Also recommended are one-to-one sessions with a trained health worker in which potential donors can assess, on the basis of questions about their personal risk factors, whether they should exclude themselves. After the Honduras Red Cross National Blood Program introduced a brochure containing information about HIV risk and the importance of not donating blood if one has engaged in high-risk activities, the HIV prevalence among donors declined from 0.38 in 1990 to 0.19 a year later, despite increases in HIV seroprevalence in the general population. In Zimbabwe, the National Blood Transfusion Service has developed special outreach programs for students 16 years and older, the source of 65% of the country's blood supply. Talks are given at schools, and students are trained to be peer promoters. School leaders are invited to register for regular blood collection services at community centers; many formally pledge to donate blood 25 times in their life-time and to seek to remain HIV-negative.
Strategies for safe blood. Reducing HIV transmission.
Blood transfusion programs can minimize the risk of transfusing infected blood through three strategies: 1) recruiting and counseling voluntary donors who are at low risk of human immunodeficiency virus (HIV), 2) screening all donated blood for HIV and other infections transmitted by blood and safely disposing of infected blood, and 3) reducing the number of blood and blood product transfusions. Schools, universities, church groups, community centers, and workplaces provide opportunities for educating and recruiting people at low risk of HIV. Avoided should be paid donors; men and women who sell their blood are often at high risk of serious communicable diseases. All donated blood should be screened for HIV, hepatitis B, syphilis, and, depending on local disease patterns and resources, hepatitis C, Chagas' disease, and malaria. Donors should be informed of their HIV infection only after two tests have produced positive results. Because of the HIV "window period," during which antibodies are not yet detectable, a few infected blood units may be released. Where possible, blood substitutes such as saline or blood pre-collected from the patient should be used. Key to reducing the number of blood transfusions, however, is the prevention of anemia and pregnancy complications -- the indications for most transfusions.
Removing risk from safe motherhood.
Although improvements in women's status are key to dramatic, sustained reductions in maternal mortality, a 50% decrease in maternal deaths by the year 2000 could be achieved through a series of direct, immediate measures. Required, as a first step, is a shift from the traditional population-based risk group approach to the identification of early signs of pregnancy complications. This, in turn, implies training community-level practitioners to recognize pregnancy complications such as hemorrhage, eclampsia, obstructed labor, septic abortion, and severe anemia and moving these women to health facilities equipped to manage these conditions. In most cases, primary health care facilities can not provide the array of services necessary for preventing maternal deaths. However, anticonvulsants, plasma expander, antibiotics, oxytocin, and--ideally--a vehicle to transport women to a hospital should be available at local health centers. Since it is impossible to predict who will need emergency measures such as cesarean section, induction of labor, blood transfusion, or removal of placenta, every pregnant woman must be linked to an emergency obstetric facility. The community is key to bridging the gap between households and the hospital, not only by assisting with transport but also by countering sociocultural norms that prevent villagers from seeking hospital care.
The impact of unregulated fertility on maternal and child survival.
Unregulated fertility is a major contributor to high-risk pregnancies in developing countries, and universal access to family planning is perhaps the most cost-effective and feasible strategy to reduce maternal and child mortality. The majority of high-risk pregnancies (unwanted, in mothers younger than 20 years or older than 35 years, closely spaced, and in women with high parity) are associated with a lack of access to family planning. Unsafe abortion, also associated with unwanted pregnancy, is a leading cause of maternal mortality, causing 500 deaths in developing countries each day. If all women were able to limit their childbearing to no more than 4 children, born when the mother was 18-35 years old and spaced at least 2 years apart, an estimated 5.6 million infant deaths and 0.2 million maternal deaths would be averted each year. In most cases, maternal and child mortality represent the endpoint of a "road to death," paved with a lifetime of socioeconomic disadvantage and lack of access to health care services. Family planning has the potential not only to improve maternal and child survival; it also provides women with a sense of control over their lives -- a dynamic that, in turn, often produces dramatic changes in their socioeconomic status and quality of life.
Unmet need in family planning in South Asia region.
Although South Asia's contraceptive prevalence rate has increased by 165% over the past 30 years and the annual population growth rate in the region has dropped to 2%, fertility rates remain unacceptably high. All South Asian countries have major unmet need for contraception. In the region as a whole, about 48% of married women 15-49 years old lack access to family planning; this statistic ranges from 30% in Pakistan to 71% in Bangladesh. Women's low socioeconomic status, the persistence of son preference, the young age structure of South Asian populations, shortages of trained health personnel, and limited access to basic health services all compound the challenge of increasing the availability of family planning programs. Also salient are basic power issues that affect relationships between men and women, health providers and clients, and the state and its people. Nongovernmental organizations in South Asia are urged to take the lead in making family planning programs that do exist more gender-sensitive and woman-friendly.
Rethinking the role of the risk approach and antenatal care in maternal mortality reduction.
In developing countries, where most women are not delivered in health facilities, screening pregnant women for nonmedical risk factors (e.g., age, weight, parity) is neither a cost-effective nor an efficient strategy for maternal mortality reduction. Since these traditional risk factors are not direct causes of poor outcome, this approach to screening has low sensitivity and specificity. Moreover, risk screening can create a false sense of security for women in low-risk categories, and health workers are likely to fail to give these women guidance about potential pregnancy complications. Antenatal care, in contrast, allows for the early identification of complications such as high blood pressure, severe anemia, and malpresentation; it educates women to recognize obstetric danger signs and motivates them and their families to seek appropriate hospital care. When an actual complication has been detected and women are referred to a high-risk facility, they are more likely to follow preventive advice than women referred for potential complications on the basis of demographic risk factors.
Eclampsia: modern outlook on prevention and treatment.
Prevention of the progression of pre-eclampsia to eclampsia can have a substantial impact on maternal mortality in developing countries. In Africa, the case fatality rate from eclampsia is estimated at 7-25%. This condition is characterized by a reversal of the ratio of prostacycline and thromboxane, increases in lipid peroxides, and a lack of invasion of the spiral arteries by trophoblasts. Since there is no ideal predictive test for pre-eclampsia, early detection through universal antenatal coverage is required. Blood pressure and urinary protein measures should be taken regularly, and low-dose aspirin is a promising preventive strategy among women at risk of eclampsia. Management includes prompt and appropriate referral, proper case management, and delivery of the fetus if the disease progresses. Essential obstetric care should be established at all levels of the health service to promote the early detection and treatment of this life-threatening condition.
Neonatal tetanus: review of progress.
Elimination of neonatal tetanus, a goal set for 1995, has been defined as less than 1 case per 1000 live births in every district of the world after active surveillance and correction for sex bias. Achievement of this goal, which would reduce infant mortality in developing countries by 25%, requires administration of at least 3 doses of tetanus toxoid to all women of childbearing age living in high risk areas. In 1993, at least 700,000 tetanus-related neonatal deaths were averted through immunization; 70% of these averted deaths were in India, Bangladesh, and Indonesia. By August 1994, 91 countries had achieved a neonatal tetanus rate under 1/1000 live births; of these, 50 may have achieved this goal in every district. Of the estimated 517,000 neonatal deaths still occurring, 80% are concentrated in 12 countries. Recommended for these 12 countries and the 14 others with an estimated rate close to or above 5/1000 is a high risk approach aimed at identifying areas with low measles immunization coverage, inadequate clean delivery provisions, and low levels of tetanus toxoid coverage. Ameliorative strategies include routine immunization with fixed, outreach, and mobile teams; supplementary activities such as National Immunization Days or Days of Tranquility in countries with civil unrest; promotion of clean delivery practices; and active surveillance in every district. The total estimated cost of prevention campaigns in high-risk districts would be US $55 million ($1.53/woman).
The Mother-Baby Package: an approach to implementing safe motherhood.
The Mother-Baby Package outlines interventions that will help achieve the Safe Motherhood goal of reducing maternal mortality by half and neonatal and perinatal mortality by 30-40% of 1990 levels by the year 2000. The principles of this package are: 1) family planning, to ensure that couples have the information and services to plan the timing, number, and spacing of pregnancies; 2) antenatal care, to prevent pregnancy complications where possible and ensure that such conditions are detected early and treated appropriately; 3) clean and safe delivery, through providing all birth attendants with the necessary knowledge, skills, and equipment, as well as postpartum care for mothers and infants; and 4) essential obstetric care, to ensure that management of high-risk pregnancies and their complications is available to all women who need it. Implementation of these measures mandates a continuum of care, linking all three levels of the health system and ensuring the necessary support and supervision. Each country should adapt the interventions to local conditions, define nationally relevant goals and targets, and draft a national action plan.
Human immunodeficiency virus (HIV) and sexually transmitted diseases (STDs) are important determinants of reproductive health, and these conditions contribute an estimated 15% of the disease burden in urban areas of developing countries with high STD prevalence. The World Bank has ranked HIV/STDs second as a cause of morbidity in women, responsible for almost as many Disability Adjusted Life Years lost as all maternal causes combined. Women's greater vulnerability to HIV/STDs, their poor health care seeking behavior, and a lack of accessible and acceptable services all contribute to this phenomenon. Essential to reducing this impact is a reorientation of family welfare services toward a more integrated approach to women's and children's health. The considerable synergism and conceptual overlap between family welfare services and HIV/STD prevention and control programs make this a logical strategy. The main complications of STDs in women relate to reproductive tract infections and the health and survival of newborns. Moreover, the behavioral focus of both family planning and STD programs is the prevention of unprotected sexual intercourse.
Social and cultural factors leading to mothers being brought dead to hospital.
A study conducted by staff at the Jinnah Postgraduate Medical Center in Karachi, Pakistan, identified the importance of sociocultural as well as medical factors to the phenomenon of pregnant or newly delivered women who were dead on arrival. The cases were analyzed of the 150 such women during 1981-92 who were dead when they reached the facility. These cases represented 25% of the maternal mortality at the hospital during the study period. The dead women, all of whom were from a low socioeconomic class, ranged in age from 16 to 44 years. None of the women had attended the facility for prenatal care; most were cared for by traditional birth attendants. All but 5 women lived in the city of Karachi, and most lived within 5-10 km of the hospital. Delivery occurred 2-4 hours before hospital arrival in 92 cases, while 48 died before giving birth; another 8 women died after abortion and 2 died as a result of ectopic pregnancy. Hemorrhage (primarily postpartum) was responsible for 63 deaths (42%); eclampsia accounted for 29 deaths (19.3%), ruptured uterus for 14 deaths (9.3%), and acute inversion of the uterus for another nine (6%). If managed in time, these medical problems were preventable or treatable. The major reasons for delay in reaching the hospital were economic (36%), sociocultural (34%), and inadequate maternity services (21%). Of particular concern are the sociocultural factors, including the opposition of husbands and other family members to hospital care, that prevent women from utilizing hospital services, not only for prenatal care but even for emergencies.
Emergency obstetric care: measuring availability and monitoring progress.
Reduction of maternal mortality in developing countries requires the existence of accessible Emergency Obstetric Care (EOC) facilities for complicated pregnancies. To evaluate indicators proposed for monitoring progress in the provision of emergency care, a survey was conducted in India in 1992-93 in 10 Child Survival and Safe Motherhood Program districts with referral units. Calculated were the number of functional emergency obstetric care facilities, geographic bed distribution within a district, proportion of expected births and complications managed in these units, cesarean section as a percentage of all births, and case fatality rates for complicated cases. Among the notable findings were the low institutional birth rate (24% overall) and the small proportion of women with pregnancy complications to reach these facilities (15.8%). Case fatality rates were below 2% in half the districts. Changes in these indicators over time can measure progress in emergency obstetric care availability and utilization, and the findings of this study are being used to develop a monitoring system for emergency obstetric care in India.
A cross-sectional survey of 3600 rural and urban women from villages in southern India's Karnataka subdistrict with populations of 500 or more revealed high levels of maternal morbidity. All respondents were younger than 35 years and had at least 1 child under 5 years old. Overall, 41% of respondents experienced at least 1 morbid condition associated with their last pregnancy. 18% reported problems during the antenatal period (e.g., severe vomiting, swelling of hands and face, hypertension, fever), 18% had problems during delivery (e.g., prolonged labor, cesarean section, episiotomy), and 23.4% had some form of morbidity during the 6-week postnatal period (e.g., excessive bleeding or hemorrhage, infection, postpartum depression). 83.9% of these women had sought treatment for these problems, often choosing to pay an unqualified private practitioner rather than receive free government services. Logistic regression analysis indicated that significantly higher levels of morbidity were associated with urban residence, higher levels of maternal education, maternal age 25 years and older (for delivery and postpartum morbidity only), and a history of abortions and stillbirths. Surgical intervention during childbirth occurred in 13.1% of deliveries (34.2% when the analysis was limited to hospital deliveries). Factors significantly associated with such intervention included 6 or more years of education, high autonomy, primigravida status, history of abortions/stillbirths, and delivery in a private hospital.
A 5-year study of maternal mortality in Faisalabad City, Pakistan.
A review of declining maternal mortality in Faisalabad, Pakistan, during 1989-93 confirmed the effectiveness of a multifaceted safe motherhood campaign. During this 5-year period, 276,717 live births and 215 maternal deaths were recorded, yielding a maternal mortality rate of 0.77/1000, compared with 10.1/1000 in 1977 and 1.9 in 1987. Components of the preventive campaign included refresher courses for traditional birth attendants, distribution of iron pills, an obstetric "flying squad," community education, free hospital services, "in street" prenatal examinations, and safe motherhood camps. A review of the characteristics of the 215 mothers who died shows that 54% had been pregnant 5 or more times, 34.4% were over 35 years old, and 90.7% were illiterate or had only attended primary school. 15.4% of the maternal deaths occurred in the antepartum period and 61.9% in the postpartum period; another 17.2% occurred at the time of abortion. 57.2% of the women had received no prenatal care. 40.9% of deaths occurred in teaching hospitals, 32.6% at home, and 26.5% in private hospitals or clinics. The most common causes of death were: postpartum hemorrhage, 23.3%; pregnancy-induced hypertension/eclampsia, 15.8%; non-obstetric causes, 15.8%; and abortion, 9.3%. Insistence on home delivery, hesitation about hospital admission, and delay in transfer to a hospital were major non-medical contributors to these deaths. Although the interventions have substantially reduced maternal mortality, the results of this study highlight preventable causes of death for further attention from Faisalabad health officials.
Training of traditional birth attendants: success and failure in Bangladesh.
In Bangladesh, the government TBA (traditional birth attendant) program, under the aegis of the National Institute of Population Research and Training, seeks to have at least one trained TBA for each village. Over 44,000 TBAs have been trained since the government initiated its program in 1978, and thousands more have received instruction through the efforts of several nongovernmental organizations. To be included in the program, TBAs must be 30-50 years of age, have been married, be a permanent resident of the village where the family welfare center is located, and have a good reputation in the community. The training curriculum seeks to impart skills and reduce misconceptions related to pregnancy, home delivery, postpartum management, and newborn care. Special emphasis is placed on eradicating pregnancy-related food taboos, ensuring a clean delivery, and recognition of pregnancy complications. Preliminary evaluations of the 3-year training program suggest that TBAs are conducting regular antenatal exams, teaching pregnant women about adequate nutrition and good hygiene practices, identifying and referring women with malnutrition and pregnancy complications, motivating women to seek immunization, promoting breast feeding, and advocating family planning. Greater community promotion of trained TBAs is needed to increase their utilization.
Discussion: TBA training program.
Investment in the training of traditional birth attendants (TBAs) is a prerequisite to significant improvements in maternal mortality in rural areas of developing countries. Unhygienic practices and adherence to dangerous taboos (e.g., avoidance of certain foods during pregnancy) on the part of untrained TBAs are contributing to both maternal and neonatal mortality. Experience with TBA training in Sierra Leone confirms the importance of a staggered and phased educational program, given problems associated with teaching new skills and concepts to illiterate women. Use of pictorial support materials, in addition to demonstration and observation, is recommended to introduce new technologies. Before a training program is designed, a needs assessment of baseline knowledge and local conditions should be conducted. In Sierra Leone, trained TBAs are provided with a full array of equipment and supplies for their delivery room, a practice that has increased their referrals. In need of consideration is improved monetary compensation for trained TBAs for the additional roles they are assuming within the health care delivery system.
Traditional birth attendants in Bangladeshi villages: cultural and sociologic factors.
The author's field experience in rural Bangladesh's Rupganj thana raises questions about the feasibility, at least in the Bangladeshi context, of recommendations to train and upgrade traditional birth attendants (TBAs) as a strategy to reduce maternal and neonatal mortality. Most births in this thana occur at home, under unhygienic conditions, with a TBA present. There is generally no prenatal care or screening for pregnancy complications. The concepts of birth pollution, food restrictions, female seclusion, family honor, and evil spirits define the cultural aspects of childbirth. In fact, the primary function of the TBA is to remove pollution, not to facilitate birth. Primary responsibility for managing births is assigned to female family members. Representing an exception to this pattern of marginality and low status are TBAs trained by the Catholic mission dispensaries throughout the country; however, many villages are not close enough to these facilities to make attendance feasible and not all families can afford the small fee. This author recommends measures to increase the knowledge base about childbirth and women's health among the villagers themselves and to create free, culturally sensitive hospital services. However, until the larger problems of poverty, disempowerment, unemployment, low income, and illiteracy are addressed, no significant improvements in the health status of Bangladesh's rural population can be expected.
A study of referrals from a primary health centre in Haryana state (India).
To assess the pattern of morbidity among patients referred from India's primary health care centers, all such referrals from an outpatient clinic in Dayalpur during May 1985-April 1987 were analyzed. This center serves a population of 51,000 spread over 25 villages. Facilities are available for routine urine, blood, stool, and sputum examinations. Of the 47,982 patients seen at the health center during the study period, 947 (1.97%) were referred to other institutions. Of the 642 patients considered emergency cases, 41 (6.39%) were referred. Communicable diseases accounted for 50% of clinic visits and 25.9% of referrals; surgical referrals comprised 31.6% of total referrals. By specialization, referrals were made to gynecologists (17.6%), physicians (16.6%), pediatricians (12.5%), and ophthalmologists (8.9%). Urinary tract-related conditions were the most common complaint. Almost 95% of referrals were to the Civil Hospital in Ballabgarth--the nearest secondary care institution. These findings should be considered in planning the allocation of scarce health personnel in the region.
Gender, culture, and power: barriers to HIV-prevention strategies for women.
A telephone survey of contraceptive use and predictors of condom use with a regular sexual partner among a random sample of 513 Latina and 184 non-Hispanic White US women confirmed the significance of gender, culture, and power issues to acquired immunodeficiency syndrome (AIDS) prevention campaigns. 2/3 of all respondents were married; however, Latina women were significantly younger, less educated, and less likely to report multiple sexual partners than their White counterparts. Among the Latina women, 48% had no need for contraception, 26.4% were contraception users, and 25.6% were at risk for unplanned pregnancy; among Whites, these rates were 42%, 35%, and 23%, respectively. 67% of Latina women and 60% of Whites had never used condoms with their steady partner. Latina women had less correct knowledge about human immunodeficiency virus (HIV), more fear of a negative reaction to a condom use request, less self-efficacy to use condoms, and less sexual comfort than White women. According to multiple logistic regression analysis, the variables most strongly associated with condom use with a steady partner among both Latina and White women were not using another contraceptive method, positive attitude toward condom use, having friends who use condoms, self-efficacy to use condoms, more sexual power, having 2 or more sexual partners in the past year, and worry about contracting HIV.
Sexual decision making by inner city Black adolescent males: a focus group study.
An analysis of the transcripts of 5 focus group discussions involving 27 Black adolescent males 15-19 years old from Madison, Wisconsin, identifies a number of beliefs and concerns underlying their sexual behavior. Respondents were recruited from sites providing employment, tutoring, or family planning services to minority and economically disadvantaged inner-city youth. The median age at first intercourse was 12 years and participants had an average of 9.7 lifetime sexual partners. Four sets of beliefs (about what it means to be a man, the good and bad things about sexual intimacy, condoms, and acquired immunodeficiency syndrome [AIDS]) were associated with sexual decisions made by these young men. Also salient to sexual decision making were 7 issues: good girls, bad girls; asking for sex; "running the game" (maintaining control in relationships); being "hooked up" (becoming an unwilling father); conflicts with other men; the relation between sex and love; and male roles and fatherhood. Overall, these adolescents viewed sexual behavior, sex partners, and condom use for AIDS prevention as elements within a complex script governing heterosexual interactions. For example, several types of women were differentiated, depending on factors such as their sexual conduct and reputation, motivation, and race, and condom use decisions were based on these perceptions.
Interviews with 515 Black and White men 18-30 years of age from Chicago, Illinois, who reported having sex with a male partner in the preceding 3 years revealed ethnic differences in sexual practices and psychosocial factors. White men reported more sexual partners than Blacks in the previous 6 months (means of 6.16 and 4.59, respectively), and more casual and anonymous sex. Blacks were more likely than Whites to have had insertive anal sex in this period (82.7% and 65.8%, respectively) and less likely to have had receptive oral sex (71.1% versus 91.7%). No ethnic differences were found in rates of unprotected sex. In the previous 6 months, 29.5% of respondents reported unprotected insertive anal sex with men and 21.8% reported unprotected receptive anal sex. Black respondents estimated that 48.19% of men are behaviorally bisexual compared to a 27.14% estimate provided by Whites, but Whites were more likely to perceive condom use in homosexual or bisexual encounters as normative. Whites perceived their social network and neighbors to be more accepting of their homosexual behavior than Blacks, and Whites were more likely to be involved in the gay community. White gay men scored lower on the self-homophobia measure than White bisexuals and Black homosexuals and bisexuals. Perceived vulnerability to human immunodeficiency virus (HIV) was related to demographic factors such as more education, higher income, and full-time employment rather than race. Finally, the psychosocial variables of involvement in the gay community, perceived acceptance of same-sex activity, and self-acceptance of homosexual activity were associated, among Blacks, with their having experienced receptive oral sex with men and, among Whites, with insertive anal sex with men.
Testing positive: sexually transmitted disease and the public health response.
This report, prepared by the Alan Guttmacher Institute, outlines the dimensions of the sexually transmitted disease (STD) problem in the US and the activities of the federal program (Centers for Disease Control) charged with combating their spread. It provides information about the most serious STDs, the factors that increase the risk of infection, and the financial implications of STDs for US society. While the government STD program focuses on secondary prevention, the human immunodeficiency virus (HIV) component focuses heavily on primary interventions aimed at reducing or eliminating high-risk behaviors. In view of the dramatically expanded spectrum of STDs in recent years, national STD/HIV strategies should be reviewed and reassessed. Recommended for consideration are the following issues: the need for chlamydia prevention to be assigned higher priority, more primary prevention activities aimed at persuading individuals to change behaviors that place them at risk of STDs, whether too many resources are allocated to partner notification at the expense of other activities, a shift in the target of STD programs from men to women and teenagers, interventions directed exclusively at teenagers, increased Congressional funding for primary prevention, and more current information on the most effective prevention and control strategies.
Models for decentralizing national AIDS control programs (NACPs) in the life developing world.
Pilot projects in Zambia and Jamaica assessed the feasibility of the decentralization of acquired immunodeficiency syndrome (AIDS) prevention and care to the community level. The model was designed to promote behavioral change, provide home-based care services, and involve people infected with human immunodeficiency virus (HIV) in income-generating activities. Project implementation was preceded by a needs assessment and the formation of District (Zambia)/Parish (Jamaica) AIDS Coordinating Teams. The frequency of team meetings was adversely affected by cost constraints, distance, and competition from other priorities. In Jamaica, the inclusion on the teams of nongovernmental organizations with a record of active community involvement strengthened the decentralization process. In both countries, the provision of non-monetary incentives such as badges, t-shirts, and training materials enhanced voluntary participation in the effort. Observed, however, was resistance on the part of health personnel to the inclusion of non-health workers in care activities. Overall, the following factors were identified as facilitating decentralization: experienced, committed, and multisectoral teams; strong leadership skills; training in strategic planning, financial management, team building, behavior change communication, and community mobilization; a decentralized budget; and a model developed for project beneficiaries by the beneficiaries. Achievements in Zambia were more pronounced, in part because groundwork for the project began three years prior to implementation.
The diffusion of drug injecting in developing countries.
The number of countries reporting the injection of illegal drugs increased from 80 in 1992 to 121 in 1995. Of these 121 countries, 82 have reported associated human immunodeficiency virus (HIV) epidemics. Also observed has been a trend toward the diffusion of drug-injecting behavior in developing countries. In Thailand, for example, opium smoking has been replaced by heroin smoking and injection as a result of expansion of local drug production to feed world heroin markets. Producer and transit countries also become consumer countries. In West Africa, where there is no history of indigenous use or injection of opiates, heroin and cocaine injection has emerged in tandem with drug transportation through the region. In Colombia, where there is a history of problematic drug use, injecting is spreading in connection with the recent introduction of poppy growing and heroin production for cocaine cartels. In countries where injecting is new, the task is to discourage injection while at the same time providing help to current injectors. Interventions in this area face many obstacles, however. There is a strong tendency for some countries to assume that their politics, national identity, religion, or culture provide them with protection from the spread of drug injecting and its consequences. In other countries, governments may benefit from drug production and distribution through corruption, investment of profits, or a multiplier effect on the economy. Finally, the introduction of harm reduction measures such as free syringes or bleach may not be feasible in resource-poor countries with other urgent health crises. Bilateral and multilateral funders must recognize the significance of drug problems in drug producing countries, and simple methods for rapid situation assessments of the extent of drug injecting and its potential spread are needed.
A partnership between the American and Jamaican Red Cross was key to developing an effective human immunodeficiency virus (HIV) health education program based on peer educators. The Jamaican project sought to provide Jamaican youth with knowledge, attitudes, and skills to prevent HIV infection and discrimination against those already infected. The Together We Can Program was based on a pooling of Red Cross experiences in the US and Jamaica with HIV prevention training. Youth were involved in program design, implementation, and evaluation. Peer educators attend a 27-hour training course. Working in pairs or triads, peer educators present a series of 14 activities involving games and other participatory methods to groups of 10-15 people their age. Printed materials were designed to facilitate information diffusion beyond peers to friends and family. The cost per student reached dropped from US $92.97 in the first year to $23.28 in the third year. When the estimated 60,000 young people exposed to a Together We Can radio drama are considered, the third year cost was only $1.60 per person reached. Major project benefits have included a transfer of essential skills between the Jamaican and American Red Cross, integration of the program into the activities of established community organizations, and greater awareness of HIV prevention. Sustainability of such programs requires core staff, continued project management, ongoing program evaluation, financial record keeping, inventory control, continued technology transfer, and the creation of political alliances.
A project carried out in Bolivia, Guinea, Zambia, and South Africa sought to assess demand for the female condom, identify the market size and intended consumers, and determine appropriate marketing and pricing strategies for social marketing of the contraceptive. Phase I included sales of the Reality female condom to likely target groups (e.g., commercial sex workers, university students, young professionals), site-based sales (e.g., brothels, university clinics, sexually transmitted disease clinics), pharmacy sales in urban areas, product demonstrations by sales promoters, and follow-up interviews with a sample of 238 consumers. The percentages of respondents who liked the female condom "somewhat" or "a lot" were 74% in Bolivia, 67% in Zambia, 96% in Guinea, and 61% in South Africa; moreover, 52%, 40%, 85%, and 36% of these women, respectively, preferred Reality to the male condom and 72-97% intended to purchase Reality again. The female condom was used primarily for human immunodeficiency virus (HIV) prevention or a combination of HIV/pregnancy prevention. Reality sales totaled 7411 in Zambia, 80 in Bolivia, and 9675 in South Africa. In general, the Reality condom was twice the cost of socially marketed male condoms. Phase II of the project will involve a price elasticity study to determine an appropriate price increase.
Working with young people on sexual health and HIV / AIDS. Resource pack.
This manual, designed for youth workers and educators, lists materials and activities that can serve as resources for educating young people (age 12 and older) on sexual health and sexually transmitted diseases, including human immunodeficiency virus (HIV). Also presented are resources to facilitate development of the ability to have healthy sexual relationships free of pressure or violence and confidence in dealing with emerging sexual feelings and situations. The 86 resources are organized into seven categories: training manuals, books, teaching tools and games, comics, videos, newsletters, and resource lists and directories. The activities, developed by young people and those who work with them, are participatory in nature, aimed at encouraging children to explore ideas for themselves, develop solutions appropriate to their needs, and practice skills needed for translating knowledge to action. The activities can be adapted to the children's age and situation and should not be introduced until they have been pretested on a small group. An index lists resources by number according to target audience, subject, and language.
For the study described in this doctoral dissertation, interviews were conducted with 254 Canadian adolescent females (16-19 years old) recruited from an urban family planning clinic. Their responses suggest that positive sexual attitudes, contraceptive use, and sexually transmitted disease (STD) prevention are being impeded by the sexual double standard inherent in patriarchal Western cultures. The study's hypothesis, that sexual narratives maintain defiling sexual attitudes and are associated with various high-risk contraceptive and STD behaviors, was confirmed. The sexual attitudes of respondents were characterized as defilement (ground keepers), 19%; quasi-defiling (ground testers), 25%; and non-defiling (ground breakers), 56%. The sexual narratives of ground breakers were more holistic and egalitarian (e.g., sex perceived as comfortable, enjoyable, healthy) than those of ground keepers (sex as dirty, scary). Ground breakers and testers had significantly higher levels of effective contraceptive use than ground keepers. The more the adolescents accepted gender inequality and romantic myths that obscure the realities of sexual behavior, the greater their guilt about sexuality and lack of communication with parents and partners about contraception. Proposed to illustrate the interactions between the study variables is a SNAB (sexual narratives, attitudes, and behaviors) Linkage Model.
This book chapter reviews the literature on the links between population growth and economic impacts and summarizes some findings on the links with socioeconomic factors as a benchmark for assessing new evidence. The authors state that economists with a specialty in demography generally support slower population growth as a benefit to economic progress. Economists find that population policies and programs can be justified as complementary to economic development in developing countries, albeit with modest impacts in the long term. It is argued that the actual size of the net economic impact cannot be determined quantitatively, even in general terms of strong or weak. Qualitative evidence suggests that there are both positive and negative impacts of population growth. Net impact varied between countries. All major studies show a negative impact of population growth with qualifications. The pessimistic view of population growth was modified during the 1980s by the impact of Julian Simon, the dominant influence of economists in the debate, and politics. Most economists focus on the mediating role of institutions, human capital, and technological change. Adult human productivity should be valued. The authors refer to the 1986 National Academy of Sciences (NAS) Report for benchmark findings on the specific economic impacts of population growth. NAS findings for the 1980s indicate a negative correlation between per capita output growth and rapid population growth, in contrast to the literature of the 1960s and 1970s. The authors caution that the new findings are based on "simple" models and tentative findings. The authors' more stringent sensitivity analysis suggests that the impact varied systematically with level of development. Impacts were positive or negative depending upon the country. The 1990s are likely to be consistent with NAS findings.
Fertility and maternal and child health.
This book chapter reviews the evidence on the link between fertility and health in developing countries and discusses whether the links justify family planning programs. The authors report that none of the empirical literature on the program effects of family planning on health fall short of the highest standards of evaluation. There is a deficit of studies establishing causal links and no experimental studies. The correlational evidence indicates a strong relationship between measures of fertility and measures of women's health and child's health and survival. It is argued that these correlations cannot be dismissed as spurious due to confounding factors. The correlations hold when socioeconomic controls are introduced and hold across a range of socioeconomic environments and program settings. The evidence suggesting causal links is strong enough that the World Bank now includes family planning in its package of essential clinical services for low and middle income countries. This chapter's discussion is divided into five sections: a conceptual framework for understanding program or policy determinants; a discussion of the mechanisms that link fertility to women's and children's health and survival; a summary of the evidence for children, and one for women; and a discussion of the impact of improved health and survival on the motivation for fertility reduction. The conceptual framework includes the following reproductive patterns as having direct effects on children's health: first births, higher order births, large families, young or old maternal age, short interbirth intervals, unwantedness, maternal death or illness, and contraceptive use. Direct reproductive factors that impact on maternal health include the number of pregnancies, high risk pregnancies, unwanted pregnancies ending in unsafe abortion, large family size, pregnancies for women already in poor health, and use of contraception.
The consequences of rapid population growth on human resource development: the case of education.
This book chapter provides a literature review of empirical econometric studies on the impact of sibsize on educational outcomes in 20 developing countries, most of which are Asian. This review uses empirical evidence to answer the question of whether population pressure reduces the pace of social development, as measured by enrollment rates, the growth in attainment, and the student-teacher ratio. The question is whether education expenditures divert funds from other social areas. This review examines the evidence that large families deter school enrollments and attainment and the issue of how families pay for schooling. Findings from this review indicate that the costs of education do not inhibit growth in educational opportunities. During program expansion, there was reduced expenditure per pupil or reduced teachers per pupil. The net impact of the shift from quality to quantity is uncertain. Financing of education does not apparently result in the diversion of funds away from other productive investments. The author cautions that firm conclusions should not be drawn from potential outcomes due to slower population growth in aggregate models. Household-level models generally show that large families did not have a statistically significant impact on educational attainment. It is cautioned that macro models may be poorly measured, educational production functions may be difficult to measure, and statistically significant effects may be misspecified. The author indicates that the greatest flaw in research is the failure to account for "feedbacks" in response to population pressure. The evidence is inconclusive about the gender impact due to large family size. It is unlikely that moderate reductions in family size due to family planning will have a recognizable impact on educational outcomes. The policy approach should be broad and include a range of human resources, including maternal and child health services, education, and voluntary family planning.
Population, housing, and the economy.
This book chapter reviews the empirical evidence supporting several hypotheses about the relationship between population growth and housing and explores the potential for population growth to contribute to favorable development impacts. The chapter describes the pattern of slower population growth and its impact on the number and demographic characteristics of households in Asia. In some households, the growth in the number of households has slowed, and in others household size has declined. The chapter discusses the link between population policy and urban growth, the characteristics of urban households, and the link between 1) housing quality and 2) prices of land and housing and household size. The quality of housing issue includes the quality of urban environments issues. The chapter reviews the evidence that rapid population growth slows economic development, by diverting investment to the housing sector. A number of models indicate that investment in housing is not growth oriented, because there are no employment-creation effects after construction is completed, unless there is continual in-migration. The demand for natural resources and specifically timber appears to be more dependent on consumption abroad than on population growth and increased demand for housing. The major work on housing and population links is identified as the Coale and Hoover model (1958) in India. The literature is flawed in its limited attention to the effects for women and children, the poor, or other marginalized groups. The literature does not distinguish in Asia between links generated by coercive government practices and by reproductive desires. The author concludes that it is difficult to quantify the importance of impacts. However, it appears that national population growth contributed to more rapid urbanization, higher land prices, crowding, poor environmental conditions, and inadequate housing for many.
An inquiry into population, resources and environment.
This book chapter discusses the impact of population growth on local environments and how households, communities, and societies respond in a variety of settings to resource scarcity and depletion. It is argued that the relationship between population and the environment is a complex relationship that is mediated by mobility, access to markets, distribution of wealth and land, and institutions, and government policies. Dysfunctional markets may lead to reduced returns to land that lead to resource depletion and degradation, rather than to investment and innovation. Sustainable development occurs when policy and market reform support efficient resource allocation and when population occurs simultaneously with market reform and produces sustained fertility decline and reduced pressure on the environment. Rapid population growth has had the greatest impact on local ecosystems in poor, agricultural areas with undeveloped markets, poor government, barriers to mobility, maldistribution of income, limited economic opportunities, and inadequate policies. The author concludes that increasing the pace of demographic transition by voluntary family planning programs and socioeconomic development would not resolve environmental problems entirely, but would influence better resource allocation and would reduce resource abundance that encourages large families. The progress of development should include policy reforms that would raise agricultural productivity, labor mobility, and non-farm employment. Policies and programs for increasing women's education are expected to lead to better resource management. The greatest threat to the environment is the weak demand for policy reform and institutional weakness. The challenges simply become tougher with a growing population and shrinking resource base.
Evaluating the impact of family planning programmes.
This book chapter examines the relationship between fertility decline and family planning programs and the use of contraceptives, assesses the impact of family planning and socioeconomic development on fertility decline, and identifies successful features of family planning. The case studies illustrate the independent effect of family planning programs on changes in individual beliefs and demand for contraception. The evidence suggests that socioeconomic development plays a role in fertility decline but not a major one. The major impact is from well-organized and designed family planning programs that reduce the costs of fertility control and decrease the demand for children. The authors refer to an expanded version of factors identified by Freedman and Freedman (1992) that determine successful programs. These factors include social and cultural acceptability, which may vary over time, between regions, and by program activities; and convenience and accessibility. The setting for contraceptive services is important. Women desire confidentiality and anonymity, explanations, trained staff, and a mechanism for encouraging continuation. A range of choices of contraception and the ability to meet the challenges of unmet need are also important ingredients of successful family planning programs. Both economic and social costs of fertility control must be within reach, particularly of the poor. Pilot studies are needed that evaluate program design. This chapter reviews a range of program evaluations, different criteria, different statistical methods, different types of data, and different countries. The most useful studies are multivariate ones that integrate individual data with family planning programs and residential area characteristics and case studies. Most studies find that family planning reduces fertility and affect maternal and child health.
Population programs and human rights.
This book chapter discusses how government population programs affect human rights. It is argued that a clear presentation of the impact of family planning programs on human rights is muddled by unclear ethical issues. The chapter presents a review of definitions of human rights and discusses the implications for evaluating government programs and their violations of human rights. The author identifies controversial issues relating to population programs, and more specifically the incentives and demographic targets. Human rights appears to involve a variety of individual freedoms and a variety of social entitlements. All human rights take precedence over other rights and apply to all races, nationalities, genders, ages, religions, and other features of population subgroups. International protection of rights appeared during the 19th century and was strengthened in reaction to the traffic in slaves. Protection included individual freedom from abuses of power and an obligation by the state to guarantee individual rights. UN documents are problematic because they include so many declarations and conventions, and some are in conflict. UN documents disagree on the issue of the limits of population policies and programs and limitations of numbers of children. Ethical issues pertain to IEC and sterilization and abortion or other controversial services. Population programs vary in the degree to which people believe that population is a problem, the belief about the causes of high fertility, beliefs about contraceptive safety, and tolerance for limiting individual freedom. Absolute freedom of choice is not an option. Evaluation of the ethics of population programs must consider women's unmet need for family planning and the cultural context. It is particularly important that the population affected by programs is directly involved.
Global energy and electricity futures.
This book chapter describes the premises for world energy projections and then generates a global energy mix for 2060. Population by the year 3000 will be four times the present, and the average energy end-use per capita might be the same as in the US today, or five times the present global average (20 times today's annual global demand). Fossil fuels would be scarce. Biomass and hydro power would reach their limits but still provide 5% of demand. Renewable energy sources would be expensive and provide about 20% of the demand. Nuclear fission or fusion would be the principal source of energy. Increased use would be mostly from developing countries; improvements in efficiency of energy use would occur. Global energy conservation would result in the reduction to 50% of the base case for nonelectric energy use, and electricity would be reduced to 66% of the base case. Future world energy growth per capita would be 1.1% annually. Electricity growth would be 1.75% annually. The global fossil fuel mix of coal, oil, and gas would remain much the same. Solar, wind, geothermal, and biomass would be used at their maximum, but would contribute minimally. Global economic growth would be 2.3% annually. The global energy demand in 2060 would increase from 321 quads in 1986 to 1408 quads in 2060. Fuel input for electricity would increase from 105 quads to 423 quads with full conservation. Less developed countries would use about 44% of global energy. If economic growth were only 1.5% annually, the same energy use would be reached in the year 3000. It is expected that global carbon emissions would double by 2050 with a 1% annual growth in global carbon dioxide, regardless of conservation efforts. Economic growth, as a mitigating factor in alleviation of poverty, starvation, and ill-health, should be a priority. A reduction of 20% in global carbon emissions is not desirable or possible. Climate changes are not a concern if the changes are gradual.
This book chapter describes some issues related to calculating potential climate change and refers to four different projections of greenhouse warming that were generated by the US intergovernmental Panel on Climate Change. Overall climate change projections are distinguished as "virtually certain" (no plausible alternative explanation); "very probable" (9/10 chance); "probable" (2/3 chance); or "uncertain" (conceptually plausible, but no appropriate evidence). 1) It is virtually certain that human burning of fossil fuels and the use of chlorofluorocarbons has increased concentrations of greenhouse gases. 2) It is virtually certain that the effect of increased concentrations of greenhouse gases eventually produces a net increased heating effect on the earth system. It is uncertain how the climate system processes respond to heating. 3) It is virtually certain that reduced ozone by chlorine compounds results in reduced absorption of solar radiation and thus in less heating. Lowered upper stratosphere temperatures are the result of decreased heating and increased cooling. 4) It is virtually certain that long time scales take place between changes in greenhouse gases and climate system responses, but the larger the changes, the longer a return to normal. 5) It is very probable that global average surface warming ranges from 2.7 to 8.1 degrees Fahrenheit. Clouds have an uncertain effect. Warming rates are affected by the growth rate of greenhouse gases, natural climate changes, and ocean and glacial ice responses. 6) It is very probable that there will be a global average increase in precipitation, a reduction of northern sea ice, and northern polar winter surface warming. It is probable that high latitude precipitation will increase, and drying and warming will occur in summer midcontinental areas. It is uncertain what the effect will be on regional vegetation changes, increases in tropical storms, and regional and local effects.
The developing countries: the China example.
This book chapter describes the extent of greenhouse gas emissions in China. The author uses conservative assumptions about China's and global population growth and fossil fuel energy use and food needs. Global carbon dioxide (CO2) generation increased from 6 billion tons (Gt) in 1950 to over 22 Gt in 1990. China's share of CO2 emissions increased from 1.3% to almost 11% (about 2.4 Gt). CO2 production was higher only in the US (22%) and Russia (14%). Uncertain estimates of global CO2 emissions from burning of biomass and deforestation range from around 3.5 to almost 10 Gt. China contributes under 5% from deforestation and about 10% from biomass burning. Methane (CH4) emissions result from anaerobic fermentation of organic matter in flooded soils and solid wastes in landfills, ruminant livestock enteric gas releases, and direct emissions from coal mines and natural gas sources. CH4 emissions range from under 200 million tons (Mt) to 500 Mt annually. China's share of CH4 ranged from 11% to 15% in 1987. The diurnal and seasonal rates of bacterial conversion of fertilizer nitrogen to nitrous oxide (N2O) are uncertain. Estimates range from 15,000 tons to 3.5 Mt, of which China would account for 23%. The adjustment for atmospheric retention and absorptive rates indicates that China had almost 10% of the global net increase of almost 22 Gt in CO2 heating equivalents. By 2020, China would be responsible for about 20% of global per capita rates of CO2 of 30 Gt. Large population size in 2020 would require 30% higher harvests requiring more fertilizer use that would produce at least 50% higher emissions of N2O and CH4 than that produced in 1990, but the proportion of global totals would remain within the present range of 20-25%. During 2010-2025, China would be the world's largest emitter of greenhouse gases. The options are to lower global greenhouse gas emissions, which would require fundamental changes in Chinese society, or to push for stabilized populations and higher efficiencies.
Potential impacts of climate change on world food supply: a summary of a recent international study.
This book chapter presents findings from a study of the impact of climate change on world food supplies in 2060. The crop models are those developed by the USAID's Benchmark Sites Network for Agrotechnology Transfer in 1989. The cereal grain crop models are run for Level 1 and 2 and current climate conditions and general circulation models (GCMs) for doubled atmospheric carbon dioxide (CO2) levels at 112 sites in 18 countries. Food yield and trade models are based on general equilibrium models in the Basic Linked System of the International Institute for Applied Systems Analysis. GCM scenarios include those from the Goddard Institute for Space Studies, the Geophysical Fluid Dynamics Laboratory, and the United Kingdom Meteorological Office. GCMs are inadequate measures of precipitation, soil moisture changes, and climate variability. The crop models account for the beneficial effects of increased CO2 concentrations, assume adequate pest and disease control, and assume no problem soil conditions. The study concludes that net climate change, with continued economic development and population growth and minor shifts in planting dates and crop varieties, would reduce global cereal production by up to 5%, or declines of cereal production of 9 kg per capita. The expanded use of irrigation would mostly overcome this decrease. Beneficial effects of climate change would vary by region and country. The ease of farm adaptation to climate change is likely to vary by crop, site, and adaptation technique. The number of hungry people in 2060 would increase to 640 million in 2060 in the reference scenario and increase by 40-300 million with a changing climate. Simulated farm-level adaptations would not compensate for this increase. Reduced cereal production would range from 1% to 7% depending upon the temperature change. World relative price increases from decreased yields would range from about 25% to 150%, but consumer food price shifts would not be as great.
Future global population growth.
This book chapter presents several UN long-range population projections up to the year 2150 by region. The pattern of population growth among large countries will be a major deciding factor in determining global totals. Rapid population growth is occurring in geographic areas that are least able to deal with it. The UN projections indicate that the force of population momentum today will determine growth tomorrow. World population growth declined during 1960-90 from 2.1% to 1.6%, with wide variation between countries. Regional variation in the year 2000 reveals a smaller range of variation than in the long run. Two UN scenarios are the stabilization of fertility rates at the present regional levels and attainment of replacement level fertility in every region. Global population in 2150 would reach 694 billion in the first scenario (1.6 billion in developed countries) and 8.4 billion in the replacement-level scenario. Global population was 5.5 billion in 1993. Death rates began to decline in developed countries in the 1700s. Fertility declines in developed countries occurred about a hundred years later. The growth rate is currently 0.5% among developed countries and 2.0% among developing countries. Death rates in developing countries began to decline after World War II, and birth rates began to decline during the 1960s. Depending upon the choice of fertility, mortality, and immigration assumptions, fertility could range from 5.6 to 20.8 billion in 2150. Under the medium variant, population in 2150 would the greatest in Africa, followed by Other Asia, North America, China, Latin America, Europe, and the former USSR. The long range projections assume a fluctuation of 5% around replacement-level fertility that would change over time and geographic region.
Population growth and land-use changes in the Philippines.
This case study illustrates the force of population pressure and migration in the Philippines into frontier forested areas. Internal migration in the Philippines occurred pre-1970 into frontier areas, during 1970-80 into urban areas, and during 1980-85 into upland areas with slopes between 18-30% or over 30%. Government agricultural settlement programs were responsible for upland migration during the 1960s. Upland migration increased from 35% of all regional movements during the 1960-70 to over 50% during 1980-85. The characteristics of upland migration differed pre and post 1980. The largest upland population is concentrated in heavily logged timberlands (over 9.1 million in 1985, or over 50% of total upland population). The rapidly increasing flow of upland migrants is settling even on remote, steeply sloped forests. The on-site replacement cost of lost soil nutrients from soil erosion is an estimated $50/hectare annually. Two regions have upland population density greater than 500/sq. km. The government has no rules on rights to ancestral lands or recognized community-based ownership. Ownership of land is uncertain. Migrants tend to be more knowledgeable about land registration procedures than indigenous population. In 1985, 6.5 million of upland population were migrants that lived on forest lands that were declared as alienable and disposable. The remaining 5.7 million upland migrant population and indigenous population live on lands without titles to the land. The land expansion into uplands has left good quality agricultural lowlands unused. The number of agricultural workers without access to land has increased over time. The author recommends research, policy shifts, and new programs for reducing population growth that fuels frontier migration, alleviating poverty by improving economic opportunities, introducing land reforms that reduce landlessness and lack of resources, and encouraging use of local technical knowledge and sustainable resource management.
Population, aquaculture, and environmental destruction: the Gulf of Fonseca, Honduras.
This case study illustrates the complex mix of economic development effects and population growth impacts on the environment in the Gulf of Fonseca region of Honduras. Degradation and productivity declines in the Gulf are attributed to destruction of the mangroves, development of nontraditional agriculture and aquaculture, the spread and intensification of hillside agriculture, overexploitation of fishing in coastal waters, and deforestation. Population increase, as part of the problem, leads to greater cultivation that increases soil erosion and sedimentation of Gulf waters. More fishermen and more effective fishing gear means greater depletion of fish populations. Increased demand for fuel from the larger population further depletes mangrove forests. Shrimp farms were developed from former stress, dwarf, and mature mangrove forests. There is concern about the impact of the use of imported shellfish stocks on potential disease organisms and the impact of wild-post-larvae collection from Gulf shrimp populations on stocks. Other concerns include declining water quality in the shrimp farm zones and population access to seasonal lagoons. Neither the population growth focus nor the technological ingenuity focus is likely to have an effect on long-term or short-term degradation of the environment in southern Honduras. The environmental solutions appropriate to this region will involve national and regional policies responsive to local conditions, productive dialogue among local self-interest groups, and informed technical and financial assistance from bilateral and multilateral development groups. The problems in this area are due to causes, such as the unequal distribution and access to natural resources, government indifference or ineptitude, and patterns of development that are based on nonsustainable use of resources. This chapter gives twelve recommendations for environmental management.
Population and land-use changes in the Brazilian Amazon.
This book chapter discusses the social and environmental impact of development policy in Brazil on the settlement of frontier areas in the North Region of Amazonia (Acre, Amapa, Amazonas, Para, Rondonia, and Roraima) by ranchers and small farmers. It is argued that the social and environmental problems in Amazonia are due not just to population increase in newly settled areas but to a dynamic interaction between demographic, economic, and political circumstances. The author identifies the underlying causes of migration to the Amazon region as rural landlessness and rural ownership of small, unsustainable plots of land, both of which lead to poverty. Although colonial administrations had the foresight to offer land tenure on plots large enough to support a family, by 1972, 72% of farms were smaller than the recommended module. 4.8% were large, productive farms, and the rest were large uncultivated or poorly exploited landholdings. Crop shifts from coffee to soybeans on large farms and mechanization reduced the inputs of agricultural labor. The migration to Amazonia was the last and most recent migration since the 1940s. The settlement of Amazonia was different from other migration streams in that the federal government encouraged migration and the military regime controlled it during 1964-85. Development policies used credit and tax incentives to promote Amazonian development. The National Integration Plan established the colonization along the new highway by small farmers. However planners neglected topography in assignment of plots, market and credit access, malaria, and poor technical assistance. The business sector changed development policy after the apparent failures. The Polamazonia Plan was established to support large-scale farming and mining. Conflict ensued between ranchers and small farmers. The civilian government after 1985 reversed development, but by that time net migrants increased to 791,156 during 1980-91 and deforestation was substantial. The author describes the extent of migration, the nature of degradation, and the tax system.
Who is changing the land? Lifestyles, population, and global land-use change.
This book chapter discusses global land use changes and who is changing the land. It is concluded that land use is changing not only due to slash-and-burn farmers, logging companies, and high-technology agribusinesses but also due to city planners, tourist managers, land management officials, regional planners, drug dealers, and many other sectors and businesses. The authors describe the three major trends that determine land use changes. 1) Land is being used increasingly for urbanization and industrialization. 2) Land use changes are due to individual mobility, trade, and tourism. 3) Land use changes accompany other fundamental changes in life styles, such as changes in food preferences. Although urbanization affects only minor changes in the size of the geographic territory, urban population needs access to water and sanitation, permanent housing, an energy supply, and other infrastructure, such as roads, that indirectly affect land use. Industrialization creates the demand for expanded transportation infrastructure and resources, such as energy, water, and minerals, all of which require large land areas. The primary function shifts from provision of individual food supplies to capital investment, entrepreneurship, and technology. High-yield agriculture requires less land to supply more food. Modernization creates other land use changes, such as the demand for recreation, consumption of drugs and other foods,and tourism. Modernization is closely linked with expansion of roads and airports. Most of the literature on change in land use has a distorted focus on deforestation and land cover change due to agricultural modernization and expansion. For instance, in China 22.4% of land is marginal and covered with glaciers, deserts, and steep mountains. Almost 25% is devoted to urban and rural settlements, industries, and infrastructures. Another 25% is cultivated land. The proportion of nonagricultural land use is larger globally than in China.
International migration and environmental refugees.
This book chapter presents a framework for discussing the relationship between population movements and the surrounding environment, and the nature and extent of migration due to environmental degradation. Humans over the centuries have always migrated in search of better living conditions. Refinement of migration flows results in a focus on the reasons for leaving: the search for freedom, escape from poverty, or the inclusion in economic development planning. Many countries today establish immigration policies to restrict the flow of migration streams. It is expected that the future will reflect increased international migration due to population pressure, shifting economic trends, and political rearrangements. Mass refugee movements and realignments of population began after World War II. The UN adopted international conventions for addressing the issue of refugees. Since 1951, the definition of refugee has changed. Large migration streams now are propelled by natural disasters, repressive socioeconomic regimes, unpopular development policies, civil unrest, and border realignments. Most migration activity occurs in Second and Third World countries. A new framework for addressing refugee issues must seek the common roots between Haitian boat people, Chernobyl victims, drought conditions among peasants, or earthquake victims. Disasters are a major cause of dislocations of people. These disasters are human-directed and naturally occurring. The numbers of disaster-driven migrants is increasing. For instance, around 1985, an estimated 10 million Africans from 24 countries were driven from their home in search of food. The author suggests the following groupings among environmental refugees: "unnatural disasters," such as floods or deforestation; ecosystem changes, such as land degradation or desertification; ecopolitical crises, such as revolutions and shifting frontiers; and socioeconomic dislocations, such as bad development plans or changes in the international economy.
Understanding the relationship between human population, wildlife, and the environment.
This book chapter uses a variety of case studies to illustrate how wildlife biologists view a balance between human populations and wildlife and what factors are important in maintaining ecological balance. Biologists promote 1) the identification and protection of fragile ecological zones; 2) maintenance of protected areas for wildlife; 3) improvement in human living conditions; 4) a reduction in human consumption of resources; 5) promotion of local ownership of resources; and 6) education of the public, globally and locally, about environmental linkages and protection. The Audubon Society established in 1991 two centers in the US for continued study of human, wildlife, and environmental relationships: the Sharing the Earth Project. The Nebraska center hosts a yearly international conference and coordinates an international campaign to save the Platte River. Program activities include community outreach, education, and establishment of "sister" sanctuaries. The Texas center at the Sabal Palm Grove Sanctuary focuses activities on education, outreach, and "shareholding" among the local human community. Local students are involved in Brownsville and Matamoros efforts to clean up the Rio Grande River and learn about environmental issues, family planning, and endangered species. Presented are some case studies that were part of the 1988 Audubon Population Program and Sanctuary Department. The international project aims to study examples of population pressure, to profile examples of preservation of plant and animal species activities, to compile "lessons learned," to learn about the links between habitat destruction and population growth and consumption, to develop policy recommendations and program action, and to form partnerships. Eight, which were all related to water resources, out of 100 Audubon sanctuaries were chosen for intensive study and briefly described in this chapter.
Air / water pollution issues in the mega-cities.
This book chapter discusses air and water pollution problems in mega-cities in the developing world. Much of what is known about urban pollution and environmental degradation is based on limited information and generalizations. Developing countries suffer from serious mega-city environmental problems. The UN Conference on Environment and Development focused on ozone depletion, while ignoring critical "brown" issues of polluted air, filthy water, and inadequate sanitation, even though hundreds of millions of people are affected directly by these issues. Urban environmental problems are related to the complex interrelationships between the natural and man-made environments, and economic, political, and social factors. Mega-cities exist in a variety of ecosystems that include coastal regions, arid regions, humid-tropical regions, cold regions, or mountainous regions. A simple typology of, for instance air pollution, is not appropriate for all ecological settings. In the case of air pollution in Santiago, Chile, the severity of air pollution episodes is the same in Santiago and Sao Paulo, which has much higher emission levels, due to Santiago's climate and altitude. In Mexico City, the high-altitude location tends to significantly increase the emissions of suspended particulate matter, hydrocarbons, and carbon dioxide from vehicles. Water is known to be a vehicle for transmission of disease-causing microorganisms. There are waterborne diseases, water contact diseases, water hygiene diseases, and water vector diseases. Bacterial contamination of piped water supplies is due to problems of inefficient water treatment and problems of supply and leakage in distribution systems. Sanitation is a major problem affecting water quality. Sewer systems are inadequate and do not meet the needs of population increase. Lead emissions are rising in developing countries. Effective policies are needed.
Linkage between population growth and air / water pollution in China.
This book chapter discusses the links between population growth in China and its air and water pollution problems and illustrates the issues in case studies. Population, development, and environmental issues became apparent during the 1970s in China. China's population was both large in size and largely undereducated. Only 2.0-2.5% of China's total population were intellectuals. There are two widely held views of China's population and environment interactions. One view posits that the impact of population growth is insignificant; another view posits that only population damages the environment. Both views are inadequate. China is a country with a diverse population inhabiting a variety of topographic landscapes. China faces greater population pressure on resources, the environment, and development than other countries. China supports 22% of world population on only 7% of the world's arable land. Population increased by over 100 million over the past decade. Arable land decreased at a rate of 741,330 acres annually. About 33% of the existing arable land in China suffers from water and soil erosion. Water resources are unevenly distributed. Water shortages are responsible for reduced grain production and livestock production. Water consumption is distributed as follows: 15% for industry and drinking; 4-7% for drinking alone; and 85-90% for agriculture. Constraints on the water supply are due to population size, expanded irrigation, small average rainfall supplies, overuse and depletion of ground water, and uneven distribution. Water supplies in 1990 amounted to 42.2 billion cu. m, but current production and human needs amounted to 50.2 billion cu. m. In drought years, supply might dwindle to 16.1 billion cu. m. Supply deficits are due to uneven distribution of rainfall in different seasons, years, and geographic regions, and to increased needs. Ideally, China has sufficient resources for 700 million.
This concluding book chapter identifies some themes common to the links between population growth and environmental problems, such as the demand on resources, air and water pollution, and ecological balance. 1) One theme concerns the expectation that rapid population growth will worsen environmental problems and their solution. 2) Patterns of resource consumption are an important feature of the link between population and the environment. Based on current consumption trends, developed country populations will consume greatly more than developing country populations. 3) The link between population and the environment is a mix of causes, effects, and feedbacks that are indirect and change overtime. 4) It is likely that environmental protection will become more difficult over time. The world's poorest nations will suffer the most and will be the least likely to adapt to environmental degradation. 5) The negative impact of environmental degradation will vary among local areas and among different groups of people. Assessments are needed that will prioritize regions and local areas by the severity of impact from growing populations or growing human demands. Solutions must involve the populations affected as well as the experts. 6) Additional research is needed to clarify the links between human populations, environment, and resource use. 7) There is now sufficient justification to promote slower population growth, regardless of the inadequate projections of environmental degradation due to population growth. 8) Economic development is compatible with environmental health and sustainability.
Environmental problems in Third World cities.
This book is the third in a series on Third World cities and focuses on urban environmental pollution. It considers the scale and scope of environmental problems in cities and offers some priorities for action. The first chapter identifies the number and diversity of urban centers that are in trouble. Chapter two concerns environmental consequences in the home and workplace, the immediate surroundings, and the district. Chapter three focuses on specific environmental conditions: toxic and hazardous wastes, water and air pollution, natural and human-induced disasters, noise pollution, and social well-being. The environmental problems of small cities are identified. Those most at risk of environmental impacts are women and children and poor communities. Chapter four discusses regional, migration, and global warming impacts. The author refers to William Rees's concept of "ecological footprints," which include the land area and natural capital that are used to sustain urban population and structure. Ecological footprints may reveal the extent to which its carrying capacity is based on natural resources brought from other regions, other nations, or the whole biosphere. The chapter discusses urban impacts on the region or the world. Chapter five discusses solutions that emphasize institution building and technical input and community consensus. Chapter six highlights contradictions involved in achieving sustainable development, while chapter seven provides conclusions and a framework for a new environmental agenda. The emphasis is on issues of local governance, accountability, participation, and the rights of citizens to be protected from environmental harm.
The economics of fertility in developed countries: a survey.
This paper will be included as a chapter in the forthcoming "Handbook of Population and Family Economics" by Rosenzweig and Starks. The paper describes trends in US fertility and presents an assessment of static and dynamic models of fertility and econometric methods of analysis. It is argued that theories of the allocation of time, of household production, and human capital investment help to improve knowledge about fertility decision making in developed countries. How these theories can be included in empirical assessments of the determinants of fertility results in the identification of "exemplary" strategies for obtaining "credible" estimates of causal relationships. Improvements in earlier models accounted for the timing of first births, the spacing of children, and contraceptive behavior. The emphasis now is on econometric models of fertility behavior within a dynamic or life cycle context. The review includes the strengths and weaknesses of different strategies for identifying price and income effects on household-level fertility and analyses of aggregate, time-series, data choices, hazard models, and estimated structural models. Ordinary least squares models are viewed as potentially inconsistent, because endogenous variables, such as women's earnings or government policies, are potentially correlated with unmodeled choice issues or other unobservables. Fixed effects models attempt to include controls for omitted variables that produce an endogeneity bias. However, these aforementioned reduced form effects of prices and income on fertility models are static. Rosenzweig and Wolpin offer alternatives for identifying the effect of exogenous variation and quantity-quality trade-offs in fertility. Another option is to apply static models to age specific fertility rates or to use hazard approaches for modeling incomplete histories. Structural dynamic approaches rely on estimable stochastic models of life cycle fertility.
This dissertation is a study of the conflicts between human and wildlife populations in and surrounding the Masai Mara, a large nature reserve in southwestern Kenya. The conflicts are recent in origin and are attributed to increasing human populations, changing land use patterns, and perceptions of wildlife. Analysis is based on secondary records; in-depth interviews with government and conservation staff; interviews with a sample of 500 heads of households; and anecdotal information from 13 older community members on crop damage, livestock raiding, and human death. The household sample includes households in five group ranches, which vary in location, type of agricultural activity, and distance from the park. The land use profile indicates poor agricultural lands in the lowlands and high potential lands in the uplands. The study focuses on an area where conservation was being integrated into development. Analysis pertains to a description of the nature, intensity, frequency, and spatial and temporal patterns of conflict. The author identifies determinants of the conflicts, assesses the effects of the conflict on wildlife and humans, and proposes management and policy strategies. The dissertation provides a description of the Masai Mara region, a literature review on wildlife protection and development, an historical perspective and background, findings, and the proposed program. Conflicts arise over the loss of livestock, crop damage, human survival, disease, and competition for resources. The greatest conflict was in lowlands and varied by season. Perceptions and attitudes were related to past experiences and socioeconomic factors. Tolerance was related to the degree of loss, the effectiveness of damage controls, the fairness of government compensation, and involvement in wildlife tourism. Conflicts and population density will eventually drive the migratory wildlife away. The proposed program includes the designation of four zones and the integration of wildlife conservation into activities that serve human self-interests.
Sampling manual. Demographic and Health Surveys Phase III.
This volume describes the Demographic and Health Surveys (DHS) Sampling Policy, sampling techniques, sampling errors, and sample description and documentation. The appendix gives an example of a manual for mapping and household listing; an example of a full sample description; and examples of dBase Programs for sample selection. This volume updates the main text and the sections on sampling errors. The unit on sample description and documentation is expanded. The DHS follows some general principles. 1) The sample should cover 100% of total country population and territory. 2) The sample is drawn based on controlled scientific probability sampling techniques. 3) The sample is self-weighting. 4) The DHS uses preexisting master samples or sampling frames, as available. 5) The sample design should be as simple and straightforward as possible. Where understanding of urban and rural differences is important, the sample might not be self-weighting and might include oversampling of urban areas. The DHS is designed for samples of 5000-6000 women aged 15-49 years, but a variety of factors affect sample size. The list of areal units in the sampling frame should be thoroughly evaluated before use. An attempt is made to keep segment size to about 500 people. Stratification is used to reduce sampling error. The optimum "take" number of women/households per cluster is about 15-20 women per cluster or 30-40 women for the rural sector and 20-25 women for the urban sector. Documentation is important at the time of the sample design, at the end of fieldwork, and at the completion of the data file.
Births to unmarried mothers: trends and obstetric outcomes.
This study examines trends in nonmarital childbearing among women who represent an inner-city urban population that includes high-risk privately insured mothers and a large number of indigent mothers. The study population includes data collected from a computerized database at the MetroHealth Medical Center in Cleveland, Ohio, during 1974-93, on 73,544 births. The subsample for the clinical analysis is based on 29,865 deliveries that occurred during 1987-93. Findings indicate that the proportion of deliveries to unmarried mothers increased by at least 20% over a 19-year period. The proportion of privately insured unmarried mothers increased from 6.7% to 27.3% during 1975-93. The proportion of staff-funded mothers increased from 63.5% to 77.5%. The proportion increased for all races, funding groups, and age groups. In the subsample of births during 1987-93, there were 51% Whites, 38% Blacks, 8% Hispanics, and 3% other. Only 15% had private medical insurance. 34.2% of births were to married mothers. 38% of births were to women who were smokers, 3.2% were alcohol users, and 15.4% were narcotic users. 15.4% were cesarean births. The infant mortality rate was 13/1000 live births. Unmarried mothers tended to be about four years younger than married mothers. Over 30% of unmarried mothers and only 10% of married mothers were teenagers. 48% of White mothers, 14% of Black mothers, 35% of Hispanic mothers, and 70% of mothers of other race were married at the time of delivery. The mean birth weight for unmarried mothers was 100 g less than for married mothers. Significant predictors of mothers' marital status were insurance status, race, age, and their interaction. The odds of unmarried status increased with younger age, delivery later in the study period, race, insurance pay status, and parity, which, when controlled for, showed Black and Hispanic mothers with increased odds of an unmarried status. Significantly more unmarried mothers had infants with thick meconium, premature delivery, and fetal distress among neonates.
This paper examines the role of remittances as a form of family wealth flows in the Pacific nation of Tonga. The authors discuss the Tongan remittance process and the incorporation of this perspective into a theoretical framework. The literature review clarifies that remittances serve to increase family wealth in traditional concepts of family exchange and support systems. Labor force migration tends to be viewed negatively in the literature, because of the loss in the sending country of human capital. The authors point out that there is loss of capital only when labor migrants lose or sever their ties to the family unit in the sending country. Tonga is described as the only surviving monarchy in Polynesia and one of the few surviving matriarchal kinship systems in the world. Tonga is a poor nation with a young population structure. It had about 100,000 population in 1995. The total fertility rate was 3.56. Out-migration is estimated at 1.3-2%, depending upon the source. Out-migration destinations include the US, Australia, and New Zealand. It is estimated that remittances were the main source of household income for 18% of all Tongan families in 1995 and were the top three sources of income for 66%. Remittances averaged US$6535. It is estimated that total remittances to Tonga amounted to about US$33.4 million in 1989. The US was the largest source of remittances. It is estimated that remittances from about 30,000 Tongans were 45% of Tonga's gross national product and covered 80% of Tonga's trade deficit. Tonga's economy relies on imports of all durable goods, and remittances help compensate, but increase the need for cash to purchase goods. Remittances are shifting to goods rather than cash. The authors posit that migration is part of a wealth flow strategy instead of being a repayment of a family debt. There is a strong motivation to maintain family ties that needs to be incorporated into migration models.
Major goals set in the programme for the development of work on aging in China, 1995-2000.
This brief news article highlights seven major goals in development plans in China that address the issue of aging. China aims to do the following: 1) speed up legislation and improve laws on population aging that would protect the rights of the elderly; 2) establish and improve the social security system for the elderly; support will be based on the cooperative efforts between government, the community, family, and individuals; 3) vigorously develop medical and health services for the elderly in order to facilitate self-care; 4) promote the health of the elderly and encourage their participation on a voluntary basis in social and economic activities; 5) create opportunities for continued education for the elderly; 6) create recreational centers for the elderly; 7) develop social welfare programs for financial and material support of the aged; and 8) intensify theoretical and applied scientific research on issues related to the elderly.
It is argued in this report that there is strong evidence that current population growth rates represent significant and interacting risks to human well-being and should be a concern for Americans. The aim of this volume is to provide a demographic explanation to justify US assistance to programs that slow population growth in developing countries. The demographic case is argued that lower rates of population growth will improve and make more widely available safe and effective family planning services and significantly contribute to improving people's lives. Improved education for girls and expanded employment opportunities for women also contribute to slowing population growth. The report discusses the three key reasons for slowing population growth: economic development, environmental protection, and safety and health. The US sets an example to follow, of foreign aid provision to other countries and of encouragement of developing country governments to strengthen their commitment to family planning and related health services. The discussion includes a brief presentation of key population facts and figures that underscore the need to balance population size, within safe and sustainable margins, with the earth's resources. Population growth rate and momentum are both important. Slower population growth will help poorer countries develop economically and help to raise wages, especially for less skilled jobs. Population pressure fuels international migration. Urbanization and urban mismanagement are leading to environmental and social service problems. A large young population strains educational resources. Housing quality must keep pace with growth. Growth indirectly increases and deepens poverty. Technology will not ease the expected shortages of water. Food supplies are in jeopardy. Climate changes are expected. Increased scarcity of critical natural resources may increase civil unrest.
A national household survey of health inequalities in South Africa.
This volume provides baseline findings from the 1994 South Africa National Household Survey of Health Inequalities among a national probability sample of 4000 South African households, stratified by race, province, and residence. Oversampling was conducted in small provinces. Findings are presented in chapters on health for children aged under 5 years, children aged 6-15 years, and adults aged 16-64 years. The chapters on access to health care, on chronic illnesses and disabilities, and on mental health apply to those aged 16-64 years. Other chapters are devoted to reproductive and sexual health, women's health, and the health of the elderly. Specific attention is directed to chapters on health knowledge and provincial comparisons. This survey was conducted in order to determine the impact of improved health and health services for the underserved Black majority population. Findings indicate the extremely poor health of Black South Africans compared to other racial groups. Vulnerability to poor health is attributed to lack of access to safe drinking water, poverty, and poor public health conditions. Almost 50% of persons surveyed reported dissatisfaction with existing health services. Dissatisfaction was higher among Blacks. About 66% of Black Africans lived in rural areas in former homelands or on white-owned farms or in squatter settlements outside large cities. About 66% of Black Africans suffered from poor public health conditions. Only 20% of Blacks had a water tap inside the house compared to 100% of White and Indian households. Almost 66% of Black Africans had incomes below the minimum living level. The public health system was relied on by Blacks, while the private system was used by Whites and Indians. The barriers to health care were cost, distance, and availability and cost of transportation.
Second Demographic Survey, Mongolia 1996. Main report.
Findings are presented from the 1996 Mongolia Second Demographic Survey among 1810 women aged 15-49 years. There was an increase in female-headed households from 8% in 1994 to 12% in 1996. About 55% of population aged 8-24 years were enrolled in schools. About 39% of a subsample of 108 women who kept their children home from school did so in order to obtain help with family work. About 31% indicated that their children were performing poorly. 18% of households lived in wooden houses, 28% lived in apartments, and 54% lived in tents. About 74% of all households and 100% of rural households obtained drinking water from springs, wells, rivers, snow, or rain water. Fetching water averaged under 30 minutes in the summer. About 70% reported a lower standard of living than in 1989. Possession of durable goods increased. About 58% were working. 54% were married, 3.7% lived with boyfriends, 2.7% were divorced, and 1.9% were widowed. About 75% of births during 1983-95 were at risk due to young or old maternal age, short birth intervals, or a birth order higher than 5. Age-specific fertility rates declined in all age groups. The total fertility rate declined from about 5 in 1989 to about 3 in 1995. The mean number of children was 6.8, and the total fertility rate during 1988-95 was 3.7 children per woman. The median age at first birth increased slightly. 88.2% of women knew about IUDs, 81% knew about the rhythm method, and 76% knew about condoms. Women were generally unfamiliar with sterilization, injections, or barrier methods such as the diaphragm. About 55% of women had ever used contraception. About 36% were current users. 40% of current users used contraception for spacing, and 56% used contraception for stopping pregnancies. 14.2% had had an abortion. 53% wanted no more children. 55% desired a family size of 4 children. 73% desired children for old age security.
At the University Gynecology Clinic of Wurzburg, Germany, a retrospective analysis was carried out second and third trimester abortions during January 1, 1992 - March 1, 1995. In Group A (16 women), abortions were induced by continuous IV infusion of sulprostone 9 hours after administration of a 3 mg prostaglandin (PG) E2 vaginal tablet overnight. In Group B (22 patients), IV sulprostone was begun 2 hours after cervical priming with 1 mg gemeprost vaginal suppositories. The outcome of these regimens was compared with that of repeated administration of 1 mg gemeprost vaginal suppositories at 6-hour intervals in Group C (25 women). A maximum of 2 sulprostone infusions were applied per day (2 ampules of 500 mcg of sulprostone in 500 ml isotonic sodium chloride solution with a dose augmentation of 60 mcg/h to a maximum of 300 mcg/h). The average induction, abortion, and birth intervals were 33 hours in Group A, 23 hours in Group B, and 23 hours in Group C. The differences between Groups A and B as well as Group C were significant (p = 0.03 and p = 0.01). The rates of fetal expulsion within 12, 24, and 36 hours in Groups B and C were similar. Women of parity >or= 1 showed significantly shorter intervals than nulliparae in Groups A and C (13 hours and 18 hours shorter than nulliparae; p = 0.04 and p = 0.01). In Group B the difference was 11 hours ( p = 0.15). Only 1 woman failed to expel the fetus after induction because of failure to tolerate either sulprostone or oxytocin. In 4 other cases in Groups A and B complications were noted (local thrombophlebitis, bronchospasm). The serial administration of 1 mg gemeprost vaginal suppositories at 6-hour intervals showed fewer side effects and seemed to be as effective as IV sulprostone after cervical ripening.
[Abortion legislation and the physician's role]
The Norwegian abortion law stipulates a 12-week limit for self- determined abortion and also permits an abortion when the fetus has a high risk of being born with an abnormality. This is made possible by genetic diagnosis before the 12th week of pregnancy. The law also requires that the woman seeking abortion should be fully informed and counseled about the medical, psychological, and social consequences of her decision. If the procedure cannot be carried out before the 12th week of gestation, a written justification by the operating physician must accompany such a request to the local abortion committee. The time of authoritarian preaching by doctors at the abortion committee is gone, and most of them now do their best to help the patient as the law decrees. If ultrasound diagnosis finds any anomalies around the 18th week of pregnancy, in general, women are ill prepared to act, which is why after a 1995 conference it was stated that the use of ultrasound in pregnancy dictates better information dissemination for the patient. As a result, in 1996 the state health agency distributed a brochure for the use of pregnant patients. When there is suspicion of a development defect the midwife and the physician of the ultrasound laboratory provide the initial information. The agony of the parents is the greatest when the test findings are unexpected. Exceeding the 12-week time limit may be justified for several reasons: most often because women are undecided and need more time to reflect, there was a miscalculation of age of gestation, or a coexisting disease. In all, the existing Norwegian law provides a good legal framework for women who need help in terminating an unwanted pregnancy.
[Low-dose combined estrogen-progestin oral contraceptives and pulmonary embolism: a case report]
A case study is presented of a 36-year-old woman who was referred to a University Hospital Department of Internal Medicine, Rome, Italy, with symptoms of paroxysmal dyspnea, pain in the left lower scapular area that was exacerbated by inhaling and accompanied by continuous fever of 38 degrees Celsius. A few hours before the appearance of these symptoms painful tumefaction had appeared in her left calf. The patient had started taking an oral contraceptive 15 days prior to admission (0.15 mg/day desogestrel + 0.02 mg/day ethinyl estradiol) for the treatment of a modest meno-metrorrhagia secondary to uterine fibromatosis. Blood gas analysis demonstrated slight respiratory alkalosis with hypocapnia and slight hypoxemia. A pulmonary scintiscan provided evidence of a perfusion defect corresponding to the medio-basal segment of the left lung with radiograph of the normal thorax. Doppler meter examination of the venous circulation of lower arteries indicated a profound deep venous thrombosis at the level of the left femoral area. Pelvic ecography demonstrated an enlarged uterus with a modestly inhomogeneous structure. Hypochromic sideropenic anemia was present with slight augmentation of LDH, AST, ALT and indirect bilirubin with moderate hyperfibrinogenopenia and XDP values of between 499 and 800 ng/ml. The blood coagulation test values were normal, as were the activity of AT II, protein C, protein S, alpha- 2 antiplasmin and plasminogen, the spontaneous and induced platelet aggregability, as well as the pure leukocyte aggregation. The heparin therapy rapidly resolved the respiratory symptoms and markedly improved the clinical signs, while the pulmonary perfusion defects disappeared and the deep venous circulation of the lower left artery was partially recanalized.
[Brazil National Demographic and Health Survey 1996. Preliminary report]
This report represents the preliminary results of the National Survey on Demography and Health (PNDS 1996) carried out by the Brazilian Agency for Family Welfare (BEMFAM) with the assistance of Macro International. A total of 14,252 households were contacted and individual interviews were conducted with representative samples of 2949 men 15-59 years old and 12,612 women 15-49 years old. The total fertility rate (TFR) for the women was 2.5 children per woman (2.3 in urban and 3.5 in rural areas). In the regions of the north and northeast the TFRs were 2.7 and 3.1, respectively. 73.1% of all women ever used some type of contraception, whereas 83.6% of women in union used contraception. The respective percentages for males were 85.2% and 93.1%. The private sector was the main source of obtaining contraceptives: 54.1% for women and 61.4% for men. Approximately 50% of men and women in union who had only 1 child wanted to have another 1. In contrast, only 10% of women and 12% of men who had 2 children wanted to have another 1. About 80% of women and men used the condom for the prevention of AIDS. On the other hand, more than 20% of men and 17% of women did not know how to avoid contracting AIDS. 50% of the pregnant women had more than 7 prenatal visits, which is the minimum recommended. 78.9% of the children 12-23 years old had a vaccination card, and their overall vaccination coverage was 72.5%. 1 of every 4 children had fever and half of them had coughing in the 15 days prior to the survey, and about 18% who had symptoms of respiratory infection received medical attention. 13.1% of children had had diarrhea in the 2 weeks prior. 1 of every 10 children under the age of 5 had chronic malnutrition, while the national rate of chronic and acute malnutrition amounted to 5.7%.
[The military medical aspects of HIV infection]
During 1988-89 the medical department of the S. M. Kirov hospital diagnosed 50 HIV-infected military personnel who had contracted the disease in Africa. Among 270,000 prisoners from 17 countries the rate of HIV infection ranged from 11% to 26%. Among US Army recruits the rate of HIV seropositivity was found to be 1.5%. Among Navy soldiers the rate was 0.24%. During 1985-87, in the navies of different countries, 2051 men had contracted HIV infection, most of whom had no idea about transmission and prevention. At the Kirov military hospital during 1988-89 a comparison of HIV infection rate was made involving 545 people. Among foreigners the rate was 17.2 times higher than among citizens. In a massive screening experiment involving 47,447 people in Kalmykia a rate of 2.9% was found among local citizens compared to 1.9% among foreigners. Diagnosis relies on various antibody tests, of which the Welcozyme test system has yielded only a 2.3% rate of false positive results. In 1989 the immunological status of 73 false positive results from 20 HIV-infected people was examined. These investigations revealed that the absolute amount of T-4 cells, the index of differentiation of T-4/T-8, and the functional activity of lymphocytes diminished in the infected people, while a slight increase of T-8 count did occur. The study of the blood lymphocytes showed that in the infected people the activity of lactate dehydrogenase and mitochondrial isoforms of malate dehydrogenase decreased somewhat, while the activity of succinate dehydrogenase and especially of glucose-6-phosphate dehydrogenase increased. In persons infected with HIV, the T- suppressor cell count increased and T-helper cell count decreased, which leads to the decrease of the functional indices of the immune system. Military health services are obliged to inform the servicemen about AIDs for health protection and the spouses of those infected with HIV should also be notified.
[Problems for discussion on contraception for women after childbirth]
Questionnaires were administered to 300 postpartum women in 3 delivery wards in Moscow to determine their opinions about contraceptives. Similarly, 100 gynecologists-obstetricians were queried in 2 wards, at 2 counseling sites for women, and at regional seminars of gynecologists-obstetricians. 52% of the physicians recommended the condom to nursing mothers whenever sexual activity was resumed and the IUD from the 3rd and 4th month on. 60% of the doctors thought that women who were not breast feeding could similarly start using the condom and from the 3rd and 4th month either the IUD (82%) or oral contraceptives (36%). 71.1% of the women were under 30 years of age, and were relatively well educated. 68% of them had their first birth, 28.3% had their second, only 3.7% had their third or higher order of births. 35% of the women did not plan the present pregnancy. 81% of the women were using contraception up to the time of the present pregnancy, and the most popular methods were coitus interruptus (36.3%), the rhythm method (35.3%), the condom (28.3%), the IUD (13%), and hormonal methods (10.6%). Although 46.3% of the women preferred the IUD after birth, only 7.3% of them preferred hormonal preparations. In this study 71.5% of the mothers were breast feeding their infants. 13.5% of the women had gestosis in the 2nd half of the pregnancy, 5.8% had anemia, and 21.3% experienced the threat of miscarriage. In 12.9% of the cases there were other pathologies unrelated to pregnancy, and 14% of the births were accomplished by means of cesarean section. Only 12.1% and 13% of the women, respectively, received information about postpartum contraception at the women's counseling sites and delivery wards. 46.3% of the women wanted to use IUDs, but only 7.3% wanted to use hormonal preparations. Only about half of the women expressed their opinion about sterilization: 23% were against it, while 29.7% were for it. The results indicated that the preparation of women for postpartum contraception should already start at the counseling place during pregnancy.
[Intrauterine devices (IUDs) and acute genital inflammation in women]
At the family counseling consultation of the Medical University of Sofia, Bulgaria, a total of 2182 patients were evaluated. 946 were using IUDs and 1236 were attending for the second time. These women had a total 13,832 menstrual cycles. Among the IUD users 480 women were using Copper TC-200, 341 were using Nova T, 53 were using Lippes loop, 28 were using Gravigard, and 44 were using Multiload. All of these patients were evaluated and followed-up after the first menstrual cycle, after the third month, and 12 months after the use of the IUDs. The control group of women consisted of 1236 women selected at random who were not using any kind of contraception. 28.5% of the women had experienced 3 or more pregnancies; among those using IUDs, 47.8% had had 2 pregnancies. Only 29 (3.1%) of the 946 women using IUDs did not report any pregnancies. 22.9% of the women studied had no children, 41.3% had 1 child, 30.1% had 2 children, and only 2% had 3 or more children. The rate of gynecological inflammation in the pelvis minor requiring hospital admission for treatment was 0.9% among those using IUDs vs. 0.32% among those who used no IUDs. 5.31% of women using IUDs and 3.12% of women not using IUDs had inflammation requiring out-patient treatment. In both case and control groups the occurrence of uterine disorder was the most frequent: acute or chronic endometritis in 31.33% of cases; unilateral or bilateral changes in the adnexa in 27 patients (2.8%), unilateral parametritis in 3 cases (0.3%), and pelvioperitonitis in 3 cases. In 4 patients where the inflammatory process was explored by means of laparotomy extrauterine pregnancy was found. The risk of having inflammation of the genital tract was the highest in the 25-29 age group, in those using IUDs, and those who had had more then 3 abortions and 1 birth. The risk of inflammation among IUD users was markedly higher compared to the users of other contraceptives: 25.73% for hormonal methods and 9.31% for the condom.
[Clinical study of a low-dose contraceptive -- Femodene]
The contraceptive effectiveness, safety during the menstrual cycle, and frequency and type of side effects of Femoden were investigated in 22 healthy women with an average age of 27.4 years, who were not smokers and for whom no contraindications existed for the use of sex hormones. All women had had previous pregnancies, of which 19 (86.4%) resulted in births. The number of abortions was 25 (abortion rate of 1.14). 8 of the women had used oral contraceptives in the past: triphasic (5) and monophasic preparations (3). 18 women had stable menstrual cycles, 7 had dysmenorrhea, and 4 had previously experienced menstrual disorders. The clinical observation was planned for 6 consecutive cycles and the measurement of the contraceptive safety was effected by using the Pearl Index (the number of observed pregnancies per 100 women during a whole year). Only 112 of 132 menstrual cycles were evaluated because of various reasons. Not a single pregnancy was registered, indicating a contraceptive effectiveness of 100%. The menstrual interval was 21-31 days in all 22 women before and during the use of Femoden. The interval was 28 days in 15 women before using Femoden and in 19 women during the use of Femoden. The duration of menstruation was 3-8 days in 22 women before Femoden use and in 11 women during use. It was over 5 days in 14 women before Femoden use and in 8 women during use. The amount of menstrual bleeding was less in 20 women during Femoden use. Pain occurred in 7 women before Femoden use and in 2 women during use. The most important side effects during the use of Femoden were: intermenstrual bleeding (5) including spotting (4) and breakthrough bleeding (1) in a total of 18 cycles (16.1% of the observed 112 cycles). Other complaints were nausea (2); headache (2); mastodynia (3); vertigo (1); weight gain by up to 2 kg (2); nervousness (2); depression (1); and decreased libido (2). In all, Femoden provided good menstrual cycle control in comparison to other monophasic contraceptives, therefore it is recommended for wide use in gynecological practice.
This master's thesis reports on a retrospective analysis of Project Teen, a multidisciplinary, collaborative intervention that involves home visits to pregnant adolescents in Palm Beach County, Florida, and continues until the focus children are 2 years old. This evaluation: 1) compared pregnancy outcomes (birth weight and pre- and postnatal appointments kept) between the intervention group and 2 control groups; 2) determined whether the outcome variables in the intervention group were affected by the number of home visits, of total program contacts, or of nursing visits; and 3) determined whether source of care in the intervention group affected pregnancy or family outcome (well child care appointments kept, current immunizations, consistency of child care site, appropriate career program and school, and no subsequent pregnancies for 18 months). The first chapter of the thesis sets out the purpose of the study and the statement of the research problem. Chapter 2 describes the conceptual framework and reviews the literature on empowerment, pregnancy outcomes, home visits to pregnant women and families, and home visits to pregnant adolescents. Chapter 3 details the study methodology and notes that the 274 subjects participated in Project Teen between October 1994 and October 1995. The results are presented in chapter 4 and discussed in chapter 5 along with implications of the results for nursing and future research. The overall finding was that the intervention was successful in positively influencing the use of prenatal services and family resources and that senior public health nursing was an essential component of program success.
The study reported in this doctoral dissertation sought to increase understanding of how family relationships affect abortion decisions of pregnant adolescents in the US. The adolescents' perceptions of the quality of parental involvement were tested against a demographic model (age, race, religious denomination, family configuration, and adolescent's perception of family income), a religious model, and a family model (cohesiveness, adaptability, communication, parenting style, family stress, and family coping) to determine if any of the models were influential and, if so, which model was most important, which variables were most influential, and whether any variables were predictive of the outcome for adolescents seeking parental involvement in resolution of the pregnancy. Data were gathered from 159 adolescents who agreed to participate in a survey administered in 7 private abortion clinics in 3 states over a period of 3.5 months. Multiple regression analysis of the data revealed that the demographic and religious models were of no value in predicting the adolescents' perceived quality of parental involvement. Only the variable of adaptability in the family model was significantly related to the perceived quality of parental involvement. In addition to presenting this study, the dissertation contains a review of the literature on: adolescent pregnancy; the role of the family in relationship to adolescent sexual attitudes, behavior, and pregnancy; and adolescent abortion in 1995.
Condom use among college students: a test of social cognitive theory.
The study reported in this doctoral dissertation used selected concepts and constructs of social cognitive theory to identify predictors of male condom use among a college-age population during vaginal intercourse. The introductory chapter discusses the public health relevance of condom use, recommendations regarding condom use, condom use among college students, and possible factors related to condom use, and presents the theoretical framework, justification, and purpose of the study. Chapter 2 provides a review of the literature on factors related to condom/contraceptive use, the relationship between condom use and variables related to social cognitive theory, programs that promote condom and/or contraceptive use, research instruments, and the relationship of social cognitive theory to health behavior. Chapter 3 describes the research methodology and data collection via questionnaire administered to 569 university students during the summer of 1995. Chapter 4 presents results, and chapter 5 contains a discussion of the results as well as conclusions, implications, and recommendations for further study. The major conclusions were that: 1) neither female nor male students used condoms consistently, 2) the students perceived their social support regarding condom use to be high but most found condoms expensive, 3) social cognitive theory appears to be useful in assessing condom use frequency and appropriateness in college students, 4) predictors of condom use frequency sometimes differed from predictors of appropriateness of condom use, and 5) reported condom use was not necessarily correct condom use.
Achieving reproductive health for all. Annual report 1996.
This annual report of the Arab Region of the International Planned Parenthood Federation (IPPF) opens with a message from the Chair of the Regional Council, who notes that the IPPF is adopting new strategies to meet the challenges in its "Vision 2000" plan. The Arab Region has aided this effort by engaging in strategic planning, amending its constitution to empower women, and boosting youth participation. Next the regional director summarizes the following areas of interest in this report: 1) training family planning associations to engage in strategic planning and project development; 2) strengthening the Euro-Arab partnership; 3) generating interest in youth-related concerns; 4) empowering women; 5) evaluating progress in implementing the recommendations of the International Conference on Population and Development; and 6) establishing firm links with other organizations. The report also deals with efforts to incorporate the concept of male responsibility, collaboration, and understanding as the notion of responsible parenthood is promoted. Specific programs described include a ground-breaking youth peer-group program in Algeria; a method of information diffusion that incorporates the oral poetic tradition; and use of operations research to upgrade service provision in Syria, Lebanon, and Egypt. Efforts to insure that the development of evaluation indicators occurs during project planning and implementation are also discussed. The report closes by presenting the financial report for 1995.
Understanding cross-cultural child development and designing programs for children.
This manual was designed to help those working with, being trained to work with, or planning programs for children in developing countries to understand the forces that influence child development. The first chapter considers the basic aspects of social and emotional development, how parent-child interactions change with modernization, and how caretaking by siblings and other children influences development. Chapter 2 describes physical development (especially nutrition) as a foundation for social, emotional, and cognitive development. Chapter 3 shows that children process information differently at different ages and proposes ways in which caretakers can promote children's learning and thinking. Chapter 4 considers the developmental needs of children of specific ages, developmentally appropriate care, and evaluation to determine whether care is appropriate. Chapter 5 looks at ways to assess development and presents a step-by-step plan for determining if intervention is necessary. The next two chapters deal with modification of caretaking practices and specific interventions for children with mental health problems, emotional needs, and living in difficult circumstances (victims of violence, homeless children, and AIDS orphans). The final chapter reviews program strategies and considers options and common implementation problems. Each of these chapters contains an outline of factual information, questions for discussion, suggestions for field research, and supplemental reading lists.
Female genital health and the risk of HIV transmission.
This publication describes some of the conditions that facilitate the transmission of HIV infection in women and looks at the barriers to prevention and treatment faced by women in developing countries. The paper opens with a brief introduction and then considers the effect of genital infection through sexually transmitted diseases and of trauma such as female genital mutilation as cofactors in the transmission of HIV infection. The next section describes some of the obstacles to diagnosis and treatment of women in developing countries. These include poor utilization of health services, inadequate access to health services, personal modesty, sexual inequality, and the stigma attached to sexual problems. After cautioning that women alone are not responsible for preventing HIV transmission, the paper presents recommendations, including the following: 1) women's health should be promoted for reasons other than child-bearing, 2) health knowledge should be promulgated through social networks, 3) traditional midwives should be used to develop awareness of reproductive health and provide treatment referral, 4) health systems should be strengthened and their mandate regarding women should be broadened, 5) prenatal patients should be screened in a culturally-appropriate manner for genital-urinary infection, 6) development of inexpensive diagnostic tests should be promoted, 7) female-controlled means of mechanical or chemical barrier protection should be developed (including a vaginal virucide that permits conception), 8) the relationship between female genital mutilation and HIV transmission should be studied, 9) inequities in the status of women should be addressed over the long term, and 10) short-term actions by women's groups must receive the necessary assistance to unify women for survival.
This paper considers the cultural determinants of maternal mortality in West Africa that lie beyond the explicative ability of quantitative analytical tools yet that must be understood in order to develop effective strategies to reduce maternal mortality. The belief system surrounding maternal mortality in this region is revealed by an expression that translates, "she fell on the battlefield in the line of duty." The assumptions behind this expression are that: 1) childbirth is like a battle; 2) any battle has risks of casualty and death; 3) women have a duty to engage in this battle to achieve ideal family size; 4) pregnant women are valued for their stoicism in the face of this battle; 5) psychological coping strategies to achieve stoicism are emphasized to prepare for this battle; 6) society develops strategies to transcend the adversity of an eventual casualty (maternal mortality); 7) this battle can not be understood because it is guided by the supernatural; 8) there is no ordinary defense in this battle; and 9) traditional interventions will be metaphorical in nature. Discussion of this belief system focuses on the importance placed in the continuation of lineage, the subordination of the individual to the group, the powerlessness of women to participate in medical decisions (both in a traditional setting and in the hands of modern health providers), the training girls receive to learn to fulfill their duty, the inadequacy of preparations for safe motherhood, and the number of births that are unassisted. An understanding of the internal logic of this system allows the results of quantitative studies to be applied in an appropriate fashion. Thus, the moral duties of children toward their mothers and the web of mutual obligations held by an extended family can be manipulated to insure that women receive proper maternal health care and that society learns to minimize the risks of this particular battlefield.
Agency performance report 1995.
This report describes the performance of the US Agency for International Development (USAID) during 1995. The introduction discusses: 1) how the agency helps the US compete successfully in the global economy, 2) how the changing role of the agency led to changes in the way it does business, 3) the agency's strategy of delivering assistance, 4) the decline in US resources devoted to foreign aid, and 5) international donor coordination. USAID objectives and activities to promote those objectives are described. The development objective of promoting broad-based economic growth centers on strengthening markets, expanding economic access and opportunity for the poor, expanding and improving access to basic education, and following an integrated strategy. The advancing democracy objective is considered in terms of strengthening the rule of law and respect for human rights, fostering genuine and competitive political systems, increasing politically active civil societies, creating more transparent and accountable government institutions, and future challenges. The objectives of stabilizing population and protecting human health involve reducing unintended pregnancies, reducing child and maternal mortality, and reducing sexually transmitted infections and HIV transmission. The objective of encouraging sound environmental management involves conserving biological diversity, reducing the threat of global climate change, improving urban and pollution management, increasing the use of environmentally sound energy services, managing natural resources in a sustainable fashion, and integrating environmental strategies with other agency goals. Finally, the agency's role in providing humanitarian and transition assistance is shown to be preventing crises, meeting urgent relief needs, helping nations emerge from the crisis cycle, and creating linkages among prevention, relief, and development efforts. Discussion of each of the major topics in this report is accompanied by specific examples of programs implemented throughout the developing world.
This report details progress made by the US Agency for International Development (USAID) in implementing the Program of Action of the 1994 International Conference on Population and Development. The report contains an introduction and an overview of the USAID program. USAID reproductive health programs have: 1) provided leadership for a supportive policy environment through multilateral, regional, and country-level initiatives; 2) developed innovative techniques for operations, biomedical, social science research and for evaluation; and 3) implemented reproductive health programs that promote access and quality in family planning and other reproductive health services, maternal health, women's nutrition, postabortion care, breast feeding, sexually transmitted disease and HIV prevention and control, integrated reproductive health programs, programs and services for youth, prevention of such harmful practices as female genital mutilation, male involvement, reproductive health for refugees and displaced people, and involvement of women in the design and management of programs. USAID programs to advance girls' and women's education and empowerment have forwarded women's legal and political rights, increased access to credit, and developed integrated programs for women. Priority challenges and directions for the future include: 1) determining the feasibility, costs, and effectiveness of reproductive health interventions; 2) improving understanding of reproductive health behavior; 3) continuing development of service delivery strategies; and 4) mobilizing resources for reproductive health.
Male hormonal contraception. What prospects exist and how acceptable are they?
While this century has given birth to a myriad of previously unimagined technologies, three of the four methods of male contraception have been in use for hundreds of years (the condom, periodic abstinence, and withdrawal), while the fourth (vasectomy) is permanent. In order for men to take more responsibility for family planning, they must be given effective, reversible, and acceptable means of contraception. Biomedical research is now attempting to: 1) prevent sperm production (through use of androgen-only methods, progestogen-androgen combination methods, and methods that combine gonadotrophin-releasing hormone and androgen), 2) interfere with the maturation and fertilizing ability of sperm, 3) interrupt sperm transport, 4) devise better condoms, and 5) inhibit sperm-egg interactions. Research is also being conducted to determine whether men would use a hormonal contraceptive if it were available. One indirect measure of acceptability, prevalence of use of a particular measure, reveals dramatic regional differences in use of male methods. Research indicates that men and women value safety, efficacy, and convenience, and that reversibility is also an important criterion of acceptability. Initial research on acceptability of hypothetical methods (a male pill or injection) indicates that most men would be amenable to such a possibility. The usefulness of a particular contraceptive (for replacing a female method that caused severe side-effects in a partner, for example) may increase the acceptability of a male method. If men had options, they might be less tolerant of the side effects than were men who participated in clinical trials of prototype hormonal methods. Acceptability research will help improve the development of new methods and the identification of appropriate niches for new methods.
Update on the global epidemiology of tuberculosis.
Because the international community neglected tuberculosis, developing countries did not mirror the decline in incidence of the disease seen in the industrialized world following the discovery of antituberculosis drugs. During the 1990s, developing countries will experience an estimated 90 million new cases of tuberculosis and 30 million deaths from the disease. Most new infections and deaths occur in Asia and Africa. In developing countries, socioeconomic conditions foster the spread of the disease, and inadequate health care systems mean that patients are not diagnosed rapidly and are not treated effectively until cured. The HIV epidemic is also contributing to the prevalence of tuberculosis in developing countries because of the large pool of coinfected people. Tuberculosis is the most frequent opportunistic disease in people with HIV/AIDS living in Africa, Latin America, and southeast Asia. A new wave of tuberculosis notifications and deaths has also occurred in the former socialist countries of central and eastern Europe because of war, conflict, impaired nutrition, stress, deterioration of the public health system following the dissolution of the Soviet Union, and a severe lack of drugs. In the US, notification increased during 1985-93 due to factors such as poor control programs. Rates have also increased or failed to decline in western Europe, and this situation has been linked with an increased number of cases among the foreign-born population. The extent and severity of drug resistance is unknown but the high rates of initial drug resistance, acquired drug resistance, and multi-drug resistance have been found. The World Health Organization is attempting to describe the true extent of the problem. Meanwhile the control situation is improving slowly but inadequately, with district-based programs giving the most hope. The extent of multi-drug resistance will have an important effect on the epidemiology of this disease. An effective eradication strategy exists but depends upon sustained political commitment.
Social marketing and communications for health.
This brochure from Population Services International (PSI) opens with a report from PSI's president, who notes that as a result of its 1991 expansion PSI is now the largest social marketing organization in the world. Products sold through PSI's programs avert thousands of new HIV infections and are making a major impact on birth spacing and on reduction of maternal and infant mortality and morbidity. PSI depends upon highly successful communication programs and speed to create demand for products and improve quality. PSI's next objectives are to launch condom marketing programs in every country in need, provide significant quantities of birth spacing and family planning products with unparalleled cost efficiency, and demonstrate that millions of children can be saved through the social marketing of essential drugs such as oral rehydration salts and vitamin A. PSI addresses the problem of inadequate resources available to prevent HIV/AIDS, stem population growth, and save children, by developing cost-efficient social marketing of essential health products through the private sector. The brochure details elements and results of PSI social marketing, cost efficiency and performance, and PSI's communication campaigns. The remainder of the brochure is devoted to a description of country programs in Africa (Benin, Burkina Faso, Burundi, Cameroon, the Central African Republic, the Ivory Coast, Ethiopia, Guinea, Kenya, Morocco, Nigeria, South Africa, Zaire, and Zambia); Asia (Bangladesh, India, Malaysia, Pakistan, and the Philippines); and Latin America and the Caribbean (Brazil and Haiti). Attention is then paid to PSI's HIV/AIDS prevention demonstration project in the US, which targets runaways and street kids in Portland, Oregon. The brochure ends with a list of program contributors, directors, staff, representatives, offices, and affiliates.
Urbanization and mental health in developing countries.
It is expected that the urban population in developing countries will double in the next 30 years. While urbanization is accompanied by health problems, population density can lower public health costs. Common mental disorders, such as anxiety, depression, insomnia, fatigue, irritability, and poor memory, account for 90% of all mental disorders, cause behavioral problems in offspring, and impede recovery from physical ailments. Those who suffer most from common mental disorders include women, those between 15 and 49 years old, and low-income populations. Strong links have been established between socioenvironmental factors and common mental disorders, and an urban environment has been associated with many possible risk factors for such disorders. Only a small percentage of people with mental disorders seek primary health care and even less receive secondary- or tertiary-level care. Common mental disorders place a large burden on primary health care services, however, but most of the patients suffering from mental disorders seek care for physical disorders that mask proper diagnosis and treatment. Thus, the World Health Organization advocates the introduction of mental health components in primary health care services in developing countries. In order to reach those who remain outside of the health care system, community-based interventions such as self-help groups or efforts to promote wider social changes or address poverty should be undertaken. Mental health in developing countries is gaining attention as the attendant loss in economic productivity of human capital has become apparent.
Teen pregnancy: a public health issue or political football?
Politicians in the US have made adolescent parents the scapegoat of changing cultural patterns by suggesting punitive solutions to nonmarital births rather than addressing underlying causes of premature child-bearing. It is known that the percentages of young people of all races and all social classes reporting early, nonmarital sexual intercourse have increased dramatically, while adolescent fertility rates peaked in the 1950s. Improved access to contraception and abortion caused a decline in teen pregnancy and birth rates from 1970 to 1986. During 1986-91, service providers could not match growing demand, and the birth rate increased 25%. Increased rates of sexual activity have also led to increases in the incidence of sexually transmitted diseases (STDs) and HIV/AIDS among adolescents. This situation was exacerbated by Reagan and Bush policies, which reduced funding for services to adolescents and supported abstinence-only sex education courses. The concern voiced by policy-makers today centers on nonmarital childbearing by low-income adolescents who will rely on public assistance to survive. A proper response to this situation would involve the following policy actions: 1) mandating comprehensive sexuality education from kindergarten through high school, 2) funding mentoring programs, 3) improving economic and educational opportunities, 4) expanding STD and HIV/AIDS prevention programs, 5) increasing access to confidential health services (including mental health care and substance abuse treatment), 6) expanding child sexual abuse prevention and intervention programs, and 7) increasing access to and acceptability of teen contraceptive usage and abortion.
Uses and misuses of vitamin A.
Vitamin A, which is available from dietary sources, vitamin supplements, and fortified products, affects numerous bodily processes through its impact on cellular differentiation. More than 300 genes are regulated by the rapid action of the vitamin. It has recently been recognized that mild vitamin A deficiency is widespread among children and pregnant women in developing countries. This deficiency increases severity of infectious diseases, iron-related anemia, and growth disturbances. Improving the vitamin A status of all deficient children could avert a million or more deaths annually, and administration of high-dose vitamin A has been advised for treatment of measles. There is also an apparent association between high beta carotene status (which may represent vitamin A status) and lower rates of some forms of cancer, but this has yet to be confirmed. Supplementation programs in developing countries rely on periodic administration of high-dose vitamin A in doses of 100,000 IU orally for those under 1 year old and 200,000 IU for those older once every 3-6 months. The optimal dosing schedule is unknown, but no cases of death have been linked to isolated vitamin A toxicity. Experts also disagree about the window of safety during which a high-dose of vitamin A can be given to pregnant and postpartum women without causing teratogenicity. It is unwise to administer high-dose vitamin A to women of reproductive age after the first 6 weeks postpartum. All women at risk should receive small daily doses or 20,000 IU weekly doses. In the US, where general dietary status is good, women should not use more than 8000 IU supplements except when indicated for a specific reason.
Reproductive preferences and behaviour: how men and women compare.
Data from the Demographic and Health Surveys completed by 1993 were analyzed to compare the ideal family size, desire for another child, and contraceptive attitudes, use, and intentions among currently married men with those expressed by currently married women. Monogamous men reported mean ideal family size of 4 or fewer children in Kenya, Rwanda, North Africa, and Asia. Tanzania reported 7.4, while the rest of east Africa reported fewer than 6. Ideal sizes in west Africa ranged from 8 in Burkina Faso to 13 in Niger. Polygynous men reported much higher family sizes. In Bangladesh and Burundi, men and women had the same ideal size. In Rwanda, women wanted 0.1 more children, and in all other countries the preferences of men exceeded those of women (in most cases by less than 0.2). Desire for another child was consistent with the findings on ideal family size, and contraceptive approval among men was very high, ranging from less than 65% in most west African countries to 90-97% in other African countries and Ghana. Women were more likely to approve of contraception, but only small differences in approval rates were found, except in Mali, where women approved 3 times as often as men, and Pakistan, where 10% more men than women approved. Men generally reported greater use of contraception than women, and current use was lowest in countries where most men had unfavorable attitudes towards family planning (FP). Women were more likely to express intention to use a method than were men except in Burundi, Niger, and Malawi. These data indicate that men's reproductive preferences and desires in Pakistan, Tanzania, and all of west Africa except Ghana may constitute a challenge to FP program success.
Restructuring the national health system for universal primary health care. A policy document.
This policy statement of South Africa's Department of Health and nine provincial health administrations deals with the restructuring of the public and private health sectors for the development of an equitable and efficient national health system. After a brief introduction, the paper provides background information in the form of an assessment of the critical problems in the organization and delivery of primary health care and other health services. These include the poor return in terms of health status achieved by the 8.5% of gross domestic product devoted to health care expenditures during 1992-93, the disproportionate amount of total financial resources for health spent in the private sector, problems confronting the public and private sectors, and the need for restructuring the national health system. The proposed policy framework for the national health system, and the organization of the public health care delivery system in terms of its basic principles, health package, and delivery model are described. Funding requirements and sources of finance for the public health care system are discussed. Regulatory reform of the private health sector is covered through a discussion of: 1) a proposal for mandatory health insurance coverage for a defined hospital benefit package, 2) regulations applying to the core benefit package under a mandatory coverage scenario, 3) regulations applying to the full benefit package offered by medical schemes, 4) further regulations to enhance the efficiency of the health insurance market, 5) regulations aimed at containing private sector costs, and 6) reform to current tax treatment of medical scheme contributions.