Pride of the Maya -- basic education project for Mayan girls in bilingual and bicultural manners.
Girls Education Project, a two-year program sponsored by the Japan International Cooperation Agency (JICA), seeks to address the educational needs of Mayan girls in rural Guatemala. The program is being implemented under the framework of the Japan-US Common Agenda for Cooperation in Global Perspectives. Preliminary fieldwork revealed the importance of ensuring that entire communities, including teachers and parents, appreciate the human right of rural girls to a basic education. The project team will conduct three-day workshops in each of the four pilot states in 1997 to discuss teaching methods, materials, and curricula to promote girls' participation and improve their achievement levels. Also planned is a three-day national seminar involving governmental officials and representatives from the public and private sectors, nongovernmental organizations, professional groups, universities, and ethnic and cultural groups. The bilingual/bicultural method selected for the intervention seeks to implement basic education for Mayan girls in both Spanish and the four main Mayan languages. Another focus is to encourage the students to maintain pride in their cultural heritage.
Abortion attitudes, gender, and candidate choice in presidential elections: 1972 to 1992.
The salience of the abortion issue to the outcome of the six US presidential elections from 1972 to 1992 was analyzed through use of data from the National Election Studies. Overall, the results indicated that the electorate has not been choosing between presidential candidates from a single-issue perspective on abortion. The Kelley-Mirer Model, used as the basis for the probit analysis, included measures of party affiliation, net candidate image, incumbent popularity, gender, and attitudes toward abortion. For every election, incumbent popularity was the strongest predictor of voting behavior, followed by political party identification. Abortion attitudes were significant in 1972, when abortion first surfaced as a political issue as a result of the Roe vs Wade ruling, but not again until 1992. To determine whether abortion politics are likely to exert a more decisive impact on future presidential elections, a detailed analysis was conducted for the 1992 election of mobilized voters (who voted in 1992 but not in 1988) and converted voters (who voted for one party in 1988 and another in 1992). Women and pro-choice voters predominated in both these subsets. Most significant in the 1992 election was the conversion of voters to the Democratic Party; however, there is no evidence such conversion was stimulated by the abortion issue alone.
Sexual behavior in pregnancy among Hong Kong Chinese women.
Changes in the sexual behavior of Hong Kong Chinese women during pregnancy were assessed through a retrospective study of 150 women randomly recruited from two teaching hospitals within 3 days after giving birth. The mean age of respondents was 28.7 years; 73.3% had had one lifetime sexual partner, while 20% reported two partners. Observed was a clear trend toward decreased sexual activity as pregnancy progressed. Before pregnancy, 116 couples (77.3%) were having intercourse less than three times a week. This statistic increased to 145 couples (96.7%) in the first trimester of pregnancy and 56 couples (37.3%) abstained from intercourse during this time. In the second trimester, no couples reported intercourse more than twice a week and 51 (34%) abstained. During the third trimester, 97 couples (64.7%) abstained. Concern about jeopardizing the pregnancy was the most commonly cited (62%) reason for the reduction in sexual activity. Frequency of orgasm and enjoyment of intercourse also decreased with advancing gestation. Although younger women were more likely than their older counterparts to experience both coitus and orgasm during the first trimester, there was no consistent relationship between age, parity, educational level, employment status, and sexual behavior either before or during pregnancy. These findings suggest that Chinese women living in Hong Kong are more conservative about sexual behavior during pregnancy than women in most cultures.
A multicenter study conducted in the UK confirmed the safety, efficacy, and acceptability of a mifepristone (RU-486)-prostaglandin regimen as an alternative to surgical termination of an early first trimester pregnancy. The 975 study subjects (median age, 24 years) were recruited from 13 hospital gynecologic units in Scotland and England; gestational age could not exceed 9 weeks. They received 600 mg oral RU-486 followed 48 hours later by vaginal gemeprost (1 mg). Of the 957 women for whom data were evaluable, 907 (94.8%) aborted successfully with no serious complications; surgical evacuation was required in another 5.2%. There was no association between efficacy and either gestational age or parity. Within 5 days of gemeprost administration, 660 women (75.6%) had ceased to bleed or had only light bleeding/spotting. Overall, 90 women (9.4%) complained of severe or excessive bleeding associated with the regimen. The incidence and severity of pain reached a maximum 2 hours after gemeprost, when 537 women (56%) complained of moderate or severe discomfort; 275 (28.5%) required narcotic analgesia. In the 4 hours after gemeprost insertion, 23.3% of women vomited and 11.2% had diarrhea. Since the majority of side effects recorded in this study were associated with gemeprost, the use of vaginally delivered misoprostol in conjunction with RU-486 may merit investigation.
Effect of Norplant implants on the pituitary-adrenal axis function and reserve capacity.
To ensure that Norplant contraceptive implants are not associated with a risk of pituitary-adrenal suppression, a series of laboratory tests were conducted in 15 women both before and 6 months after Norplant insertion. Comparisons of hormonal profiles before and after Norplant insertion revealed a significant drop in morning serum cortisol levels (404.33 +or- 84.07 nmol/l vs. 353.67 +or- 56.65 nmol/l, p < 0.05), but no significant change in evening readings. The observed changes in morning cortisol values were still within the normal range. Serum ACTH values and 24-hour urinary 17-hydroxy steroids, 17-ketogenic steroids, and 17-ketosteroids were not different after insertion compared to baseline. Before Norplant insertion, injection of synthetic ACTH resulted in a 259.59 +or- 169.53% increase in the mean level of serum cortisol 5 hours later; 6 months after Norplant insertion, the percent rise above baseline was 165.85 +or- 91.64%. The significantly lower adrenal response among Norplant users (although still within normal limits) is presumably due to a local inhibition of the adrenal itself and not of the hypothalamic-pituitary axis. Although these findings suggest a minimal suppressive effect of prolonged microdose release of levonorgestrel from Norplant implants, the suprarenal response to acute or prolonged stresses (e.g., surgical operations or shock) in Norplant users requires investigation.
Reports appearing in the mass media in October 1995 citing a two-fold increase in the risk of venous thromboembolism in users of third-generation compared to second-generation oral contraceptives (OCs) were followed, in Norway, by a 17% drop in total OC sales and a 70% drop in sales of the only third-generation OC (Marvelon) on the market. More than 25,000 Norwegian women discontinued OC use in November-December 1995. Abortion data from one Norwegian county, representing 6-7% of the country's population, showed no significant changes in the total number of induced abortions in the first quarter of 1996 compared to the first quarter of preceding years. However, the steady decrease in the abortion rate for women 24 years of age or younger recorded in 1992-95 was interrupted by a 36% increase during the first quarter of 1996 (5.7/1000, compared with 4.2/1000 in the first quarter of 1995). Most of the growth in abortion cases occurred among single, childless students--a subgroup in which OC use tends to be high. Although this finding suggests that the mass media's "pill scare" may have led many young women to discontinue OC use or switch to less effective formulations, evaluation of the full effect of this event cannot be completed without national data on induced abortion and the completion of birth registration.
Contraceptive practices of women requesting termination of pregnancy: a study from China.
A survey of 1520 consecutive Chinese women seeking induced abortion at eight hospitals in Zheng Zhou City, Hunan Province, during March-May 1996 revealed the presence of contraceptive failure in 1093 women (71.9%). The mean age of abortion seekers was 26.9 years; 235 women (15.5%) were unmarried and 871 (57.3%) had no children. 938 (61.7%) of these pregnancies were potentially predictable as a result of nonuse of contraception (427 women) or timely recognition of contraceptive failure (511 women). Condoms accounted for the highest proportion (29.7%) of contraceptive failures, followed by IUD (23.5%), and rhythm (15.9%). 77.1% of abortion seekers had previously used at least one contraceptive method, although only 299 (19.7%) used a method at first intercourse. Overall, 57.6% of contraceptive users had experienced contraceptive failure at some point. In most cases, these failures resulted from user noncompliance (e.g., forgetting to use condoms and missed or delayed pill-taking), suggesting a need for more thorough counseling. Only 10 women (1.1%) had used emergency contraception, but without success. If the remaining 928 women who either had unprotected intercourse or recognized contraceptive failure immediately had used the Yuzpe emergency contraception regimen, about 75% would not have become pregnant. These findings suggest that condom and rhythm users should be targeted for the introduction of an emergency contraception program aimed at reducing the high rate of abortion in China.
The results of a clinical study of 15 women suggest that Anuelle norethindrone (NET) biodegradable subdermal implants provide a promising alternative to both the pill and non-biodegradable implants. Study subjects were randomly assigned to receive either four pellets (174 mg NET) or five pellets (266.5 mg NET). An initial burst effect in 24-hour postimplantation serum NET levels was observed in both groups (to 3.17 +or- 0.39 ng/ml in the four-pellet group and to 3.71 +or- 0.37 ng/ml in the five-pellet group), followed by a decline, then sustained levels, and finally undetectability at 36-38 months. Menstrual cycles were normal in 65% of women in the four-pellet group and 47% of those in the five-pellet group; no subject dropped out due to abnormal vaginal bleeding patterns. The incidence of ovulation was 22% in the four-pellet group and 1% in the five-pellet group; no pregnancies occurred in either group in 24 months of observation. Plasma lipids showed reduced total and low density lipoprotein cholesterol and triglycerides. No major adverse local or systemic side effects were noted. Acceptability was good in terms of cosmetics, convenience of implantation, biodegradability, and ease of removal (if required) and most study participants expressed the desire to use NET implants as their contraceptive method of choice.
The pregnancy termination potency of varying doses of mifepristone, onapristone, and ORG 3806--alone and in combination with the estrogenic/antiestrogenic compound anordiol--was evaluated in adult rats. The antiprogestins and anordiol alone were administered to pregnant female rats on days 7, 8, and 9 of pregnancy and the presence or absence of embryos in utero was determined on day 16. ORG 31806 at a dose of 2 mg/kg/day, mifepristone at 4 mg/kg/day, and onapristone at 8 mg/kg/day terminated pregnancy in 100% of animals; 5 mg/kg/day of anordiol was required. Anordiol acted synergistically with all three antiprogestins. Antiprogestin doses that were either partially effective or ineffective became 100% effective when administered with a noneffective dose of anordiol. The combination of ORG 31806 (1 mg/kg/day) and anordiol (0.31 mg/kg/day) had the most potent pregnancy termination activity. The administration of antiprogestins in combination with anordiol at doses that effectively terminate pregnancy was associated with a significant, persistent reduction in serum progesterone, but no change in serum estradiol levels. The effectiveness of ORG 31806 and anordiol in terminating pregnancy should be evaluated in a non-human primate model to determine its potential clinical use.
A perspective on the concept of "risk".
Compared to the risks inherent in pregnancy and daily activities of living, the increased risk of nonfatal venous thromboembolism (VTE) among users of oral contraceptives (OCs) containing desogestrel and gestodene is relatively benign. About 20-30 cases of nonfatal VTE per 100,000 users of third-generation OCs containing these progestins can be expected compared to 10-15 cases per 100,000 users of levonorgestrel-containing OCs. Pregnancy, on the other hand, confers an increased risk of about 60 cases of nonfatal VTE per 100,000 women. Since OCs remain the most popular reversible method of birth control, their discontinuation because of VTE concerns would have serious public health consequences in terms of unwanted pregnancy prevention. Moreover, OCs confer a number of noncontraceptive health benefits, including protection against ovarian and endometrial cancer, osteoporosis, benign breast disease, ovarian cysts, and pelvic inflammatory disease. The lives saved by OCs should be considered in any analysis of the small VTE risk they may impart.
Coagulation and thrombosis with OC use: physiology and clinical relevance.
Recent studies suggesting that oral contraceptives (OCs) containing the progestins desogestrel and gestodene are associated with a two-fold increased risk of nonfatal venous thromboembolism (VTE) compared to earlier formulations have raised new issues for clinicians. The increased risk of 20-30 cases of VTE per 100,000 women annually compares with 60 VTE cases associated with pregnancy. Women with a documented history of unexplained VTE should not use OCs, and when there is a family history, physicians should weigh factors such as age of onset of thrombosis in the affected relative, the clinical setting (e.g., after surgery or trauma), and severity of the episode. The effects of OCs on procoagulants and anticoagulants are minor, except in the 5% of women with factor V Leiden mutation. A clotting assay can determine activated protein C resistance and a polymerase chain reaction test can identify the presence of this mutation; however, widespread screening of OC users is not recommended due to the low incidence of factor V Leiden and the low likelihood these women will develop clots. The present state of knowledge about OCs and VTE risk supports the application of informed clinical judgment.
Epidemiology of venous thromboembolic disease and OC use.
A review of recent epidemiologic studies that have detected an association between the use of oral contraceptives (OCs) containing the progestins gestodene and desogestrel and venous thromboembolism (VTE) risk suggests evidence of bias. Reviewed are five major case-control and cohort studies: World Health Organization Collaborative Study, Boston Collaborative Drug Surveillance Program Study, European Transnational Study, and the Leiden Study. Three major sources of bias could account for the increased VTE risk among users of third-generation compared to second-generation OCs: 1) selective prescription of newer formulations to higher-risk women; 2) the increased tendency for women with suspected VTE to be more likely to be referred for diagnostic testing and hospitalization if they are taking the newer OCs rather than older formulations; and 3) attrition of susceptibles. The lack of any proposed biological basis for the observed association between VTE and the new progestins, compared with previous knowledge about the responsibility of estrogen for increased VTE risk, raises additional doubts about the findings. Any evaluation should balance the effects of OCs on overall risk of cardiovascular disease against protection from pregnancy and noncontraceptive health benefits such as a reduced risk of certain cancers.
Major study finds no link between abortion and breast cancer.
A large-scale, methodologically rigorous Danish study has concluded that, among women of similar age and reproductive history, those who have had one or more induced abortion are no more likely than women with no abortion history to develop breast cancer. The reliability of previous studies of this association has been limited by many women's reluctance to be truthful about their abortion history. This potential source of bias was overcome, in the present study, through the linkage of data from the Danish Cancer Registry with information from the National Registry of Induced Abortions, which provides statistics on the patient's age at the time of a pregnancy termination as well as the duration of pregnancy at abortion. Although the relatively small group of women who had abortions after 12 weeks of pregnancy demonstrated a slightly increased risk of breast cancer compared with women with earlier terminations or no abortion history, the number of women involved was too small to permit any generalizations at this time.
Trial court blocks Iowa parental notification requirement.
A US District Court ruling has declared that parental notification requirements create a substantial obstacle to a young woman's access to abortion, in violation of US Supreme Court precedent. On January 3, 1997, Southern District of Iowa Judge Ronald Longstaff issued a temporary restraining order blocking enforcement of a new law that requires physicians performing an abortion on a woman under 18 years of age to notify one of her parents at least 48 hours before the procedure. Although the law contains a provision that the young woman may seek a court waiver to the notification mandate, the certification requirements threaten to subject physicians to criminal liability and do not guarantee confidentiality. The court order against enforcement will remain in effect until January 23, 1997, when Judge Longstaff will rule on a request for a preliminary injunction against the measure.
Appeals court invalidates Utah ban on late abortions.
On December 23, 1996, the US Court of Appeals for the Tenth Circuit ruled that a 1991 Utah law that bans all abortions after 20 weeks of pregnancy (except when necessary to save the woman's life, prevent "grave damage" to her health, or prevent the birth of a child with "grave defects") is unconstitutional. The three-judge panel reaffirmed that viability determinations must be left to a physician's medical judgment and not be dictated by the state. Typically, viability occurs between weeks 24-28 of pregnancy. According to a precedent established by the US Supreme Court in 1992's Planned Parenthood vs. Casey, a state may not unduly restrict access to abortion prior to fetal viability; even after viability, a woman's health must be the primary consideration.
The road to worldwide sexuality education [editorial]
The articles in this "SIECUS Report" document the organization's involvement in the development of sexuality education programs around the world. Topics covered by the articles in this issue include efforts by the Bolivian Government to increase understanding and acceptance of family planning methods, work with the Soros Foundation to train teachers to teach health education, a sexuality education pilot project in Russia, development of a culturally sensitive sex education program in Indonesia, and life education for youth in India. In the year ahead, SIECUS will implement country-specific programs in Nigeria, Swaziland, Russia, and India aimed at establishing frameworks for reproductive health, family planning, acquired immunodeficiency syndrome prevention, and population education programs.
Nigerian guidelines for sexuality education introduced at ceremony in Lagos.
The 1996 publication of "The Guidelines for Comprehensive Sexuality Education in Nigeria," a result of collaboration between SIECUS and Nigerian organizations, is a major step toward incorporating sex education into current reproductive health and population initiatives. A National Task Force of 20 key Nigerian agencies and institutions working in the area of adolescent health, education, and development prepared the document with technical assistance from SIECUS. Days before the document's public release, a workshop was held for members of the mass media to increase their understanding of adolescent reproductive and sexual health in Nigeria. 70% of males and 50% of females attending secondary school are sexually active before the age of 20 years; by the time they leave school, one out of every five Nigerian girls has terminated an unwanted pregnancy. The Guidelines seek to help Nigerian youth to acquire knowledge and develop responsible behavior to reduce high rates of unwanted pregnancy, complications from unsafe abortion, sexually transmitted diseases, and acquired immunodeficiency syndrome.
Survey supports arguments to start sexuality education in Russia.
In October 1996, Russia launched a 3-year sexuality education pilot project. A survey conducted in 1995 by the Transnational Family Research Institute confirmed both the need for such a program and widespread youth support. The survey found that 43.9% of 16-year-old boys and 24.0% of 16-year-old girls had had sexual intercourse; these rates were 62.7% and 46.9%, respectively, among vocational school students. Early initiation of sexual activity was associated with behaviors such as smoking, drinking, and using drugs as well as with lower grades in school. Almost 60% of young people surveyed believed that sexual relationships were as important as education or a career; 75% of females and 80% of males considered it necessary for a male to have sexual experience before marriage. Only 17% of sexually inexperienced and 30% of sexually experienced students considered their knowledge of sexuality to be adequate. Support for introducing sex education into the school curriculum was expressed by 74.9% of inexperienced males, 85.3% of inexperienced females, 78.9% of experienced males, and 90.7% of experienced females.
Reproductive Health is in Your Hands: the national media campaign in Bolivia.
To strengthen awareness of the National Reproductive Health Program, the Bolivian Government launched a mass media campaign aimed at low- and middle-income males and females 18-35 years of age. Specific objectives of the campaign were to increase positive attitudes toward reproductive health, knowledge of at least one benefit of reproductive health and where to obtain these services, knowledge of where to obtain family planning services, partner communication about reproductive health, and use of reproductive health services at health centers. To facilitate understanding of family planning decision making in Bolivia, 16 focus groups were conducted and all campaign materials were pretested. The campaign included 11 television spots, 44 radio spots, leaflets and posters, videos for clinic waiting rooms, and audiotapes for use on city buses. A survey conducted immediately after the communication campaign of 2354 men and women from seven urban areas indicated 85% had been exposed to the campaign; family planning was the most frequently remembered message. A positive attitude toward reproductive health increased from 86% at baseline to 91% after the campaign. The percentage of women 18-35 years old who reported speaking to someone other than their partner about reproductive health in the past 6 months increased from 71% to 82%, while the percentage of male respondents who stated they definitely intended to use or continue to use contraception in the future rose from 25% to 60%. Family planning use among those most exposed to the campaign increased from 5.4% to 8.7%. Given the success of this campaign, the challenge is to meet the increased demand for quality services.
Researching cultural backgrounds to establish effective sexuality education programs.
The sociocultural environment in Indonesia's Batam Island has been disrupted by tourism, trade, prostitution, temporary marriages with foreign businessmen, and a general infusion of Western values. To facilitate the design of an effective sex education and reproductive health program, the Perspective Foundation of Indonesia conducted a reproductive health survey of 125 men and women from 11 island villages. Polygamy was defended as an alternative to sex with prostitutes, although younger men had more favorable attitudes toward sex outside of marriage. Contraception is viewed solely as a means of pregnancy prevention, and many women expressed discomfort with side effects. Younger men use condoms for protection with prostitutes, but not with their primary partners. Human immunodeficiency virus is viewed as a homosexual disease spread by touching. Views about sex roles are traditional, and men are considered as not masculine if they support their partner's needs. Finally, islanders believe that the male sexual drive is designed for procreation and pleasure, while the female sex drive is strictly for procreation. On the basis of these findings, researchers have decided to incorporate sex education within the broader context of health promotion and disease prevention.
Making sense, talking sexuality: India reaches out to its youth.
To reduce the incidence of adolescent pregnancy, unsafe abortion, and sexually transmitted diseases (STDs) in India, Parivar Seva Senstha (PSS) Family Planning Programs has launched a program to provide family life education to young people. A preliminary survey administered to 236 South Delhi youths 12-20 years of age revealed widespread lack of knowledge about reproduction and STDs and a lack of comfort discussing sexuality. Based on the survey results, PSS designed curricula for ages 12-14, 15-17, and 18-20 years to be disseminated through schools and colleges, the National Service Scheme, Bharat Scouts and Guides, nongovernmental organizations, teacher training institutes, and a distance learning program. As the program evolved, a reproductive health hot line, face-to-face counseling sessions, workshops for engaged couples, and a radio question-and-answer program were added. Although teachers are supportive of the program, they remain inhibited about discussing sexuality with their students and prefer that PSS conduct the classes. At present, PSS is training trainers to teach the curriculum.
Strategies to build support for HIV-prevention and sexuality education programs. Fact sheet.
A needs assessment conducted by SIECUS of 150 education and health leaders from the US resulted in a set of suggestions for building support for human immunodeficiency virus (HIV) and sex education programs. The recommendations are grouped under eight general directives: 1) work with other groups, 2) develop models, 3) provide up-to-date information, 4) engage the media, 5) build community support, 6) organize public meetings, 7) prepare for challenges and conflicts, and 8) involve parents.
"Sluts" or "sleazy little animals"? Young people's difficulties with carrying and using condoms.
A survey of 105 young people (mean age, 18.3 years) from Perth, Western Australia, revealed significant obstacles to carrying and using condoms. Respondent were asked to describe their perceptions of what the opposite sex thinks of young women/young men who carry condoms. Although both men and women were concerned that carrying condoms would have a negative effect on their reputation, these fears generally were not matched by the responses of the opposite gender. 45% of men were positive about women carrying condoms, yet only 10% of women thought that men would be supportive; 40% believed that men would consider women who carry condoms "sluts," but only 18% of men had such negative views. Similarly, while only 24% of men believed women would support their carrying condoms, the actual rate was 36%. When asked to describe actual experiences with condom use, 71% reported negative experiences (e.g., condom broke while being put on or fell off during sex, loss of sexual arousal), 32% gave neutral responses, and only 5% were positive. Few respondents had used lubricated condoms. Recommended is the provision of inter-gender information to reduce the misperception that neither males nor females approve of the other sex carrying condoms and to promote the correct use of lubricated condoms.
Use of culture care theory with Baganda women as AIDS caregivers.
In Uganda, where up to 25% of urban residents in the sexually active age group are infected with human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) patients are largely cared for at home by women in their traditional role as family caregivers. To investigate the meanings, patterns, and expressions of care to Baganda women as AIDS caregivers, interviews were conducted with 12 key and 25 general Baganda informants from the rural Masaka/Rakai districts and the semi-urban areas of Kampala. Access to informants was gained through mobile AIDS home care nursing teams. The data analysis, grounded in Leininger's Culture Care Theory, identified six major themes: 1) for Baganda women, culture care means responsibility, love, and comfort derived from their kinship, religious, and cultural values and reinforced by their health beliefs and those of professionals; 2) culture care means survival to help secure a future for the next generation and is reinforced by education and land claims; 3) culture care means continuing on in the face of adversity and burden; 4) AIDS-related morbidity and mortality have created major changes in traditional gender roles; 5) culture care diminishes the void left by the death of a family member from AIDS; and 6) culture care means making the most of life for HIV-positive women. These findings can be used by health workers to provide culturally congruent nursing care to Baganda families affected by AIDS and to facilitate intergenerational care.
The risk factors for human immunodeficiency virus (HIV) infection were compared in a cross-sectional analysis of 370 general nurses, 370 nurse-midwives, and 370 office workers and teachers. Positive HIV tests were obtained from 163 general nurses, 146 nurse-midwives, and 156 office workers/teachers. Office workers and teachers were less knowledgeable about the routes of HIV transmission than nurses and nurse-midwives; only 31% of women in the former group, compared with 43% of those in the latter groups, had adequate knowledge scores. The only significant risk factor for HIV infection among nurse-midwives was blood transfusion (odds ratio (OR) 2.17, 95% confidence interval 1.13-4.14). Among general nurses, significant risk factors included a history of genital ulcers (OR 3.59, 1.30-10.85), history of a sexually transmitted disease after 1980 (OR 5.17, 1.60-15.05), and more than one sexual partner (OR 4.08, 1.54-13.0). Among office workers and teachers, the only significant risk factor was scarification (OR 1.66, 1.07-2.57). The variation in risk factors identified in these three groups suggests a need for HIV prevention interventions tailored to different sectors of the Zambian population.
HIV / AIDS related knowledge, attitudes, and preventive behavior of pregnant Korean women.
A cross-sectional survey of 409 women recruited from six prenatal clinics in Seoul, Korea, in 1993 indicated that Korean women are at risk for heterosexual transmission of human immunodeficiency virus (HIV) as a result of their husband's extramarital sexual encounters. In general, respondents had high knowledge levels regarding the major risk factors for HIV (mean knowledge score of 15.5 out of a maximum possible score of 22) and most reported adoption of at least one behavior that prevents HIV transmission (mean preventive behavior score of 19.4 out of a maximum possible score of 28). Preventive behavior was significantly associated with 12 or more years of education, having an acquaintance with HIV, urban residence, a high HIV-related knowledge score, and personal risk appraisal. Although 16% provided their husbands with condoms for extramarital sex, only 28% of respondents were aware HIV can be transmitted through heterosexual vaginal intercourse. Also alarming were findings that only 18% would continue relationships with friends who became infected and 90% believed children with HIV should not be allowed to attend school with noninfected children; on the other hand, 60% would not cut off a relationship with an infected family member and 45% agreed they would care for that relative until death. Overall, these findings suggest a need for an educational campaign focused on heterosexual transmission of HIV, self-protection, and increased acceptance of unrelated HIV-infected individuals.
Legal, socio-cultural and economic aspects of HIV transmission and prevention in Ghana.
Although policy makers in Ghana have conducted educational campaigns on the modes of transmission of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), insufficient attention has been given to the legal, sociocultural, and economic factors that hinder prevention and control efforts. Traditional medical practitioners, who provide care to 70% of the population, have not been incorporated into the national AIDS program. Women's low socioeconomic status, as well as biological factors and cultural norms, make them especially vulnerable to HIV infection, yet policies and laws have not been enacted to empower women. Moreover, laws that either legalize or ban prostitution fail to take into account the need for vocational and educational skills to make sex workers financially independent. A gag rule on issues related to sexuality has hindered discussion of heterosexual modes of transmission. To attach credibility to AIDS educational messages, influentials such as chiefs and elders should be actively involved. The speed with which the AIDS epidemic can be controlled in Ghana will depend on adoption of safe sex behavior, mobilization of financial and technical support, and mechanisms to assist HIV-infected persons.
Coercive sterilisation: its eugenical underpinnings and current manifestation.
Although the manifestation and implementation of coercive sterilization have changed throughout history, this practice has consistently disproportionately affected poor women, the disabled, and women of color. Sterilization can be considered coercive if an individual cannot legally give informed consent, due to mental incapacity or age, or is deceived or compelled to accept the procedure. Both feminists and eugenicists who pushed for birth control in the late 19th and early 20th centuries in the US, Canada, and the UK shared a racist, classist social ideology. Disguised as a science, eugenics provided support for the view that reproduction by certain groups of women would produce a deterioration in the moral and intellectual fiber of society. Through its exclusive emphasis on sexism, the contemporary feminist movement has ignored race and class oppression. Recent claims of a racial basis of intelligence, beliefs that poverty amelioration depends on the poor limiting their fertility, and proposals for human genetic engineering have created conditions for a resurgence of eugenics. The current practice in Canada of failing to fully inform Aboriginal and disabled women of their options before sterilization and promotion of Norplant implants are examples of continued reproductive abuse. Needed is an international feminist movement that advocates for all women's right to reproductive choice.
Cervical dysplasia treatment: key issues for developing countries.
Financial, technical, and logistical factors have impeded the establishment of effective cervical cancer control programs in many developing countries. Efforts are now underway to strengthen cytology services and identify simple, inexpensive, alternative screening strategies that will improve early detection of cervical intraepithelial neoplasia (CIN). As part of this effort, the Program for Appropriate Technology in Health (PATH) surveyed the CIN treatment practices and preferences of 110 health practitioners from 33 developing countries. The survey revealed widespread reliance on invasive inpatient procedures such as cone biopsy and hysterectomy and a tendency to treat all preinvasive CIN, rather than only high-grade or severe CIN. Simple, low-cost, effective (80-95%) outpatient procedures such as cryotherapy and the loop electrosurgical excision procedure (LEEP) were selected more widely in Asia, the Caribbean, and Latin America than in Africa, but remained underutilized relative to inpatient treatments. In many settings, colposcopes and other basic equipment were not available. Respondents identified hysterectomy, cone biopsy, and LEEP as the most effective treatments of severe dysplasia. Overall, these findings suggest a need for more efficient use of scarce medical resources. Cryotherapy and LEEP, combined with proper follow-up, are particularly appropriate for developing countries in cases where invasive cancer and endocervical involvement have been ruled out.
A review of available case-control and cohort studies suggests a causal association between certain types of human papillomavirus (HPV) and cervical cancer. Case-control studies using highly sensitive polymerase chain reaction-based assays have detected HPV DNA prevalences of 90-94% in women with invasive cervical cancer and odds ratios over 15. Of the 30 types of HPV that infect the uterine cervix, HPV 16 and 18 are associated with the highest proportions (50% and 12%, respectively) of cervical cancers. Prophylactic and therapeutic vaccines are now under development, although their efficacy and safety must be assessed in phase I, II, and III trials, and HPV typing is being integrated into pilot study screening programs in selected developed countries. Until a vaccine is available, HPV testing as a primary screening tool or to support cytologic examination remains the best approach for the control of cervical cancer in developing countries. Although there is no effective treatment once HPV is detected, cytologic surveillance of carriers of high-risk HPV types can be initiated.
Comparison of the cervical cytology test using the PAPNET method and conventional microscopy.
Comparison of cervical smear analyses conducted in Mexican laboratories through conventional microscopy with the results of quality control studies conducted by the National Institute of Epidemiologic Diagnosis and Reference (INDRE) using both conventional and automated (PAPNET) methods revealed an alarming lack of agreement. A total of 10,098 slides prepared by technicians working at state public health laboratories in 28 Mexican states and the federal district were reviewed. Most slides (about 78%) yielded negative results or an inflammatory process; 8-14% indicated mild or moderate cervical dysplasia, and 2-3% revealed severe dysplasia or cervical cancer. The Kappa correlation coefficient for agreement between positive and negative diagnoses made by the states and INDRE was 0.62, near the lower limit, while comparison of diagnoses made by INDRE and PAPNET produced a coefficient of 0.80, near the upper limit. Diagnostic agreement between state laboratories and INDRE was greatest (93%) with slides classified as normal or exhibiting inflammatory changes. Agreement rates were lowest when it was necessary to differentiate degrees of abnormality: unspecified carcinoma (13.3%), invasive carcinoma (51.4%), and moderate dysplasia (63.1%). PAPNET generated substantially more false-negative results than traditional microscopy performed either by INDRE or the states and underestimated the presence of human papillomavirus virus, Candida infection, and trichomoniasis. Inadequate fixing, staining, and mounting of the slides compromised PAPNET analysis. Overall, these findings indicate a need to improve the quality of cervical cytology diagnoses at state laboratories through increased training and supervision.
Predictors of African American adolescents' condom use and HIV risk behavior.
To facilitate identification of factors that place low-income African American adolescents at increased risk of human immunodeficiency virus (HIV), interviews were conducted with 312 youth 12-19 years of age attending a Public Health Service-funded clinic in Mississippi. The analysis was restricted to the 114 sexually active youth in this sample. The full variable set included age, gender, acquired immunodeficiency syndrome (AIDS) knowledge, condom attitude, perceived risk of AIDS, self-efficacy, social provision, church attendance, AIDS Risk Index, and Condom Use Index. Correlations between these variables were small to moderate (0.0 to -0.48). Separate regression analyses revealed significant relationships between the full variable set and the AIDS Risk Index (p < 0.0001) and the Condom Use Index (p < 0.02). Half of the teens reported unprotected intercourse in the preceding 2 months, yet most perceived themselves at low risk for AIDS. Multivariate analyses of variance revealed that variables most predictive of unprotected sex with multiple partners differed from those associated with condom use. Males who reported lower self-efficacy in avoiding AIDS and perceived themselves at greater risk were most likely to engage in high-risk behaviors. Consistent condom users were younger than intermittent and non-users and had more positive attitudes about condoms and higher AIDS knowledge scores. Interventions aimed at Black teens may need to expand beyond condom promotion to include broader media and community-based educational programs.
Multiple sexual partners and condom use among long-distance truck drivers in Thailand.
A 1992 survey of 327 long-distance truck drivers in Thailand revealed a negligible sense of vulnerability to AIDS despite widespread contact with commercial sex workers (CSWs). The study was conducted in Saraburi--the site of three large cement factories. The drivers' median age was 33 years (range, 15-54 years); 83% were currently married. Seven men (2.3% seroprevalence) were infected with HIV. 87% of truck drivers reported encounters with a CSW at some point; for 48%, a CSW was their first partner. In the 6 months preceding the survey, 23% of men currently living with a spouse had contact with a CSW, 13% had sex with a noncommercial partner, and another 8% reported both types of extramarital encounters. 78% of drivers whose first CSW experience occurred before 15 years of age had visited a CSW in the past year compared with 41% of those whose first contact was at 16-18 years and 34.5% of those whose first contact occurred at age 19 years or above. Only 58.5% of truck drivers who reported CSW encounters in the year preceding the study used condoms consistently; 28% claimed occasional use and 14% never used condoms. Only 3% of drivers perceived themselves to be at high risk of HIV infection; 62% claimed to be at no risk. Common were misconceptions about AIDS; for example, 25% felt they could not get HIV from someone who looked healthy.
Recent studies suggest that female pelvic actinomycosis occurs most commonly in IUD users. In such women, actinomycosis is considered to arise as an ascending infection originating in the perineum, or through ano- and orogenital contact. Actinomycotic infections related to IUD use range from mild endometrial inflammation to pelvic inflammatory disease with abscess formation. Most women who develop abscesses have been wearing an IUD for an average of 8 years, suggesting that risk increases with duration of IUD use. Other factors associated with actinomycosis in IUD users include the use of plastic rather than copper devices, lower socioeconomic status, and increased symptoms such as abdominal pain and vaginal discharge. The primary initial treatment should be high-dose penicillin for 6-12 months. The diagnosis of pelvic actinomycosis in an IUD user who presents with abdominal pain or a pelvic mass can be confirmed by aspiration, ultrasound, biopsy of involved tissue, or examination of tissue adhering to a removed IUD. Samples should be examined by standard histologic means, anerobic culture for 2 weeks, and immunofluorescence. Papanicolaou smears have been used for screening purposes; however, failure to detect actinomycosis on Pap smear does not exclude the possibility of an ongoing pelvic process and organisms detected through this means are often clinically insignificant, disappearing without treatment after IUD removal.
Two long-acting hormonal contraceptive options.
Careful acceptor selection and individual counseling can maximize efficacy and patient satisfaction with the long-acting progestin contraceptives Norplant and Depo-Provera. Both methods should be administered within 5-7 days of the onset of menstruation to ensure the patient is not pregnant. Method initiation also can occur immediately after induced abortion or childbirth, with no adverse effect on lactation. Pregnancy rates average 0.8/100 woman-years during 5 years of use for implant users and 0.3/100 woman-years for Depo-Provera. Menstrual changes are the most significant side effect of long-acting progestins. These methods may be especially suited for adolescents who have problems complying with a daily pill regimen and women in whom estrogen use is contraindicated; those with psychiatric problems or mental retardation may also benefit from their convenience. The 14 brief case studies accompanying this review cover concerns such as reduced libido, thromboembolism history, weight gain, anticonvulsant drug use, and uterine fibroids.
A risk-benefit assessment of the levonorgestrel-releasing intrauterine system.
The levonorgestrel-releasing intrauterine system (LNG-IUS) provides fertility control comparable to female sterilization, convenience, and complete reversibility. This method appears to combine the benefits of oral contraception and the IUD, while avoiding most of their side effects. The low level of LNG released (20 mcg every 24 hours) minimizes the systemic adverse effects associated with hormonal contraception. Unlike inert or copper IUDs, the LNG-IUS is associated with a profound reduction in the duration and quantity of menstrual bleeding and alleviates dysmenorrhea. Moreover, there is evidence that the LNG-IUS prevents the endometrial proliferation associated with estradiol therapy and induces regression of endometrial hyperplasia; its potential for regulating the growth of uterine fibroids and preventing pelvic inflammatory disease remains undetermined. Although large multicenter studies have not detected differences in cervical cytology or breast cancer incidence between copper IUD and LNG-IUS users, long-term epidemiological studies are needed to confirm this finding. Fundal positioning of the LNG-IUS is essential to ensure uniform exposure of the endometrium to the progestogen, prevent expulsion, and maximize efficacy. A promising future use for the LNG-IUS is in protecting the endometrium during postmenopausal hormone replacement therapy. Overall, the research suggests that the LNG-IUS comes close to meeting many of the requirements of an ideal contraceptive.
Depot medroxyprogesterone acetate and breast cancer. A review of current knowledge.
Although further epidemiological studies of the long-term effects of depot medroxyprogesterone acetate (DMPA) on breast cancer risk are needed, preliminary research results are reassuring. Pooled analysis of the results of two large case-control studies--the World Health Organization Study (involving women newly diagnosed with breast cancer in 1979-88 in Thailand, Kenya, and Mexico) and the New Zealand Study (comprised of women with breast cancer diagnosed in 1983-87)--has facilitated assessment of this association. Overall, 219 of the 1768 breast cancer cases and 1725 of the 13,905 controls had ever used DMPA (odds ratio, 1.1; 95% confidence interval, 0.97-1.4), with no increase in risk with increasing duration of use. Women under 35 years of age at diagnosis and those initiating DMPA use before 25 years of age had marginally statistically significant increases in breast cancer risk. The highest risks were recorded among women who had initiated DMPA use within 5 years of diagnosis. Risks declined with time since first use in all age categories. After 5 years since last use, DMPA use for more than 2 years was associated with a decreased risk of breast cancer. The raised relative risks in certain subgroups are difficult to interpret and may reflect surveillance bias. Enhanced understanding of the biology of breast cancer will aid interpretation of these results.
To evaluate the lipid and blood chemistry profiles associated with an experimental triphasic contraceptive (35 mcg of ethinyl estradiol and 7 days each of 0.18, 0.125, and 0.25 mg of norgestimate), 39 non-smoking female volunteers were enrolled in a 12-month study. Biochemical determinations of 21 variables were made at baseline and after 3, 6, and 12 months of exposure. There were no significant changes throughout the study period in the complete blood count, hemoglobin, hematocrit, or platelet count. Thyroxine increased, while resin uptake thyroxine 3 and urinary cortisol decreased--a finding consistent with hormonal contraceptive use. Slight increases in cholesterol and triglycerides were recorded, as well as nonsignificant increases in both high-density (HDL) and low-density lipoproteins (LDL). Most significant changes in chemistry profiles occurred in the 14 women with no previous history of oral contraceptive (OC) use. Overall, this low-dose triphasic contraceptive had a less deleterious effect on lipids than biphasic OCs and may provide some cardiovascular protection through its beneficial effect (17% increase) on HDL-cholesterol.
[Crisis and demographic transition in Africa]
The main task of CEPED, the French Center on Population and Development, is to deal with the relations between population and development. The center in this paper questions the nature of the demographic consequences of adjustment policy and reforms in developing countries. There is no doubt that such policies had important social consequences. The dearth of available statistical data, however, makes it difficult and even pointless to try and dissociate the effects of adjustment policies from the economic crises which put them in place. CEPED asked a group of experts to offer their views on to what extent the global economic crisis and the structural adjustment policies effected during the early 1980s affected demographic trends over the long term in sub-Saharan Africa. Whatever effects the economic crisis and the structural adjustment policies had upon the continent will remain to be felt for years to come. Further research is therefore warranted.
Trade Union Reform and Employment Rights Act 1993 [1 July 1993].
This document contains major provisions of the 1993 Trade Union Reform and Employment Rights Act. This Act contains many new and improved individual employment protection rights (many of which bring the UK in line with European Community directives). All pregnant employees have a new right to 14 weeks of maternity leave in addition to the existing right to return to work up to 29 weeks after child-birth. The law also strengthens the protection against dismissal or selection for redundancy on the grounds of pregnancy or child-birth. Additional protections cover sex discrimination in collective agreements.
Slide set for family planning course.
This slide set accompanies a family planning training course consisting of nine workshop modules. The course, which was field-tested in India, was developed to enhance the in-service reproductive health training of nurses/nurse-midwives and physicians in Asia, but is also applicable world-wide. These slides accompany modules one through eight, and the slides for the ninth module are available elsewhere.
Internal migration and urbanization.
This is a general review of contemporary trends in rural-urban migration and urbanization in developing countries. The author examines the reasons for and consequences of the rapid growth of cities in the developing world. Some possible solutions to the resulting problems of overurbanization are presented. (ANNOTATION)
World population growth: trends and prospects, 1960-2020.
"Using mostly United Nations estimates, [the author] outlines salient features of the most recent trends in global population growth and considers the determinants and likely future evolution of these trends. The focus of the discussion is on the six decades centered on 1990. Comments on demographic change in a more remote past and glimpses to more distant demographic futures are also offered to place the period 1960-2020 into a broader perspective....The discussion begins with comments on the demographic transition--a descriptive device that summarizes some common patterns of mortality and fertility that have driven population change over time in the modern era. This is followed by a description of recent regional trends in population growth and its main proximate determinants, mortality and fertility. The concluding sections interpret these trends and consider future population prospects." (EXCERPT)
Evaluation of standard mortality projections for the elderly.
"In this chapter we will discuss how the official population projections, made by governmental agencies, have treated mortality at higher ages, and evaluate how successful they have been in making projections of the future number of elderly people. Attention will be restricted to the experiences in developed countries and, in particular, to the situation in European countries....We first give an overview of the different approaches used in projecting mortality. In the next section, we will review the recent population projections made by the statistical agencies in Western countries, giving particular attention to how the highest age-groups are treated in these projections. We will then evaluate the accuracy of a series of population projections for the elderly population made in developed countries during the period 1950-90." (EXCERPT)
Mortality projections for Japan: a comparison of four methods.
"In this chapter, trends in death-rates for total and cause-specific mortality for Japan are examined in an attempt to forecast the future level and pattern of Japanese mortality. In particular, an attempt is made to answer the following questions: `Will life expectancy continue to rise in Japan, or will it reach an upper limit?' `How will the proportion of the Japanese population that is older than age 65 (or 85) change in the future?' `What causes of death will have the greatest influence on trends in total death rates?'" Particular attention is given to some methodological issues involved in making these mortality projections. (EXCERPT)
Future longevity among the elderly.
Probable future trends in life expectancy among the elderly in Europe are explored using national data on causes of death reported to the World Health Organization for the period 1950-1990. "The projections presented...try to follow an approach which will take into account the possible impact of the new life-styles of more recent cohorts on future mortality levels among the elderly. In particular, to take better account of life-styles and any changes which have occurred, these projections will be made with reference to specific causes of death, selecting those which play a crucial role in determining mortality trends among the elderly." (EXCERPT)
Social support, life satisfaction and survival at older ages.
The authors examine the effects of social support on both life satisfaction and survival at older ages, as well as the relations between life satisfaction and survival, in developed countries in general. The analysis is based on a review of the literature. They then use data from a longitudinal study of people living in the London borough of Hackney to analyze some of the factors associated with survival of the very old. The results are suggestive of a link between social support factors and survival in this elderly population. (ANNOTATION)
Comparative mortality trends among older persons in developed countries.
"The purpose of this chapter is to provide an overview of mortality levels and trends for 33 countries that are considered to be more `developed'....Major differentials by age, sex, and major causes of death are examined. An effort is also made to assess, using decomposition procedures, the relative importance of changes in age- and sex-specific causes of death that account for overall improvements in life expectancy. Although the chapter focuses on mortality and survival at older ages, in order to fully understand these trends it is necessary to place them within the context of changes that have been occurring at younger ages as well. The analyses are based on life-tables that have been prepared using recent World Health Organization (WHO) mortality data, which enable us to examine patterns through the year 1990 for most of the developed countries." (EXCERPT)
International population movements: imbalances and integration.
Global trends in international migration are analyzed in the context of underdevelopment, international inequalities, and the process of growing international political and social integration. The author concludes that developed countries must attempt to manage immigration rather than prohibit it, and to strive for full integration of those immigrants who are admitted. (ANNOTATION)
Some preliminary results from an ongoing survey of centenarians in France are presented. The objectives and methodology of the survey are first described. The characteristics of this population are then analyzed and life tables for centenarians presented. (ANNOTATION)
Strategies to maximize health and functioning and increase life expectancy.
This chapter explores ways to maintain good health and active function in the elderly population in a time of increasing life expectancy and demographic aging. The authors present "a model which represents the effects of nutrition, exercise, and other nontechnical interventions, societal conditions, and the interface of individual physiology and social conditions on functioning and survival. This model can be used to forecast changes in active life expectancy in developing and developed countries." (EXCERPT)
Prospect for extended survival: a critical review of the biological evidence.
The authors present a critical review of the logic behind competing estimates of human longevity in an attempt to establish why there are such large differences in estimates of future human life expectancy. They suggest that the study of longevity is an excellent subject for an interdisciplinary approach involving both biologists and demographers. They conclude that low-mortality countries are approaching the upper limits for life expectancy, and that a law of diminishing returns is likely to prevent further significant gains in longevity. (ANNOTATION)
"In this paper I...seek to contextualise the relationship between gender, education and autonomy within the family [in India], by asking how far familial considerations of feminine propriety, protection of female sexuality, feminine domain and social roles affect women's participation in education, its perceived benefits, the reasons for sending daughters to schools, and the type and amount of education received by women. More specifically, I explore three dimensions of autonomy, namely, husband-wife communication; mother's role in influencing decisions regarding children's education; and the twin issues of daughters' right to property and dowry demand." (EXCERPT)
Formal and informal care: new approaches.
In this chapter, the author reviews the Scandinavian experience in organizing available resources to provide for a growing elderly population. The focus is on care and services, rather than on pensions and other forms of cash transfer to the elderly. (ANNOTATION)
Strategies for the provision of social and health care services for the elderly.
The authors examine the impact of population aging on health and social services with respect to the need to reorganize financing, the types of services required, and the way the services are delivered. (ANNOTATION)
"We argue...that low fertility or mortality [in Kerala, India] cannot be a result of the higher level of autonomy among its women (since that predates the declines in fertility and mortality) unless this autonomy has also been increased by any of the other changes which took place in Kerala during the past 50 years. We therefore need to examine the levels of female autonomy among women in Kerala using a known set of indicators. Our data come from the [1991] Kerala Fertility Survey (KFS)...." (EXCERPT)
Regional variations in female autonomy and fertility and contraception in India.
"This chapter has three distinct objectives. Firstly, I outline an approach to women's autonomy by delineating analytical categories that can be measured in large surveys. Secondly, I present district level data, derived from surveys conducted in two Indian states--Gujarat in Western India and Kerala in South India--to understand whether the degree of female autonomy and gender relations are different in the two regions. Thirdly, I consider fertility and related measures for women enjoying different degrees of autonomy to understand the extent to which autonomy is associated with or can explain regional variations in fertility behaviour." (EXCERPT)
Malnutrition and human development.
Focusing on protein-energy malnutrition, this chapter explores the extent of nutritional deficiencies and their impact on child development around the world. The relationship between nutritional deficiency and poor development among succeeding generations is noted. (ANNOTATION)
The state of children's health in the developing world.
This is a general review of the factors affecting infant and child health and mortality in developing countries, with particular attention given to data for Pakistan. The author considers the negative impact of population growth on child health, the efficacy of breast-feeding in reducing infant mortality, and the link between infant mortality and birthrates. (ANNOTATION)
Disability and functional status among elderly people: cross-national comparisons.
The epidemiology of functional abilities and disabilities of elderly people living in urban areas of various countries around the world is described. Data are from four WHO surveys carried out between 1979 and 1986. Differences in the level of functional ability are analyzed by sex as well as culture. (ANNOTATION)
Trends and differentials in disability-free life expectancy: concepts, methods, and findings.
Some of the problems, concepts, and issues involved in the study of disability-free life expectancy are discussed in this chapter. Attention is given to the differences among total survival, handicap-free survival, disability-free survival, and impairment-free survival. Comparisons are made among selected developed countries with regard to differences in life expectancy and disability-free life expectancy. (ANNOTATION)
The health and survival of the elderly: evidence from the Gothenburg Longitudinal Study.
"This chapter presents research results mainly from a longitudinal study of 70-year-olds in Gothenburg, Sweden. The aim is to illustrate possible answers to some of [the] questions about health and mortality trends in the older Swedish population, as well as to shed light on some of the determinants of and implications for better societal planning for future generations of older people." (EXCERPT)
The impact of the demographic transition on government spending.
"The goal of this research is to determine the impact on government budgets of predicted changes in demographic structure in the United States over the next 90 years....Our basic approach identifies those government programs for which beneficiaries can be distinguished....We calculate the cost to taxpayers of maintaining the 1986 level of age/family-structure-specific payments for each of 22 government programs for which we could identify beneficiaries. We estimate these costs for 1990, and at 20-year intervals from 2000 to 2080. These programs include Social Security, Medicare, Medicaid, education, and a range of income support, welfare, and work-related government programs....In total, the programs we examine account for about 40 percent of all government expenditure. We find that maintaining the benefit levels for each age-specific family type would require quite dramatic increases in the total funds allocated to these programs." (EXCERPT)
This training pamphlet presents a hypothetical scenario in which the director of a family planning (FP) training program was told by the head of her region's largest FP nongovernmental organization (NGO) that clinic assistants who had completed her six-week training program continued to perform some basic tasks incorrectly. The training program director had relied on the high rating given the course by its participants, but now she recognized that the program has no way of evaluating its effect in the field. She decided to have some of the trainers form an impact evaluation team and accompany an NGO supervisor on field trips. The impact evaluation team planned to determine whether the clinic assistants were implementing their training by evaluating specific tasks, such as instrument sterilization and FP counseling. The evaluation would involve preparing evaluation instruments, determining the sample size, conducting visits, collecting data, and analyzing and interpreting findings. Recommendations based on the findings may include strengthening training modules by improving content, methodology, or trainers' skills. In addition, trainee qualifications for the course should be reviewed. If organizational factors rather than inadequate training were found to be affecting performance, recommendations should be made to the NGO to review its systems and procedures or to strengthen its supervision. Agreements for upcoming training courses should indicate which outcomes the training program will and will not be responsible for, a course summary, course logistics, criteria for trainee selection, resources the NGO will provide trainers, and a definition of acceptable results.
Assessing the impact of training on staff performance.
This pretested document was prepared as a management and reference tool for a world-wide audience of family planning (FP) policy-makers, program managers, service managers, and trainers. The report describes a training impact evaluation (TIE) process that helps managers identify and strengthen the links between training and staff performance. Introductory information deals with understanding training evaluation, the various types of training evaluation, and conducting a TIE. The following steps of the TIE process are then described: 1) identifying job performance issues (defining key job-related tasks and choosing indicators/setting standards); 2) collecting data (evaluation techniques and instruments, how to design an effective evaluation instrument, sample definition, and how to plan and organize the data collection process); 3) analyzing the data (tabulation, aggregation, cross-tabulation, and disaggregation); 4) interpreting the data (using a decision-tree); 5) reporting the findings (developing a written report and making an oral presentation); and 6) making changes (responsibilities for acting on recommendations, handling resistance to change, agreeing on a new or revised training course and/or changing organizational procedures or systems, and clarifying expectations for a training event). An example is provided of the process and results of a TIE conducted in the Central Asian Republics. The report ends with a discussion of ways to continue the TIE process, the comments of reviewers about various aspects of the process, and a checklist to use when making a TIE.
To assess the blood coagulation effects of an experimental triphasic contraceptive (35 mcg of ethinyl estradiol and 7 days each of 0.18, 0.215, and 0.25 mg of norgestimate), 39 non-smoking female volunteers were enrolled in a 12-month study. Coagulation variables were determined at baseline and after 3, 6, and 12 months of exposure. The increased risk of thromboembolism associated with some oral contraceptives has been linked to changes in the coagulation cascade. This new formulation produced no changes in overall hemostasis. Slight decreases were recorded in the intrinsic and common pathways of coagulation. There was a marked decrease in fibrinogen, especially in the 14 women with no prior exposure to hormonal contraception, and increases in several vitamin K dependent factors. Protein C antigen, a coagulation inhibitor, was elevated. The continual reduction over 12 months in fibrinogen activity recorded in this study should reduce the potential for fibrin deposition in the vascular system. Moreover, the slight activation of some clotting factors associated with low-dose norgestimate is effectively countered by the protein C increase.
Development of new immunocontraceptives -- industrial perspective.
Immunocontraception represents a promising new frontier for fertility control research and development. Advantages of such an approach include reversibility, lack of effect on the menstrual cycle, and the need for only one or two injections per year. The zona pellucida, a noncellular surrounding of all mammalian eggs, is a potentially feasible target for immunological interference with the fertilization process; however, animal trials have resulted in irreversible oophoritis. Human chorionic gonadotropin (hCG) vaccine has the advantage of attacking a target that is present only during pregnancy, but raises political issues related to abortion. An anti-sperm contraceptive vaccine is another possibility, although sperm antigens that result in a B-cell- rather than T-cell-mediated immune response have not been identified. Anti-trophoblast vaccine represents an alternate strategy, but the problem of mucosal immunity remains an obstacle. If an immunological contraceptive is developed, careful risk-benefit analyses must be performed.
A comparative study of four treatment regimens for women with a history of poor response to controlled ovarian hyperstimulation (COH) during attempts at in vitro fertilization (IVF) and embryo transfer suggested the feasibility of pretreatment with oral contraceptives (OCs). The 60 women enrolled in the study exhibited one or more of the following in an initial stimulated IVF cycle: three or fewer dominant follicles recruited, serum estradiol levels of 300 pg/ml or below, and/or a spontaneous luteinizing hormone (LH) surge prior to oocyte retrieval. Study subjects were assigned to one of four protocols: Group I--OCs for 3 weeks followed by COH; Group II--luteal phase leuprolide acetate with subsequent COH; Group III--short-flare Lupron with subsequent COH; and Group IV--COH alone. COH consisted of 150 IU/day of pure follicle-stimulating hormone (pFSH) and 150 IU/day of human menopausal gonadotropin (hMG). The mean age of women in each group ranged from 36.0 to 38.8 years. There were no significant differences among groups in terms of number of days of stimulation, total ampoules of hMG and pFSH required, peak serum estradiol and progesterone, number of oocytes retrieved and fertilized, and embryos transferred. However, the pregnancy rate was significantly higher (p < 0.05) in Group I (9/30, 30%) than in Group II (2/32, 6%), Group III (0/11, 0%), and Group IV (0/10, 0%). The good outcome associated with OC pretreatment may reflect production or alterations of local ovarian growth factors and/or changes in endometrial expression. Administration of exogenous estrogen may be particularly beneficial for perimenopausal women in their forties with ovarian follicular depletion.
In October 1995, all physicians in the UK were notified by the Chairman of the Committee on Safety of Medicines (CSM) of the substantially increased risk of venous thromboembolism associated with use of third-generation oral contraceptives (OCs) containing desogestrel or gestodene. At the time the CSM contacted physicians, none of the studies substantiating this risk was published; moreover, the CSM advice was reported in the mass media before physicians received their letters, creating considerable anger in the medical profession. Once the studies on which the CSM action was based were available, the British Medical Association concurred with the recommendation. Of concern, however, is the contrast between the UK Medicines Control Agency's regulatory action on grounds of safety against these third-generation OCs and the Department of Health's inertia regarding the even more hazardous risk posed by young women's smoking.
The lives of many adolescent girls are restricted by gender discrimination, poverty, illiteracy, poor nutrition and health care, violence, and premature motherhood. This sourcebook, intended for facilitators and trainers working with girls ages 12-20 years, is based on the principle that girls have the right and can develop the capabilities to make choices about their futures. Essential to choice-making are self-respect and self-esteem development, supportive peer relationships, expanded decision-making and negotiating skills, and access to resources. The 12 modules (48 sessions) in this volume cover the following topics: Me, Myself; Goals and Plans; Our Families; Community; Work; Friends; Marriage, Partnership, and Parenthood; Puberty and Reproduction; Health; Legal Rights; Environment; and Us, Together. Each session is based on an experiential learning model that emphasizes active participation, problem solving, and open expression. Specified for each session are an objective, time needed, activities, materials required, discussion guidelines, and ideas for action. The idea for this project emerged from the Center for Development and Population Activities' Better Life Options Program and was tested extensively in such groups in India, Mexico, Ghana, Nigeria, and Uganda.
Teen sex, AIDS, and contraception: part three [editorial]
The acquired immunodeficiency syndrome (AIDS) pandemic in the US is becoming increasingly similar to the scenario in the Third World, where almost half of all new infections occur in women. In the US, AIDS cases among Black women 25-44 years of age (most of whom became infected as adolescents) now exceed those among White men in the same age group. Although African Americans and Hispanics 13-24 years of age comprise only 27% of the US population, they represent 59% of AIDS cases. Despite findings that long-acting progestogens have a thinning effect on the vaginal epithelium in monkeys, facilitating transmission of simian immunodeficiency virus (SIV), Norplant and Depo-Provera continue to be promoted, especially for inner-city teenagers. Neither contraceptive provides any protection against sexually transmitted diseases (STDs) and may, if the SIV finding is applicable to humans, actually increase the risk of AIDS. Recent shifts in the class and racial background of AIDS patients raise concerns about whether the US government will continue to allocate the requisite resources for inpatient care, drugs, and hospice services. Urged is contraceptive research aimed at the development of a safe, effective method that provides protection against STDs as well as pregnancy.
Investigated, in this retrospective study, was an observation of hospital staff that use of gemeprost in mid-trimester pregnancy terminations was associated with a longer induction-delivery interval when the fetus had been diagnosed with a neural tube defect or hydrocephalus. The records of a consecutive series of 247 women admitted to Western Suburbs Hospital (Waratah, New South Wales) in the second trimester for gemeprost-induced abortion were reviewed and women were divided into three groups according to indication: Group A (n = 24)--fetal death (not from neural tube defect or hydrocephalus) diagnosed by ultrasound; Group B (n = 88)--all chromosomal and structural abnormalities other than neural tube defect and hydrocephalus; and Group C (n = 75)--neural tube defect and/or hydrocephalus diagnosed by ultrasound. The mean induction interval was 11.3 hours in Group A, 19.7 hours in Group B, and 31.7 hours in Group C. The percentages of women with an induction to delivery interval equal to or exceeding 24 hours were 4.8%, 15.9%, and 43.4%, respectively. The proportion of women requiring further surgical intervention was 4% in Group A, 14% in Group B, and 33% in Group C. These findings should be considered when counseling women who request pregnancy termination for fetal abnormalities. It was hypothesized that fetuses with a neural tube defect or hydrocephalus have a deficiency of the hypothalamic-pituitary-adrenal axis, resulting in decreased corticotrophin-releasing hormone release and difficulty initiating parturition. Use of RU-486, in addition to gemeprost or extra-amniotic prostaglandin, may be indicated in such cases.
Overdose and termination of pregnancy: an important association?
A retrospective review of the records of 1359 female patients 15-39 years of age registered with a general practice in the UK revealed an association between deliberate self-harm and induced abortion. 163 (12%) of these women had undergone pregnancy termination, primarily at age 19 years or younger, and 47 (3.5%) had a history of deliberate overdose; 15 women had a history of both of these events, generally within 2 years of each other. The association between induced abortion and overdose was significant (p < 0.01). Although abortions were more likely to follow than precede overdoses, this trend was not significant. It was speculated that both events are related to similar psychosocial factors, including socioeconomic deprivation and self-destructiveness. If this association is confirmed in larger studies, methods to identify women at risk should be explored.
Lessons from the Dutch abortion experience.
Not only does the Netherlands have the lowest induced abortion rate in the world, but Dutch youth have the lowest rates of both adolescent pregnancy and abortion. This record is attributed to a general stance of openness and acceptance of sexuality as a healthy part of life that emerged in 1965-75 in response to recognition of the public health impact of unwanted pregnancy. Modern contraceptives (excluding condoms) are provided at no charge by the national health service and are easily accessible to teenagers. Sex education, which begins at an early age, seeks to instill skills that enhance partner communication and negotiation. By the late 1980s, unplanned births represented only 6% of all first births. In 1992, 38% of Dutch women terminated their first pregnancy compared with 47% in the US; that same year, the Dutch adolescent pregnancy rate was 9.2/1000 women 15-19 years old compared with 95.9/1000 in the US. In 1995, 85% of Dutch youth used contraception at first intercourse (46% condom, 13% pill, 24% pill and condom, and 1% other method). Overall, the Dutch experience suggests that a less ambivalent public approach to sexuality might encourage more responsible reproductive behavior in the US.
Bellagio Consensus Meeting: a model for health policy development.
The Bellagio Consensus Meeting on the use of breast feeding as a family planning method represents a useful model for health policy development. The 1988 meeting, organized by Family Health International and attended by 25 researchers from around the world, aimed to obtain agreement on the level of protection from pregnancy conferred by lactational amenorrhea. The meeting resulted in consensus on the following statement: "During full or nearly full breast feeding as long as the mother remains in amenorrhea, then for up to a full 6 months, she will have 98% protection from pregnancy." Elements considered key to the consensus process included a single objective, good rapport among participants, a spirit of cooperation rather than competition, intensive pre-meeting preparation (required readings), and endorsement by influential organizations such as the US Agency for International Development and the World Health Organization. The consensus has been widely disseminated in the medical and scientific literature and presented to international family planning conferences. Moreover, numerous publications have set forth detailed guidelines for translating the consensus statement into policy change and program implementation.
Indicative of increased interest in breast feeding promotion on the part of the international donor community, United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) co-sponsored the first meeting of the Interagency Group for Action on Breast Feeding. This 1987 gathering was followed by an interagency needs assessment, establishment by WHO of an international data bank, and identification of successful breast feeding promotion programs. The long-term goal, however, is to influence high-level policy makers to support the goal of empowering all women to exclusively breast feed for 4-6 months and continue supplemented breast feeding well into the second year of life. One of the most effective ways to promote support of breast feeding is to convince governments that this practice decreases the incidence of diarrheal and respiratory disease and increases child spacing, thereby reducing infant mortality. A review of the efforts of selected countries to reverse declining trends of breast feeding initiation and duration is underway, and health care worker training programs are being developed. Two WHO-UNICEF publications--a Joint Statement on the role of health services and "Ten Steps to Successful Breast Feeding"--are facilitating implementation of breast feeding promotion activities.
Evolution of policy related to breastfeeding at the Agency for International Development (A.I.D.).
Breast feeding promotion in developing countries has been hindered by the absence of formal, explicit breast feeding policies and a lack of accurate knowledge on the part of health professionals. In response to these concerns, the US Agency for International Development (USAID) has strengthened country-specific breast feeding efforts in its sectors concerned with fertility, health, and nutritional status. All three sectors share the goals of optimizing child survival, maternal health, and promotion of the contraceptive effects of breast feeding. The USAID Child Survival Strategy incorporates breast feeding interventions into the control of diarrheal disease, malnutrition, and inadequate birth spacing through supportive birthing and hospital practices, improved information and support for health personnel and lactating mothers, integration of oral rehydration and breast feeding promotion, promotion of breast feeding in family planning programs, community support, and legislative and policy initiatives. Of the 72 long-term USAID-supported breast feeding projects in 30 countries, 47% are being implemented by local private voluntary organizations and 16 are national in scope. Current goals include evaluation of the quality and impact of USAID-assisted projects in this area, strengthening of existing field and centrally funded projects that address or have the potential to address breast feeding, and formulation of a BREASTECH project.
The Institute for International Studies in Natural Family Planning (IISNFP), based in the Department of Obstetrics and Gynecology at Georgetown University, has reformulated its breast feeding strategy to focus on three areas: policy change, health care provider development, and provider support for introduction of the lactational amenorrhea method derived from the Bellagio Consensus Statement. IISNFP is collaborating with other universities and research organizations to demonstrate the feasibility and efficacy of breast feeding interventions and develop curricula for health professionals. In addition, IISNFP distributes Institute Issues Reports aimed at policy and program decision makers and is collaborating with the IMPACT program to produce a booklet for policy makers entitled "Breast Feeding: Protecting a Natural Resource." Finally, through its role as Technical Secretariat to the Interagency Group for Action on Breast Feeding, the Institute is helping to forge an international breast feeding strategy for the 1990s and to develop a definitional schema that differentiates between levels of full and partial breast feeding.
Private voluntary organizations and breastfeeding policies.
Private voluntary organizations can influence breast feeding policies through their roles in education of Congress, support for and evaluation of breast feeding promotion projects, research on the determinants and consequences of breast feeding, and information dissemination about successful programs. Until policy makers accept breast feeding as an essential component of child survival and primary health care programs, interventions in this area will remain underfunded. Crucial is the dissemination of information to policy makers documenting that breast feeding programs save lives, are cost-effective, and can be successfully implemented. The Center to Prevent Childhood Malnutrition has estimated that breast feeding promotion can save 7-10 million lives each year through its prevention of malnutrition, diarrhea, and acute respiratory infections.
Reproductive preferences and fertility trends in post-transition Thailand.
Estimations, based primarily on the 1990 census, that Thailand's total fertility rate fell below replacement level in the late 1980s sparked alarm about extinction of the Thai race and calls to abandon public subsidies for family planning. Recent low total fertility is considered a temporary phenomenon, however, related to the rapid rise in age at marriage and first birth. Birth registration data suggest that the fertility decline levelled off, probably close to replacement level, during the first half of the 1990s and fertility is unlikely to fall below two children. Although the 1988 and 1993 Social Attitudes Toward Children Surveys documented a consistent trend toward declining family size preferences (64% of 1993 respondents, and 74% of women under 30 years of age, stated a preference for two children), only 5% desired fewer than two children. This lower limit of two children prevailed across regional, educational, and socioeconomic categories and appears to reflect a desire to have a child of each sex. In 1993, three-quarters of married women under 30 years of age expressed a preference for one son and one daughter. Despite this preference, Thai couples who fail to achieve this goal generally subordinate gender ideals to the prevailing preferred limit of two children. Although the Thai Government has succeeded in exhorting couples to reduce their family size, any abandonment of subsidized family planning programs could have a deleterious impact on poor families in rural areas.
A community-based investigation of avoidable factors for maternal mortality in Zimbabwe.
A community-based survey of maternal deaths in a rural province (Masvingo) and urban area (Harare) of Zimbabwe in 1989-90 revealed a high incidence of avoidable factors, both within and outside the health sector. During the 2-year study period, 109 maternal deaths were identified in Masvingo (168/100,000 live births) and 66 in Harare (85/100,000 live births). In Masvingo, the three leading causes of death were hemorrhage (25%), postabortion sepsis (15%), and puerperal sepsis (13%); in Harare, these causes were eclampsia (26%), postabortion sepsis (23%), and puerperal sepsis (15%). In Masvingo, the locations of maternal deaths included rural hospitals (50%), provincial hospitals (13%), home (13%), and travelling to or between health facilities (11%); all deaths in Harare occurred in central hospitals. One or more avoidable factors were identified for 90% of maternal deaths in Masvingo and 85% of those in Harare; these factors occurred at the community level in 47% and 38% of deaths, respectively. Among patient-related factors, delay in the decision to seek care for symptoms was most widespread (32% of deaths in Masvingo and 28% of those in Harare). Problems of access to transportation from home to health facility were implicated in 28% of deaths in Masvingo and 3% in Harare. Avoidable factors within the health sector were identifiable in 67% of Masvingo deaths and in 70% of Harare deaths. Notable was failure of health personnel to assess the severity of postabortion conditions and puerperal sepsis and initiate aggressive treatment. Recommended, to reduce maternal mortality in Zimbabwe, are community awareness of risk factors for pregnancy and delivery, collective emergency transportation mechanisms, maternity waiting shelters, appropriate obstetric management protocols, more effective identification and treatment of emergency conditions, and liberalization of existing abortion legislation.
This review of women's rights related to marriage, divorce, property, inheritance, child custody, evidence, and rewards and punishments as set forth in both the Quran and Islamic Law indicates that Islam fundamentalists have seriously misrepresented the spirit of these texts. Current claims of male superiority in Indian society are sociological rather than theological in origin. The Quran makes it clear that women are not to be treated as adjuncts to their fathers, husbands, or brothers. Although the Quran concedes a degree of superiority to men in their social context, it awards equal status to both sexes in the normative sense. It states that a man should maintain his wife and, in return, the wife must look after the children; there is no prohibition of a woman's right to work. The Quran never intended to place restrictions on women's movements or to require them to completely hide their faces while out of the home. Many current interpretations were formulated in the first century of Islam, when women were viewed strictly for their procreative function. Changed socioeconomic circumstances call for adoption of a common civil code to eliminate religious discrimination in laws related to women's status. An appendix contrasts marriage and divorce laws among Muslims, Christians, and Parsis.
This book compares the status of Muslim women in India according to Islamic law and in contemporary life (as revealed by survey data from the National Seminars). A review of the Holy Quran and the Traditions (sayings by the Prophet) suggests that current religious leaders have deviated from the principle of equality between the sexes outlined in these ancient writings. The Quran has been misinterpreted by Islamic fundamentalists to justify the imposition of restrictions on women's rights and freedom. In fact, the rise of Islam was associated with encouragement of women to participate in building up the social life of the Muslim community. Islamic conservatism has led many women to adopt permissive Western ideals, to the detriment of family honor and public decency. To close the gap between the Quran and reality, the government of India must fulfill its constitutional obligation to provide free and compulsory primary and middle education to all boys and girls; the Muslim minority should be given special funds to start its own schools for the education of Muslim girls; Muslim philanthropies should prepare books for teaching religious education at all levels; and modern education in areas such as the social sciences, medicine, and business management should be promoted to prepare Muslim women to participate effectively in development.
A critical review of sexual and reproductive health.
The 1990s marked a shift from family planning programs primarily intent on achieving fertility decline to a broader sexual and reproductive health approach to service delivery. At the 1994 International Conference on Population and Development, reproductive health was conceptualized as the capability to have a safe and satisfying sex life and to reproduce under conditions of personal freedom. Implementation of this approach requires family planning and health administrators to plan cost-effective, available, integrated programs of high quality tailored to the specific needs of diverse clients in different settings. Central is awareness of reproductive health as a gender issue. Gender- based inequalities create unwanted pregnancies, unmet needs for contraception, lack of access to prenatal care, higher risks of maternal mortality and sexually transmitted diseases, and female genital mutilation. Implementation of a reproductive health care approach has been hindered by a lack of clarity on issues such as whether sectors outside of health and family planning should be involved, top down versus participatory administrative structures, selection of the most feasible interventions, and the role of cost- benefit analysis in determining priorities; other obstacles include a lack of empirical research on reproductive health and of indicators that can serve as outcome measures for program evaluation. The few studies that do exist (reported in an annotated bibliography) suggest that community-based approaches are most effective when they involve both men and women in defining problems and identifying action strategies.
A critical review of structural adjustment and increasing women's economic participation.
Structural adjustment and stabilization programs, implemented after the worldwide economic crisis of the 1980s, have had a generally negative effect on women's role in economic development in the Third World. Recommended instead, for the poorer segments of the population, is a market-oriented strategy that improves access to employment opportunities and assets while raising the productivity of these assets. This article evaluates the results of projects in the agricultural and informal sectors aimed at promoting women's economic participation; an annotated bibliography is appended. In general, these projects have been hindered by failure to involve women at the beginning of the planning process and isolation of such projects from mainstream development activities and the broader macroeconomic environment. In the agricultural sector, attention should shift from developing employment opportunities or alternative income-generating activities for women to bringing more resources under the control of women to augment agricultural productivity. Also recommended are dissemination of information on mainstream agriculture, improved access to resources such as land and credit, increased productivity and marketing, child care provision, and enhanced water and fuel wood supply. A shift is essential from a women-in-development strategy focused on women's activities to a gender-and-development approach that strives for mainstreaming.
A critical review of women's status and rights.
Although a dismantling of the inequalities that subordinate women and prevent them from realizing their potential is essential to social progress, the benefits to society of a balanced approach to undoing injustice must be recognized as well. Contextual differences in women's positions relative to both men and women of other social classes and ethnic groups hinder global efforts to promote women's human rights. A key policy issue relates to how to bring about equal participation of men and women in the mainstream of development without resorting to separatist strategies (e.g., women's bureaus) that perpetuate the marginalization of women. Emerging is a less gender-segregated approach to gender inequalities that identifies strategies for involving men, both separately and with women. Given men's power, gender planning must be as explicit about men's interests as it is about women's interests, and it must address both gender conflicts and gender complementarities. Social planners are urged to find contextualized win-win solutions to gender inequalities that are perceived by both men and women as being in their combined interest. Appended to this review is an annotated bibliography of research on interventions aimed at improving women's status.
Although international donor agencies place an emphasis on infectious diseases, problems caused by reproductive tract infections (RTIs) during pregnancy are not only at least as serious as those caused by immunizable diseases, but interventions are often more cost-effective. To avert one case of gonorrhea and to avert one adverse outcome associated with syphilis during pregnancy would cost about US $1.40 and $12,00, respectively, compared with $40-150 to prevent an immunizable disease. In a typical developing country, an intervention for gonorrhea would cost about $65,000 for 1 million births and would avert 47,000 cases of gonorrhea. An intervention to test and treat for syphilis during pregnancy would cost about $900,000 for 1.5 million pregnancies and avert 75,000 adverse outcomes. Urged is a reallocation of resources toward RTIs and research into the most cost-effective approaches to syphilis, gonorrhea, chlamydia, herpes. In addition, research aimed at one or more specific organisms should be conducted to assess the efficacy of antibiotic treatment and the role of genital infections in ascending intrapartum infections and prematurity. A simulation model should be developed that could be used to estimate the effects of different prevention strategies on pregnancy outcome and child survival.
Economic impact of reproductive tract infections and resources for their control.
The economic costs associated with reproductive tract infections (RTIs) and their complications and sequelae in developing countries are substantial. Direct costs include the costs of diagnosing and treating the disease and preventing its spread, while indirect costs include the value of labor lost from morbidity, debility, and premature mortality, as well as the value of any labor diverted from other productive uses to care for the ill. The current lack of data on these economic consequences has contributed to the implementation of and allocation of funds for interventions in this area. Recommended, to better estimate the resources needed for RTI prevention and control, are the following: 1) development of strategies and priorities for RTI control, as well as a plan of action, by an ad hoc group of donors, women's health advocates, and health system specialists; 2) sensitizing of policy makers in governments, donor agencies, and RTI-related programs to RTIs and both a health and development issue; 3) immediate incorporation of selected interventions for RTI control into primary health care, family planning, maternal-child health, safe motherhood, and AIDS control programs; 4) development and evaluation of biomedical, behavioral, and societal interventions for RTI control and treatment in the developing world and an assessment of their cost- effectiveness; and 5) support of intervention-oriented research and the development of female preventive technology.
Previous studies have demonstrated the efficacy, in mice, of synthetic peptides derived from zona pellucida (ZP) glycoprotein in blocking fertility without ovarian dysfunction. This study used bonnet monkeys (closely related to humans in the primate evolutionary tree and less susceptible to summer amenorrhea than rhesus monkeys) to explore the design of an immunocontraceptive vaccine based on synthetic peptides, recombinant glycoproteins, or proteins corresponding to ZP. Immunization of female monkeys with pig ZP3 glycoprotein using adjuvants permissible for human use produced infertility. Although only half the animals conceived after antibody titres declined, monkeys that failed to conceive did not show any obvious ovarian changes. Mapping of the epitopes recognized by monoclonal antibodies against ZP3 alpha and beta and possessing contraceptive efficacy in vitro identified an N-blocked decapeptide from the N-terminus corresponding to 23-32 amino acids of the precursor protein of pig ZP3 beta. When DNA encoding bonnet monkey ZP3 was cloned and sequenced, the deduced primary amino acid sequence showed a 93.9% similarity with human ZP3. Bonnet monkey ZP3 corresponding to an internal 975 nucleotide fragment excluding the N-terminus signal sequence and the C-terminus transmembrane domain has been expressed in Escherichia coli.
Evaluation of zona pellucida antigens as potential candidates for immunocontraception.
Antibodies directed against the zona pellucida (ZP) have been demonstrated to interrupt sperm-egg recognition in vitro, yet the mechanisms by which anti-zona antibodies exert this contraceptive effect in vivo are unclear. Emerging evidence suggests that active immunity against zona antigens both induces infertility through an antibody-mediated interruption of sperm-egg interaction and disrupts normal ovarian function. This study used the marmoset monkey to assess the consequences of inducing active immunity against purified recombinant human ZP3 and human ZP3 peptides. Although recombinant human ZP3 induced infertility in these animals, it was associated with suppression of folliculogenesis and depletion of the primordial follicle pool. Immunization with continuous human ZP3 peptides, identified by epitope mapping studies, did not induce ovarian dysfunction, but the antibody titers were insufficient to suppress fertility significantly and consistently. Future homologous active immunization trials will depend on generation of epitope maps of the marmoset ZP3 sequence.
Working women and health problems. Identity of a nurse.
Working women in India are forced to perform dual roles, wage earner and household manager, to the detriment of their health. Depending on their profession, working women may face stresses such as shift work (including night duties), transportation problems, frequent job transfers, and lack of child care near the workplace. That they are unable to be fully attentive to the physical and mental development of their children can cause considerable distress. Women's labor force participation has been linked to emotional depression, chronic fatigue, malnutrition, high blood pressure, adverse pregnancy outcomes, and musculoskeletal disorders. The burden of ill health associated with women's employment in India impedes both family life and national development. Nurses are promoting community services in the areas of immunization, nutrition, and family planning. Recommended is extension of the Maternity Benefits Act to one year to enable working women to regain their health after pregnancy. The goals of health for all, universal literacy, and poverty elimination can be achieved only if women's health concerns become a priority.
Epidemiology of syphilis in pregnancy in rural South Africa: opportunities for control.
A case-control study involving 200 pregnant South African women indicates that maternal syphilis infection has a substantial impact on pregnancy outcome. The first 50 women diagnosed with syphilis at booking for antenatal care in Hlabisa Health District in KwaZulu/Natal served as cases; 3 women who tested negative for syphilis and who presented for antenatal care at the same time and to the same clinic as each case served as controls. The overall prevalence of syphilis in the 7723 women booked for antenatal care at district clinics in 1994 was 6.5%. Multiple logistic analysis identified 2 independent risk factors for maternal syphilis: gravidity 3-5 (odds ratio (OR) 2.3, 95% confidence interval (CI) 0.9-5.8 when compared to gravidity 2 or less and OR 3.2, 95% CI 1.0-10.3 when compared to gravidity 6 or more) and previous perinatal death (OR 3.1, 95% CI 1.0-8.8). 6 of the 8 perinatal deaths (4 early neonatal deaths and 4 stillbirths) in this study involved women with syphilis; all 4 of the stillbirths were to cases. The OR for an adverse pregnancy outcome in women with syphilis was 11.8 (95% CI 2.0-67.4). Only 22 women with syphilis received all 3 recommended doses of penicillin. Women who had 0-1 dose of penicillin had a greater risk of perinatal death than those who received 2-3 doses (OR 19.4, 95% CI 1.7-944.6). On-site screening for syphilis and immediate initiation of penicillin treatment could have a substantial impact on pregnancy outcomes in this district.
The sensitivity and specificity of reproductive morbidity data (obtained, first, through questionnaires administered by female lay interviewers and, 1-2 weeks later, through physician interviews, physical examination, and laboratory tests) were compared in a cross-sectional study conducted in Istanbul, Turkey. The 696 female respondents were sampled from a clinic-based community register. The presence or absence of 5 morbidities (reproductive tract infection (RTI), urinary tract infection (UTI), menstrual disorders, pelvic relaxation, and anemia) was determined by algorithms. The prevalence of medically diagnosed morbidities was 7% for UTI, 16% for menstrual disorders, 20% for RTI, 27% for pelvic relaxation, and 33% for anemia. Except for anemia, questionnaire replies were more specific than sensitive in detecting morbidity, presumably due to acceptance of many of these conditions as normal. Specificity was 93% for home reports of menstrual disorders, 95.7% for pelvic relaxation, 81.2% for RTI (abnormal discharge and pain), 80.7% for UTI, and 41.7%% for anemia. The corresponding sensitivity rates were 45.4%, 17.3%, 49.3%, 17.3%, and 58.3%. Reliability between the interviews was highest for pelvic relaxation (66.1%) and lowest for menstrual disorders (39.9%). Perceived symptoms of ill health were reported more frequently to physicians than to lay interviewers. Overall, these findings suggest that questionnaire-based information is useful for assessing perceptions of ill health, but it has limited utility for identifying medically defined conditions.
In a comparative study designed to investigate the effect of cervical anesthesia on the perception of pain during IUD insertion, 102 women presenting for IUD insertion at a community family planning clinic in Leeds, England, were randomly assigned to 1 of 3 groups: A, no pretreatment, B, pretreatment with 2% lignocaine gel (Instillagel) applied to the cervical canal, and C, pretreatment with an inert gel. Pain scores for women in groups A and C combined were significantly higher (p < 0.025) than those in group B. The percentages of women reporting the most intense pain (scores of 5-7 on a 7-point scale) were 26.3% in group A, 18.2% in group B, and 35.0% in group C. There were no significant differences in pain perception between nulliparous and parous women overall or by group. Postinsertion symptoms attributable to cervical stimulation (e.g., pallor, lightheadedness, transient brachycardia) were noted in 9 of 58 women (15.5%) in groups A and C combined, but in only 2 of 44 women (4.6%) in group B. These results suggest that the Instillagel system has potential for reducing the pain and discomfort experienced by IUD acceptors at insertion. Recommended, however, are additional studies to determine whether a greater analgesic effect could be obtained from a longer delay between gel installation and insertion and to compare this method with paracervical infiltration.
Postnatal contraceptive advice -- midwives' attitudes.
A survey conducted among midwives working in the Maternity Unit of Billinge Hospital (UK) assessed the postnatal family planning counseling provided by these health workers. All 67 respondents indicated they discussed contraception with their clients before discharge from the hospital; 75% directed their clients to family planning clinics, 64% referred them to their family practitioners, and 37% provided leaflets listing family planning clinics in the area. Although 52% of midwives presented all contraceptive methods, 37% discussed only those methods with which they were familiar (e.g., barrier methods, the pill, and Depo-Provera). 96% of midwives perceived themselves as the most suitable professional to provide such counseling due to their established relationship with their clients. The immediate postpartum period was identified by 79% as the most appropriate time for this service. The effectiveness of midwives in this role would be facilitated by both further training in the range of contraceptive methods and the availability of initial contraceptive supplies.
Human immunodeficiency virus transmission and oral contraceptives [letter]
A recently published study by Plourde et al of 600 women attending a sexually transmitted disease clinic in Nairobi, Kenya, identified oral contraceptives (OCs) as a significant risk factor in human immunodeficiency virus (HIV) infection. The odds ratio of HIV for women using OCs for 12 or more months was 1.9 (95% confidence interval, 1.04-3.6) compared to OC use for under 12 months when adjusted for number of lifetime sexual partners and 1.9 (95% confidence interval, 1.05-3.6) when adjusted for condom use. This analysis is flawed, however, by the inclusion of women with no history of OC use in the < 12 months of OC use group. Also suggestive of methodological bias is the finding of an odds ratio for condom use (adjusted for OC use) of 3.02 (95% confidence interval, 1.6-5.6). The high correlation among OC use, condom use, prostitution, and genital ulcers present in this study creates potential for bias and misclassification. The finding of another case-control study that OC use confers a 60% reduction in HIV risk suggests a need for further research in this area before OCs are designated a risk factor for HIV.
Human immunodeficiency virus transmission and oral contraceptives. Reply [letter]
The authors, in this reply to Nicolosi's letter to the editor, concur with his identification of potential sources of bias inherent in their study of oral contraceptives (OCs) as a risk factor in human immunodeficiency virus (HIV), and they urge cautious interpretation of their findings. The high correlation noted by Nicolosi of HIV with condom use was entirely due to the behavior of prostitutes. When prostitutes were excluded from the analysis, this correlation disappeared. Although further HIV transmission studies are needed to assess factors such as the impact of duration of OC use, it is likely that OCs strongly interact with sexually transmitted diseases such as genital ulcers, facilitating heterosexual HIV transmission. Since OCs are not effective in the control of sexually transmitted diseases, family planning programs should promote concurrent use of a barrier method.
HIV and commercial sex in Cambodia.
Population shifts, socioeconomic change, and an influx of foreign business and tourism are stimulating an increase in commercial sex activity in Cambodia and the rapid spread of human immunodeficiency virus (HIV). HIV seropositivity rates are over 40% among commercial sex workers in the country's western provinces and seaports; nationally, this rate is 33%. In this culture, commercial sex is sanctioned as an essential part of the male experience; 60-70% of Cambodian men are estimated to visit prostitutes. Most commercial sex workers are young, uneducated, unskilled, and have limited economic opportunities. Government- sponsored programs aimed at shutting down brothels or registering commercial sex workers have been ineffective, pushing the industry underground and deterring visits to government sexually transmitted disease clinics. Most effective are programs that gain the support and participation of the communities they serve. Local and international voluntary agencies are working with brothel-based prostitutes to provide condoms and acquired immunodeficiency syndrome (AIDS) education. However, even if commercial sex workers are motivated to use condoms, fear of abuse by brothel owners or offers of more money by clients obstruct their decision making power. Recommended is the social marketing of condoms for family planning purposes in order to reduce their association with illicit sex.
An evaluation of dipstick-dot immunoassay in the detection of antibodies to HIV-1 and 2 in Zimbabwe.
The Program for Appropriate Technology in Health has developed a simple, inexpensive dipstick enzyme-linked immunosorbent assay (ELISA) to detect antibodies to human immunodeficiency virus (HIV)- 1 and 2 that requires no specialized washing or reading equipment. To evaluate the reliability of this test under local conditions, stored sera from a factory worker cohort of blood donors in Zimbabwe were tested. Before storage, the sera had been tested by Abbott recombinant peptide HIV-1 and 2 ELISA and Enzygnost synthetic peptide HIV-1 and 2 ELISA. Thawed sera were tested concurrently with the Abbott method and the synthetic peptide dipstick assay (ICLD). The 546 sera were classified into 3 groups: 266 true negatives (defined as negative by all 3 ELISAs); 250 true positives; and 30 problematic sera (discrepant results between the 2 pre-storage ELISAs). When compared with the concurrently run ELISA, the overall accuracy of the ICLD was >98% Both the sensitivity and specificity of the ICLD were 99.6% when using sera that were true positives or negatives. When discordant sera were analyzed, the ICLD concurred with findings of Western blot and p24 antigen detection. The cost of the ICL Dipstick is less than US $2.00, compared to $3-3.50 for conventional ELISAs. The accuracy, low cost, and ease of operation of the ICLD suggests that this test has an important role in detecting HIV antibodies at a district level in developing countries.
HIV infection and vaginal douching in Central Africa.
Previous research has suggested that frequent vaginal douching modifies vaginal flora and increases the risk of cervical infections -- a probable risk factor for human immunodeficiency virus (HIV). To assess the association between HIV infection and vaginal douching, 397 women attending a sexually transmitted disease clinic in Bangui, Central African Republic, during 1994-95 were interviewed regarding their sexual behavior and vaginal douching practices in the preceding 3 years. The overall HIV prevalence rate was 34%. Douching, primarily for hygiene or treatment of a vaginal discharge, was reported by 195 women (49%); its mean weekly frequency was 7 times. A commercial antiseptic was used by 140 women (72%); 48 (25%) used a noncommercial preparation (largely herbs) and 7 (3%) used water. The analysis was restricted to women who used commercial or noncommercial preparations at least once a week (104 and 32 women, respectively). 25 (21.7%) of the 115 HIV-positive women reported use of commercial antiseptics compared with 79 (35.4%) of seronegative women (odds ratio, 0.6; 95% confidence interval, 0.4-0.9 after adjustment for condom use, lifetime number of sexual partners, and marital status). Use of noncommercial preparations was reported by 17 (14.8%) seropositive and 15 (6.7%) seronegative women (adjusted odds ratio, 1.7; 95% confidence interval, l.0-3.0). Although these findings should be considered preliminary, it is speculated that the antifungal and bacteriostatic properties of commercial antiseptics used after sexual intercourse may reduce the inoculum of HIV through a flushing mechanism or reduce the frequency of sexually transmitted diseases that serve as co-factors for HIV infection. Moreover, the agents used in noncommercial preparations may irritate vaginal mucosa, enhancing HIV transmission.
Adherence to tuberculosis preventive therapy among HIV-infected persons in Chiang Rai, Thailand.
A prospective study of 412 men and women infected with human immunodeficiency virus (HIV) who were enrolled in a hospital-based tuberculosis prevention program in Chiang Rai, Thailand, identified factors that contribute to non-adherence. Program participants were provided a 9-month supply of isoniazid, which has been shown to be effective in reducing the risk of developing clinical tuberculosis among asymptomatic HIV-infected individuals. Of the 412 individuals enrolled in the program, 286 (69.4%) completed the treatment regimen, 109 (26.5%) defaulted by failing to take the medicine for more than 60 consecutive days, and 17 (4.1%) developed acquired immunodeficiency syndrome (AIDS) or died. Among defaulters, 20 restarted the regimen and eventually complied with treatment, raising the completion rate to 74.3%. Married people, women, outpatients, surviving spouses, the self-employed, and those with no history of physical symptoms were more likely to be adherent. The primary reasons for default included outmigration for job search, denial of HIV status, perceived drug side effects, and confusion about the duration of treatment. Although this study suggests that good adherence to a tuberculosis prevention regime is possible among HIV patients, it highlights factors that should be considered (especially migration potential) in the selection of participants.
HIV-1 infection among female commercial sex workers in rural Thailand.
A retrospective study of 821 commercial sex workers attending a sexually transmitted disease (STD) clinic in northern Thailand's Chiang Rai Province from 1989 to 1993 revealed an explosive epidemic of human immunodeficiency virus (HIV). The overall seroprevalence among the 556 women for whom antibody tests were available was 52.3%. However, a dramatic increase in HIV-1 seroprevalence occurred from 1989 (29.3%) to 1990 (54.1%), followed by a leveling off through 1993. Among the 96 (36.2%) initial seronegatives who underwent subsequent testing, 64 seroconverted over a mean follow-up period of 5.9 months, yielding an incidence rate of 12.6/100 person-months. Incidence increased from 12.0/100 person-months in 1989 and 1990 to 17.0/100 person-months for 1991, and then declined to 9.3/100 person-months in 1992-93. The cumulative risk of seroconversion was 57% at 6 months after initial testing and 77% after 12 months. Diagnosis of chancroid during follow up was the only factor significantly associated with seroconversion. Although the retrospective nature of this study limits analysis of predictors of HIV infection in this population, the findings suggest a need for improved STD management.
An association between HIV-1 subtypes and mode of transmission in Cape Town, South Africa.
Investigations of the genetic heterogeneity of human immunodeficiency virus (HIV) -1 are important both to monitor the spread of the virus to new population groups and to the development of vaccines the efficacy of which could be influenced by virus variations. This study analyzed serum samples from 61 HIV-1 infected individuals recruited from clinics in Cape Town, South Afr