A number of studies have shown that glucose tolerance declines with decreasing birth weight and that people with low birth weight and high body mass index (BMI) as adults are at the highest risk of developing type II (non-insulin-dependent) diabetes mellitus. The authors explored the relation between glucose tolerance and birth weight in a group of 7-year old Black South Africans for whom longitudinal anthropometric data were available. Oral glucose tolerance tests (OGTTs) were conducted on 152 subjects and inverse correlations were found between birth weight and the total amount of insulin secreted during the first 30 minutes and last 90 minutes of the oral glucose tolerance test, and also between birth weight and the 30 minute glucose concentrations. Children born with low birth weights, but who had high weights at age 7 years had higher insulin concentrations and indices of obesity compared with those with low birth weights and low weights at age 7 years. Positive correlations were also found between weight velocity and BMI, and weight velocity and insulin resistance as measured through homeostasis model assessment. Therefore, low birth weight together with rapid childhood weight gains, especially in subcutaneous fat, produces poor glucose tolerance in 7-year old children and can make them susceptible to the development of type II diabetes later in life.
Newborn infants were studied longitudinally to assess their serum copper (Cu) and ceruloplasmin (CLP) status. All infants were born between July 1, 1991, and June 30, 1992, at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Preterm infants (PI) of a maximum gestational age 36 weeks were divided into sick (A) and stable (B) cohorts, beginning with 30 in each of the 2 groups. The groups were matched with respect to gender, gestational age, birth weight, Apgar scores, and socioeconomic class. Cu levels were also determined in 30 stable, full-term infants. Sick PIs had significantly lower mean Cu and CLP levels at birth, while Cu level was significantly increased by 4 weeks in cohort A and approached levels of the stable PIs. With regard to CLP, catch-up of levels was delayed until 8 weeks, and a triphasic pattern of linear rise in Cu and CLP was discernible by 24 weeks. Sick PIs had mean serum CLP levels of 0.5 mcmol/dl, 5.9, 15.2, 17.3, 21.2, 25.1, and 23.7 mcmol/dl at birth, 4, 8, 12, 20, and 24 weeks, respectively, and were similar from 8 weeks in cohort B. Generally, CLP paralled serum Cu levels. Cu levels in the full-term infant (FI) were higher at birth and became similar to PIs from 12 weeks, but were overtaken by levels in PI at 24 weeks. FIs' Cu was significantly elevated by 8 weeks. Decreased growth rate, nonpitting pedal edema, exaggerated physiological anemia, and chronic lung disease were morbidities noted in association with very low Cu and CLP levels. Newborns with serum Cu and CLP higher than 0.2 mcmol/ml and 2.3 mcmol/dl, respectively, did not have a poor outcome.
Seasonal pattern of morbidities in preschool slum children in Lucknow, north India.
Findings are reported from a study conducted to quantify the burden of common morbidities in each month in 1 year among preschool children at 32 randomly chosen anganwadi centers in urban Lucknow, India. Overall, there are 153 anganwadi centers in the city. All eligible children registered with the anganwadi worker were enrolled over a period of 6 months from July 1995 to January 1996, and then contacted again 6 months later. Findings are based upon the study of 549 boys and 512 girls aged 1.5-3.5 years. The annual incidence rate (IR) per 100 child-years for respiratory, diarrhea, and skin diseases, and pneumonia were 167, 79.9, 30.6, and 9.6, respectively. When compared to other seasons, the IR of pneumonia was lowest during October-February, the winter months, while those of diarrhea and skin diseases were the highest during March-June and July-September, respectively. Season-specific diseases were measles in summer, and fever as the isolated symptom in monsoon season. The IR for combined morbidities was the highest during the monsoon season. These findings warrant the consideration of season-specific intensification of existing health care resources for such morbidity.
Prevalence of malnutrition and intestinal parasites in preschool slum children in Lucknow.
Findings are reported from a study conducted to assess the prevalence of intestinal parasites and their association with malnutrition in a sample of preschool children from 32 randomly chosen anganwadi centers in urban Lucknow, India. Overall, there are 153 anganwadi centers in the city. All eligible children registered with the anganwadi worker were enrolled. Findings are based upon the study of 549 boys and 512 girls aged 1.5-3.5 years. 67.6% were underweight, 62.8% were stunted, and 26.5% were wasted. Parasites were detected in 17.5% of children by a single direct fecal smear examination. Of those, Ascaris lumbricoides was found in 124 (68.1%) and Giardia lamblia in 60 (32.9%). There was no association between weight or height and parasite positivity. The mean hemoglobin levels for children who were smear positive rather than smear negative for ascaris or giardia were 9.1 g/dl and 9.6 g/dl, respectively. Urgent steps are needed in this setting at the community level to improve children's nutritional status and control parasite infestation.
A prospective cohort study on the survival experience of under five children in rural western India.
Findings are presented from a prospective study conducted in 45 villages in Shirur Development Block in Pune District, Maharashtra, to gain insight into the role of birth weight, nutrition, immunization, and other medical and social factors in determining child survival. 4129 children were followed from birth until age 5 years, with child weight and length/height measured at birth and at 3 monthly home visits. Information was also obtained on common childhood morbidities, immunization status, and other biomedical factors, and the cause of death was ascertained through verbal autopsy. The neonatal, infant, and under-five mortality rates were estimated to be 37, 60, and 79 per 1000 live births, respectively. Diarrhea and acute respiratory infections (ARI) contributed to the major mortality burden. The Kaplan Meier Survival curve showed a sharp fall in the neonatal period, a less rapid decline during the post-neonatal period, followed by a marginal fall in the post-infancy period until age 5 years. Girls had a better survival during the early neonatal period, but the trend reversed during the late neonatal period. Normal birth weight children had better survival curves compared to low birth weight children. Survival improved with increasing birth order. Multivariate analysis found that birth weight, immunization status, and mother's and child's nutritional status influenced infant and under-five mortality. Since birth weight continues to influence survival and mortality even up to age 5 years, strategies to improve child survival should include immunization and breast-feeding.
A phase 1, double-blind, placebo-controlled trial was conducted in Longchuan County, China, to evaluate the safety and immunogenicity of a prototype HIV-1 synthetic peptide vaccine in a sample of 26 IV drug users and 4 of their sex partners, and to establish the infrastructure for future large-scale HIV vaccine efficacy trials. 29 subjects of mean age 27.2 years completed the full 3-immunization regimen, with 12 subjects receiving a 100 mcg dose of the vaccine, 12 receiving a 500 mcg dose, and 5 receiving placebo. Each subject was given 3 injections on an accelerated 0-, 1-, and 2-month schedule. The vaccine was well tolerated with no significant local or systemic reaction observed in any subject. 55% of 100 mcg dose and 64% of 500 mcg dose subjects who received the vaccine produced binding antibody to the immunogen as determined by ELISA. However, HIV-1 neutralizing antibody was detected in only 23% of subjects with detectable HIV-1-specific binding antibody. This prototype vaccine was therefore well tolerated, safe, and immunogenic, but the 0, 1, and 2-month schedule was not as effective in stimulating HIV-1-specific neutralizing antibodies as were previous trials using a 0, 1, 6-month schedule. This clinical trial site in Yunnan should be considered for conducting larger trails of candidate HIV vaccines.
Towards evaluation of the quality of care in health centres.
In accordance with Spanish and Portuguese conditions, a strategy was designed to implement quality assurance in health centers on a voluntary basis, with particular attention to internal involvement. The main elements of this project, which became known as the Iberian Program of Training and Implementation of Quality Assurance Activities in Primary Health Care, were training, involving problem-solving, a phased approach, and the use of real cases; internal commitment; professional leadership; teamwork; external support; and intrinsic professional incentives. Training was the most important strategic factor. Also probably significant was the adequate ad hoc implementation of the principles of planned change. A high degree of reliance was placed upon the intrinsic motivation and self-determination of professionals. The complete training program reached 213 professionals attached to 203 health centers. Program elements are described.
Willingness to pay for district hospital services in rural Tanzania.
Health sectors are being restructured in many parts of the world to shift the financial burden of health care away from the public sector onto individual citizens. This paper describes a study conducted to investigate the willingness of patients and households to pay for rural district hospital services in northwestern Tanzania. Surveys conducted included interviews with 500 outpatients and 293 inpatients at 3 district-level hospitals, interviews with 1500 households, and discussions with 22 focus groups within the catchment areas of the primary health care programs of these hospitals. Information was collected on the willingness to pay fees for certain hospital services, willingness to become a member of a local insurance system, and exemptions for cost-sharing. The surveys found a considerable willingness among respondents to pay for district hospital services. However, most respondents favored a local insurance system over user fee systems, a finding which applied at all places and in all of the surveys. More female respondents favored a local insurance scheme. The conditions needed to introduce a local insurance system are discussed.
Regulating the private health care sector: the case of the Indian Consumer Protection Act.
The private sector provides an important proportion of overall health care delivery services in India. As such, efforts must be made to ensure that such services are of acceptable to high quality. With professional organizations such as the Medical Council of India and local medical associations unable to influence the behavior of private providers, the recent decision to bring private medical practice under the Consumer Protection Act (COPRA) 1986 is considered an important step toward regulating the private medical sector. The author surveyed the views of 130 private health care providers from the city of Ahmedabad on the legislation. Data were also analyzed on cases filed with the Consumer Disputes and Redressal Commission in Gujarat since 1991. While respondents believe that COPRA will reduce the levels of malpractice and negligent behavior among private practitioners, they envision an increase in physicians' fees, a greater number of prescriptions made and diagnostic tests conducted, and an adverse effect upon emergency medical care. Medical associations have argued that introducing COPRA will foster expensive and needless litigation. Other concerns have been raised by consumer forums.
Applying medical anthropology in the control of infectious disease.
Anthropological interest in infectious disease control is relatively recent. Now, however, anthropology plays 2 roles in controlling infectious disease. First, anthropologists can identify and describe concerns and understandings of disease, including local knowledge of cause and treatment relevant to disease control. Second, local concerns can then be translated into appropriate health interventions by providing information to be incorporated into education and communication strategies for disease control. Problems arise in infectious disease control programs with competing knowledge and value systems. Anthropology's role has traditionally been in translating local concepts of illness and treatment, and adapting biomedical knowledge to fit local etiologies. Medical anthropology, however, can be applied to better understand the local context of disease diagnosis, treatment, and prevention, as well as the structural and conceptual barriers to improved health status. National and international public health goals which respect local priorities are uncommon, and generic health goals rarely coincide with specific country and community needs. The success of interventions and control programs is moderated by local priorities and conditions, and sustainable interventions need to acknowledge and address country-specific social, economic, and political circumstances.
Incorporating gender in the anthropology of infectious diseases.
Over the past 2 decades, increasing attention has been given to the impact of gender upon health status, outcomes, and health-seeking behavior. This paper examines how a gender-sensitive perspective can influence our understanding of the nature and epidemiology of disease and guide the design and evaluation of interventions for its control. The author focuses upon key issues in the research and control of infectious diseases to stress the utility of combining a gender perspective with anthropological investigation. Gender-sensitive research is essential to the understanding of the nature of the disease, its prevalence, distribution, determinants, and consequences. Examples are drawn from anthropological studies on infectious diseases, including research on urinary schistosomiasis, malaria, leprosy, leishmaniasis, and onchocerciasis. Defining and conceptualizing gender are discussed.
This paper considers the following issues of broad relevance to the role of medical anthropology in infectious disease control: the nature of interdisciplinarity, the role of rapid assessment methodology, and data interpretation. Focus is given to the tensions created by the inherent conflict between the need for the rapid production of apparently relevant data for use in disease control projects and the development of truly valuable anthropological insights. Rapid assessment procedures informed by anthropology are increasingly being used in the formulation of a range of international disease prevention and control strategies. However, the refinement of these rapid procedures has narrowly focused upon their methods, compared with the broader potential scope of context-based anthropological contributions. The control of HIV and other sexually transmitted diseases (STD) in India is used to describe the potential role of anthropologically informed insights and investigations in the development of effective interventions, with particular reference to the examples of syndromic management, symptom presentation, and treatment provision. Anthropological, epidemiological, and clinical studies need to be properly integrated.
Onchocerciasis is known for both its ocular and dermatological effects. Although the former effects have received more attention in efforts to control the disease, more than half of the 17 million affected persons in Africa live in forest areas where onchocercal skin disease (OSD) is common, but onchocercal blindness is rare. For onchocerciasis-affected people, the most severe complication of infection is intense itching. Findings are reported from a multicenter, double-blind placebo-controlled trial conducted among 4072 residents of rural communities in Ghana, Nigeria, and Uganda to determine the effects of ivermectin therapy in annual, 3-monthly, and 6-monthly doses upon OSD and severe itching. Baseline clinical examination categorized reactive skin lesions as acute papular onchodermatitis, chronic papular onchodermatitis, and lichenified onchodermatitis. The presence and severity of itching was assessed through open-ended questions. Clinical examination and interview took place at baseline and each of the 5 subsequent 3-monthly follow-up visits. While the prevalence and severity of reactive lesions decreased for all 4 arms, those receiving ivermectin maintained a greater decrease in prevalence and severity over time. The difference between ivermectin and placebo groups was significant for prevalence at 9 months and for severity at 3 months. The differences between ivermectin and placebo groups were far more pronounced for itching; from 6 months onward, the prevalence of severe itching was reduced by 40-50% among those receiving ivermectin compared to those receiving placebo.
While the blackflies' innate immune system is unable to encapsulate and melanize intruding parasites, blackflies are nonetheless capable of killing and clearing Onchocerca microfilariae. Using the bovine species Onchocerca ochengi as a model for human onchocerciasis, the authors have been investigating the immune response of Simulium damnosum s.l., the main vector of human onchocerciasis in sub-Saharan Africa. The parasite is naturally transmitted by S. damnosum s.l. and occurs throughout the cattle-breeding areas of Africa. This study explored how to kill Onchocerca parasites inside the vector and the hypothesis that apoptosis is one of the main causes of death among Onchocerca parasites in the vector insect. The injection of female S. damnosum s.l. with 5 microfilariae of noncryopreserved microfilariae of O. ochengi and the protease inhibitors z-VAD.fmk and boc-D.fmk led to significantly increased survival of the parasites. Subsequent in situ apoptosis detection assays demonstrated that in the case of boc-D.fmk, enhanced survival was due to a diminished apoptosis level of the microfilariae in vivo. Additional assays using O. ochengi microfilariae coinjected with serine protease inhibitors into S. damnosum s.l. revealed that certain serine protease inhibitors can reduce the level of apoptosis. Study findings clearly demonstrate that apoptosis is involved in eliminating Onchocerca parasites in blackflies.
The Health Behavior in School-Aged Children (HBSC) study was implemented by 3 European countries in 1982, and has since been adopted by more than 25 countries, including Canada and Australia. It is generally expected that African and Asian countries will follow suit. The 1996 HBSC study in Indonesia was conducted to collect information on the health-related behaviors of Indonesian youth, and to provide recommendations for the further adaptation and use of the HBSC in non-Western countries. This paper reviews some methodological constraints in adapting the HBSC study in Indonesia. While the international HBSC team reported methodological problems in the cross-national study, no attempt to extend the original European study to Southeast Asia has been described before. Cultural, religious, economic, and social differences create specific obstacles and challenges in such an adaptation. Structural problems in preparation and implementation were experienced. Efforts are needed to assess the validity of the HBSC study in non-Western countries, while specific strategies need to be elaborated to accommodate the future participation of developing countries in the study.
Quality of care in sexually transmitted diseases in Zambia: patients' perspective.
Sexually transmitted diseases (STD) are the most common infectious diseases in Zambia, affecting mainly adolescents and young adults across society. Zambia, with a total population of about 8 million people, experiences approximately 125,000 cases of STD annually. Findings are reported from a study conducted to describe Zambian STD patients' response to treatment and compliance with partner notification, as well as their satisfaction with health care received. 92 male and 87 female patients were interviewed twice at an urban health center 5 km outside of Lusaka. The men and women were aged 17-55 and 15-37 years, respectively, of mean ages 26 and 23. 48% of the men and 78% of women were married. Most of the patients were unsatisfied with the care received. Their response to treatment and compliance with partner notification were unsatisfactory. For example, lack of funds prevented 13 patients from buying medicines, and 125 patients had asked 134 sex partners to come for treatment, but only 60% of them had actually done so and been treated. The most important factors defining good quality STD care noted by study participants were the provision of free medicines, privacy, injections rather than tablets, pre-treatment examinations, and information about their diagnoses. Health care providers must improve their communication and counseling skills to better understand patients' needs.
A tension exists between the aim of health policy-makers to achieve high quality standards of care on the one hand and the district multi-crisis reality in sub-Saharan Africa on the other. Disintegrating health services together with deteriorating living conditions adversely affect the population's health status and contribute to an increase in health inequalities both nationally and internationally. Constraints and some examples of achievements in district health management in Mporokoso and Kaputa districts in Northern Province, Zambia, are presented. A strong focus should be given to community-based health care, partnership with communities, and accelerated health system support through the strengthening of on-site supervision. Decentralization and self-reliance can help in flexible crisis management, but demand continuity in human resource development and appropriate care for carers. To increase operational efficiency, there is a need to conceptualize a practical approach of minimum primary health care.
The provision of zidovudine drug therapy to pregnant women has been shown to reduce the vertical transmission of HIV in non-breast-feeding study populations. However, many women in developing countries have little to no option but to breast-feed their infants. Findings are presented from an assessment of the acceptability, tolerance, and 6-month efficacy of a short regimen of oral zidovudine in African populations practicing breast-feeding. The randomized, double-blind placebo-controlled trial was conducted in public clinics of Abidjan, Cote d'Ivoire, and Bobo-Dioulasso, Burkina Faso. Eligible participants were women aged 18 years or older, with confirmed HIV-1 infection and pregnancy of 36-38 weeks duration, and who gave their written consent. Exclusion criteria were severe anemia, neutropenia, abnormal liver function, and sickle-cell disease. Subjects were randomly assigned to receive either zidovudine or placebo. The 214 women who received zidovudine did so in a 300 mg dose twice daily until labor, 600 mg at the beginning of labor, and 300 mg twice daily for 7 days postpartum. 217 women received placebo. The women were enrolled between September 1995 and February 1998. The Kaplan-Meier probability of HIV infection in the infant at age 6 months was 18.0% in the zidovudine group and 27.5% in the placebo group. Adjustment for potential confounders did not change the treatment effect. A short-course regimen of oral zidovudine given during the peripartum period is therefore well accepted and well tolerated, and provides a 38% reduction in the level of early vertical transmission of HIV-1 infection despite breast-feeding.
Many developing countries have not implemented the AIDS Clinical Trials Group 076 zidovudine regimen to prevent perinatal HIV-1 transmission because of the regimen's complexity and cost. In a randomized, double-blind, placebo-controlled trial, HIV-1-infected pregnant women at 2 Bangkok hospitals were randomly assigned either placebo or zidovudine therapy of 300 mg twice daily from 36 weeks' gestation and every 3 hours from the onset of labor until delivery. Mothers were given infant formula and asked to not breast-feed. Between May 1996 and December 1997, 397 women were randomized, of whom 393 gave birth to 395 live-born babies. The median duration of antenatal treatment was 25 days, with a median of 3 doses given during labor. 99% of women took at least 90% of scheduled antenatal doses. Adverse events were similar in the 2 study groups. Of 392 babies with at least 1 PCR test, 55 tested positive; 18 in the zidovudine group and 37 in the placebo group. Estimated transmission risks were 9.4% on zidovudine and 18.9% on placebo. Between enrollment and delivery, women in the zidovudine group had a mean decrease in viral load of 0.56 log. About 80% of the observed treatment effect was explained by reduced maternal viral concentrations at delivery. This short course of zidovudine was safe, well tolerated, and capable of reducing the risk of vertical HIV-1 transmission by half.
Given the high risk of vertical HIV-1 transmission in Africa, the authors assessed the safety and efficacy of a regimen of short-course perinatal oral zidovudine among HIV-1-seropositive breast-feeding women in Abidjan, Cote d'Ivoire. From April 1996 to February 1998, all consenting, eligible HIV-1-seropositive pregnant women attending a public antenatal clinic in Abidjan were enrolled at 36 weeks' gestation and randomly assigned placebo or zidovudine (300 mg tablets), 1 tablet twice daily until the onset of labor, 1 tablet at the onset of labor, and 1 tablet every 3 hours until delivery. HIV-1 DNA PCR was used to test the infection status of babies at birth, 4 weeks, and 3 months. The study was stopped on February 18, 1998, when efficacy results were available from a study in Bangkok, Thailand, in which the same regimen was used in a non-breast-feeding population. 280 women were enrolled in the study. The median duration of the prenatal drug regimen was 27 days and the median duration of labor was 7.5 hours. Treatment was well tolerated with no withdrawals due to adverse events. All babies were breast-fed. Among babies with known infection status at age 3 months, 30 of 115 (26.1%) in the placebo group and 19 of 115 (16.5%) in the zidovudine group were identified as HIV-1 infected. The estimated risks of HIV-1 transmission in the placebo and zidovudine groups were 21.7% and 12.2% at 4 weeks, and 24.9% and 15.7% at 3 months, respectively. Efficacy was 44% at age 4 weeks and 37% at 3 months. Short-course oral zidovudine therapy was safe, well tolerated, and decreased mother-to-child HIV-1 transmission at age 3 months.
Control of malaria vectors: cost analysis in a province of northern Vietnam.
The cost of permethrin-treated (twice yearly) bednets was compared to the cost of annual residual spraying with lambdacyhalothrin in Hao Binh, a mountainous province in northern Vietnam. Calculations of the amounts of insecticides needed were based upon national guidelines, cross-sectional survey data, and district activity reports. The actual cost of insecticide required per person per year for impregnation was US$0.26, lower than the US$0.36 required for spraying, although the total cost for impregnated bednets per person per year was US$0.90, compared to US$0.47 for spraying. The determining factor for the large difference in overall cost was the cost of the net, amounting to US$0.58/person/year, assuming a 5-year net life. Other materials, labor, and transport combined accounted for only 17% of the impregnation cost and 23% of spraying expenses. However, for the National Malaria Control Program of Vietnam, the cost per person per year for impregnated bednets was only US$0.32, because most nets are bought by the population. For spraying, the program had to bear the entire cost.
While some herald the growth monitoring (GM) of children in developing countries as the cornerstone of the child survival revolution, others see it only as an ineffective and useless ritual. Findings are presented from a prospective cohort study designed and conducted to assess the value of anthropometric, clinical, biological, and dietary indicators in predicting the short-term morbidity of young children in rural central Africa. The population-based follow-up study was conducted in Northern Kivu, Congo, involving 842 children under age 2 years who completed weekly follow-up interviews and health examinations during a 3-month period. Anthropometric indicators appeared to be poor predictors of morbidity. In contrast, however, nonanthropometric variables such as growth as judged by the caregiver, child's diet at the time of examination, and the occurrence of disease during the month preceding the interval of observation were useful. In the context of the Sick Child Initiative, simple tests and diagnostic tools to improve the quality of prevention and cure in first-level facilities need to be identified. Focus upon nonanthropometric variables should be encouraged to most comprehensively evaluate child health status.
Syndromic management of sexually transmitted diseases: is it rational or scientific?
Sexually transmitted diseases (STD) are of major public health importance since they mainly affect young adults, carry stigma, facilitate the transmission and acquisition of HIV, and can have costly complications. The World Bank estimates that for people aged 15-44 years, STDs excluding HIV are the second most important cause of healthy life lost among women after maternal mortality and morbidity. However, despite the importance of preventing and controlling STDs, they are of only low priority in many developing countries. Indeed, many such countries do not even have an effective STD control program. The control of STDs improves the reproductive and sexual health of afflicted individuals and lowers the community burden of HIV. Preventing STDs or their complications requires health education, condom promotion, and effective case management. Since clinical diagnosis is often incorrect and laboratory-confirmed etiological diagnosis is expensive, the syndromic management of STDs makes sense in resource-poor countries which lack trained personnel and laboratory facilities. Although the approach is simple in design, it nonetheless requires the regular monitoring and evaluation of protocols as well as the supervision and training of clinicians.
More than half of all cases of onchocerciasis reported in the Americas are recorded in Mexico and Guatemala. Mass ivermectin administration and nodulectomy campaigns are conducted in these countries in an attempt to alleviate the clinical manifestations of the disease and interrupt transmission. Mass ivermectin treatment efficiency is typically evaluated by assessing the apparent prevalence and intensity of infection as measured by numbers of microfilariae (mf) in skin snip biopsies. There are, however, obstacles and limitations to this approach. This study compares the utility of an ELISA using 3 recombinant antigens with that of the skin biopsy to estimate the incidence of infections in a sentinel cohort of individuals living in an endemic community in southern Mexico during a set of 11 subsequent ivermectin treatments. The apparent community prevalence of infection and microfilarial skin infection before and after 11 treatments with ivermectin plus nodulectomy were 78% and 13%, and 0.68 mf/mg and 0.04 mf/mg, respectively, as measured by skin biopsy. Of 286 individuals participating in all surveys, a sentinel cohort of 42 mf and seronegative individuals were followed since 1994. The annual percentages of subjects becoming seropositive in the cohort was 24%, 28%, 0%, and 4.3% in 1995, 1996, 1997, and 1998, respectively. Likewise, the incidences in children aged 5 years and younger were 15%, 18%, 0%, and 11%, respectively. All subjects became positive to both tests simultaneously, indicating that seroconversion assessed infection incidence as accurately as skin biopsy in the sentinel group.
Facing the challenge: household responses to HIV / AIDS in Mumbai, India.
With an estimated 3 million adults infected with HIV, India is a major epicenter of the AIDS pandemic. How households and families in India will respond to AIDS is of key importance when it comes to designing programs and interventions to provide support and care to people living with HIV/AIDS. Where household and family responses are negative, different kinds of interventions may be needed from those where responses are more supportive. Based upon data collected in individual and couple interviews, findings are presented on household and family responses to HIV and AIDS in India. Participant responses were greatly influenced by prevailing gender relations, with men responded to more positively than women, as well as other variables such as social status. The quality of responses is also influenced by pre-existing patterns of support and discord within the family. Where trust is high and spousal conflict minimal, HIV and AIDS are reacted to more positively than when there is mistrust and interspousal conflict.
Ethnic minorities and their vulnerability to AIDS in a border state of India.
The social vulnerability of ethnic minorities, indigenous, or aboriginal populations to HIV infection is an area of concern for AIDS policy-makers, researchers, and program managers. Findings are presented from a study conducted to document aspects of community response to HIV/AIDS in Churachandpur town, Manipur, India, where a high rate of HIV infection is reported among IV drug users (IVDUs). The authors also sought to identify any gaps in existing HIV/AIDS prevention programs. Interviews were held with 635 opinion leaders from 8 tribal groups in the community, including teachers, students, and community leaders. 67% of respondents were male, and 31% were married. 81% of respondents were aged 15-19 years. Most respondents were generally aware of how HIV/AIDS is transmitted and supported HIV/AIDS, sex, and drug education in schools. 76% believed AIDS education could reduce the transmission of HIV among young people. A great majority of the respondents were willing to help with AIDS education in the study area. More than half of respondents were willing to care for relatives if they were infected with HIV. However, also about half of the study population believes that people with HIV/AIDS should be identified and isolated from the community. Almost half of the study population was worried about becoming infected with HIV, but only 7% were aware of their own personal vulnerability. Students were the most concerned about the threat of AIDS.
Prevalence of HIV infection among hospital patients in north west Tanzania.
A study was conducted to assess the prevalence of HIV infection among patients at Bukoba regional government hospital in the Kagera region of Tanzania, the economic impact of AIDS upon health care, and the implications of HIV testing upon clinical suspicion of AIDS. 1471 consecutive admissions were recruited into the study, of whom 1422 completed questionnaires and had their blood sera tested for HIV antibodies. The overall age-adjusted HIV-1 prevalence among the hospitalized patients was 32.8%, with no statistically significant difference in the age-adjusted, sex-specific HIV-1 prevalence rate. The highest HIV-1 prevalence of 53.3% was found among people aged 25-34 years, as well as in the gynecological and medical wards (41.2% and 40.4%, respectively). HIV-1-infected patients were more likely to have a history of previous hospital admissions, and were at an increased risk of developing tuberculosis (TB). The diagnostic categories with the highest HIV-1 infection prevalence were clinical AIDS (88.5%), herpes zoster and other HIV-1 skin manifestations combined (85.7%), and pulmonary TB (58.3%). The prevalence of HIV-1 infection was high among these patients, indicating that the major cause of illness leading to admission to the hospital may have been underlying HIV-1 infection. However, since the diagnostic category of clinical AIDS was only 11.3% sensitive, only 11.3% of the HIV-seropositive cases would have been HIV tested on the clinical suspicion of AIDS. These findings indicate that in a high HIV-1 prevalence area, testing for HIV infection on the basis of clinical suspicion of AIDS alone is insufficient to provide rational care to the majority of HIV-infected patients.
Data on health-seeking behavior were collected in Vihiga and Homa Bay Districts of western Kenya, as part of formative research for a sexually transmitted disease (STD) control and HIV/AIDS home care project with the main goal of securing information to guide project design and implementation. Community-based, ethnographic research methods were used from January 1995 to June 1996, including key informant interviews, focus group discussions, and in-depth interviews. Illness narratives of STDs provided the basis for an analysis of sequential steps in health-seeking behavior, namely recognizing, classifying, overcoming stigma, identifying treatment options, and selecting a course of therapy. A range of terms were used to identify STDs, including multiple terms referring to "women's disease." Stigma associated with STDs was based upon a set of beliefs of the causes, contagiousness, and sequelae of STDs, and resulted in treatment seeking delays. 5 commonly used treatment options were identified, with multiple sources of care often used concurrently. The desire for privacy, cost, and belief in the efficacy of traditional medicines strongly influenced health-seeking behavior. The belief that STDs must be transmitted in order to achieve cure was held by several respondents and promoted by a traditional healer. Implications for STD control strategies are considered, including the development of educational messages and clinic design.
As HIV has spread throughout sub-Saharan Africa, persistent diarrhea has become a major problem in hospitals and communities in severely affected areas. Antiprotozoal therapy, however, has been shown to reduce diarrhea in AIDS patients in urban Zambia. Findings are presented from a randomized, placebo-controlled trial conducted in the home care service of Ndola Central Hospital, Zambia, to determine whether the clinical response to albendazole can be improved by oral micronutrient supplementation. 106 HIV-seropositive patients with persistent diarrhea were randomized to receive either albendazole plus vitamins A, C, and E, selenium, and zinc orally, or albendazole plus placebo, for 2 weeks. While serum vitamin A and E concentrations before treatment were powerful predictors of early mortality, supplementation did not reduce time with diarrhea or mortality during the first month, even after considering initial vitamin A or E concentrations, CD4 cell count, or clinical markers of illness severity. Serum concentrations of vitamin A and E did not increase significantly in supplemented patients compared with those given placebo, and there were no changes in CD4 cell count or hematological parameters. No adverse events were detected except those attributable to underlying disease. Short-term oral micronutrient supplementation fails to affect diarrhea-related morbidity or mortality in such patients.
Infection with M. tuberculosis is the most common bacterial infection in humans, and HIV infection is the strongest risk factor for tuberculosis (TB). The World Health Organization estimates that more than 4 million people, mostly in Africa, are coinfected with both organisms. Randomized controlled trials, however, have demonstrated that isoniazid (INH) prophylaxis may reduce the incidence of TB in HIV-negative populations at high risk of developing active disease. The efficacy of INH in preventing TB in tuberculin skin test-positive and negative individuals with HIV infection was assessed through the meta-analysis of 7 randomized controlled trials from Mexico, Haiti, the US, Zambia, Uganda, and Kenya. Findings are based upon 2367 subjects treated with INH and 2162 in control and placebo groups. The mean follow-up of trial participants varied between 0.4 and 3.2 years. Pooling all 7 trials, the risk ratio (RR) of INH versus placebo for TB was 0.58, and 0.94 for death. In groups of tuberculin skin test-positive and -negative subjects, the RR of TB was 0.40 and 0.84, respectively, and the difference in the effectiveness of INH versus placebo between the groups was statistically significant. Consistency of results was found across trials for all comparisons. Prophylaxis with INH therefore reduces the risk of TB in HIV-infected individuals. However, the effect is limited to tuberculin skin test-positive persons.
The treatment of tuberculosis in HIV-infected persons.
Tuberculosis (TB) is one of the most important infections affecting HIV-infected individuals in the world. Rates of HIV-related TB have risen in countries in Europe, the US, and South America, and so rapidly in India and the rest of Asia that they may equal those in sub-Saharan Africa by 2000. Globally, 1 in 11 cases of TB are attributed to HIV, with the proportion expected to rise to 1 in 7 cases by 2000. The authors review the evidence from clinical trials of the efficacy of rifamycin-based short-course regimens for TB when rifamycin is used for the entire treatment period or only in the intensive phase. The authors also examine the drug-drug interactions between anti-TB and antiretroviral drugs, and consider possible TB regimens which could be used in HIV-positive patients on or beginning antiretroviral therapy, and suggest best practice treatment strategies.
The transmission of HIV-1 infection from an infected mother to her infant is estimated to be 15-40%, with more than half of transmission probably occurring late in pregnancy or during labor and delivery. Nevirapine, a non-nucleoside reverse transcriptase inhibitor, is an excellent candidate for a single-dose antiretroviral intervention administered during labor. Findings are presented from a study assessing the safety, pharmacokinetics, tolerance, antiretroviral activity, and infant HIV infection status following the administration of 1 dose of nevirapine to HIV-1-infected pregnant women during labor and their newborns during the first week of life. 200 mg of nevirapine were given as a single dose during labor to 21 HIV-1-infected pregnant women in Kampala, Uganda. 8 of their infants did not receive the drug, while 13 infants received 1 dose of nevirapine, at 2 mg/kg, at 72 hours of age. Nevirapine was well tolerated by both the women and infants, with no serious adverse events related to the drug observed. Median nevirapine concentration in breast milk 1 week after delivery was 103 ng/ml. Plasma nevirapine concentrations remained above 100 ng/ml in all infants from both cohorts tested at age 7 days. Maternal HIV-1 RNA levels decreased by a median of 1.3 logs at 1 week postpartum, and returned to baseline by 6 weeks postpartum. Detectable plasma HIV-1 RNA was observed in 1 of 22 (4.5%) infants at birth, 3/21 (14%) at 6 weeks, and 4/21 (19%) at 6 months of age. This regimen has promise as a prophylaxis against intrapartum and early breast milk HIV transmission in a breast-feeding population.
A sterilization outreach program camp for minilaparotomy was established in December 1996 in Bajura, one of India's least developed rural districts. A vasectomy camp was also organized. This paper describes the reproductive behavior and morbidity among women who came to receive sterilization services. Such family planning camps can play a major role in addressing some of the burden of reproductive health problems. The camp was organized at 2 sites in the district, offered services including counseling, screening, and surgery over a 3-day period at each site. Potential clients were identified over several months by community-based health or social workers. The main criteria for preliminary selection in the communities were that the women wanted to bear no more children and that they were currently not pregnant. The sparse distribution of villages demanded that many women walk for several hours or days to visit the camp sites. The profile of women visiting the camps and morbidities of women during the 3 months preceding their interview are presented.
Aedes aegypti is the only known vector of dengue, dengue hemorrhagic fever, and dengue shock syndrome in the Caribbean. Since the virus and its vector threaten the well-being of people in the Caribbean, public health authorities in the region support efforts to manage the mosquito vector. During an outbreak of dengue fever in Jamaica during October-December 1995, a study was conducted to assess the impact of aerial ultra-low volume malathion treatment upon adult Aedes aegypti. Researchers monitored oviposition rates of the vector in 3 urban communities in Kingston and exposed caged mosquitoes directly and indirectly to the aerial treatment. The insecticide was delivered at a rate of 219 ml/ha between 7:10 a.m. and 8:45 a.m. This intervention failed to interfere with Aedes aegypti oviposition, and adult mosquitoes held in cages inside dwellings were largely unaffected. This type of intervention therefore seemed to have little impact upon arresting or abating dengue transmission.
Efficiency of hospital cholera treatment in Ecuador.
The efficiency of cholera treatment was assessed in 3 hospitals representative of the Ecuadorian public health system to provide hospital directors, administrators, and health service policy-makers with information to plan responses to future epidemics, as well as to reduce the general costs of cholera treatment. Total and excess cholera treatment costs were calculated using hospital files and statistics, and an in-hospital surveillance system of cholera cases. 45% of cholera treatment costs were excessive, with the most important contributor being excess recurrent costs, including extended hospital stays, the disproportionate use of IV rehydration solutions, and unnecessary laboratory tests. Excess capital costs from land, buildings, and hospital equipment represented 10% of the total excess treatment costs. While no significant relationship was found between treatment costs and the severity of illness, nor between costs and a patient's age, patient's sex seemed to be an important variable, with the cost of treating women notably higher than for men. An inverse relationship was found between treatment costs and the complexity of the hospital.
Effectiveness of nutrition centers in Ceara state, northeastern Brazil.
Childhood malnutrition has been a major, longstanding health concern in northeastern Brazil. Therefore, during 1992-94, the state government of Ceara, with financial support from the World Bank, established 34 new nutrition centers. During 1996, these centers were evaluated to assess their operational effectiveness and identify weaknesses in the system and possible solutions. Also evaluated were the adequacy of resources, admission and discharge criteria, staff training, and community satisfaction. Each center was visited for 3-5 days during January-April 1996 for observation and the collection of relevant data. The level of effectiveness was found to be low, with treatment procedures failing to conform with World Health Organization recommendations. Rates of weight gain were inadequate, and the mean 8.7 months of rehabilitation was too long. Case fatality levels in 2 centers were too high, at 40% and higher, while entry and exit criteria for rehabilitation were ill-defined. Few staff were adequately trained; knowledge was weak, especially about case management; and mothers were not effectively instructed. Objectives should be set for these centers, referral systems improved, entry criteria standardized, case management improved, and performance indicators established.
Findings are described from the epidemiological surveillance of influenza virus in Mar del Plata and Cordoba, Argentina, during 1987-93. Data are presented on disease notification, the serologic characterization of influenza virus isolates, and the sequence of the HA1 subunit in 5 isolates of type A subtype H3N2 from the epidemics of 1990 and 1993. Clinical samples were obtained and processed in the National Institute of Epidemiology in Mar del Plata and the Institute of Virology in Cordoba. Patients providing samples were being treated for acute respiratory infections in hospitals and health centers in the 2 cities. Some samples were also worked up from employees of an automobile factory serving as a sentinel surveillance site. The incidence of illness, type of viruses isolated, and H gene sequences were similar to what has been reported from other parts of the world during the same period. The H3 strains isolated in the 1990 and 1993 seasons were somewhat removed in their molecular characteristics from the strains of the World Health Organization recommended for vaccines for those years, and appeared closer to the strains recommended for vaccination in subsequent seasons.
A new vision for adolescent sexual health.
US adults are generally uncomfortable with the subject of adolescent sexuality. As such, they either pretend that teenagers do not have sex or try to control and limit the information which young people receive about sex and contraception. Sexual abstinence until marriage is the US Congressionally mandated message to students. In contrast, adults, and society in general, in the Netherlands, France, and Germany are comfortable with adolescent sexuality, and understand that teens have sex as a natural part of growing into sexually healthy adults. Perhaps paradoxically, adolescents in these 3 countries have first intercourse 1-2 years later than do US teens. The US also has a higher teen birth rate than the Netherlands, France, and Germany, as well as Morocco, Albania, Brazil, and more than 50 other developing countries. The teen birth rate in the Netherlands is almost 8 times lower than that of the US. Adolescent HIV and STD rates are also higher in the Netherlands, France, and Germany than in the US. At the heart of these 3 European countries' success in achieving low teen pregnancy and HIV/STD rates is a cultural openness and acceptance of adolescent sexuality which respects young people's rights and responsibilities as sexually maturing members of society. Rather than following the American model of trying to prevent young people from having sex, the Dutch, Germans, and French teach and empower their youths to behave responsibly when they decide to have sex. The US could learn from the Dutch, French, and German experiences with adolescent sexuality in developing and implementing a more balanced approach to adolescent sexuality.
The health care services of African countries are coming under increased stress due to limited budgets and growing demands for services. To address this situation, some African countries are adopting quality assurance and quality improvement approaches. A range of quality assurance and improvement approaches are being combined and integrated to meet particular needs based upon circumstances and available resources. Quality improvement activities in Ghana, Kenya, and South Africa are described. While a number of programs implemented in the 3 countries are showing promise, the challenge will be to use the growing body of knowledge and expertise being developed to improve all facilities and services, including rural services which are severely deprived, to ensure that patients who enter health care facilities will receive acceptable care with minimum risk. The problems of low use of public health services and substandard health care will continue until all governments seriously commit themselves to improving the quality of care. National level policy is required.
Hits for Hope. Delivery of Improved Services for Health (DISH) Project, Uganda.
Delivery of Improved Services for Health (DISH) Project, a joint project of the US Agency for International Development and the Uganda Ministry of Health, was developed to teach in-school and out-of-school youths about healthy sexual and reproductive behavior, and increase the demand for and use of integrated reproductive health services. 12-45-year olds in 10 urban and rural districts were expected to be exposed to the project's activities and messages. The project disseminated the following key messages: youth can prevent HIV infection by practicing safe sex; young men need to make their own decisions; young people who have not had sex should abstain until finding a monogamous partner; the best way to avoid HIV/AIDS is to abstain from sex; condoms should be used if having sex; and condoms are the only way to protect oneself when having sex. District and national level campaign activities and materials are described, as well as follow-up survey findings on the target audience's exposure to various mass media sources and related knowledge and behavioral change.
Short-course zidovudine for prevention of perinatal infection.
In 1994, the Pediatric AIDS Clinical Trials Group (PACTG) protocol 076 showed that a 6-week course of zidovudine, given to the mother during pregnancy and labor, and then to the neonate for 6 weeks, reduced HIV transmission rates by almost 70%. The adoption of this regimen in the US and Europe has caused perinatal HIV transmission rates to decline to 6% or less, while transmission rates of 2% have been reported when zidovudine prophylaxis is combined with elective cesarean delivery. However, in absolute terms, the impact of perinatal HIV transmission prevention measures will be greater in developing than in industrialized countries, in part because the overall level of HIV infection among pregnant women in developing countries is far higher than the overall level in industrialized countries. While trials must continue to identify simpler and more cost-effective HIV prevention measures, effort must still be given to implementing the already proven effective regimens in developing countries. To implement short-course HIV prophylactic regimens requires available and accessible antenatal care, HIV testing and follow-up for pregnant women, available and affordable zidovudine, and patient compliance with the drug regimen. To ensure intrapartum zidovudine administration, deliveries must be attended by professional birth attendants. Then, to prevent postpartum HIV transmission, there must be a safe and effective strategy for reducing the risk of HIV-1 transmission through breast milk.
Cameroon and Chad: cost recovery.
African Ministers of Health adopted the Bamako Initiative in 1987 to ensure sustainable and efficient primary health care (PHC), with an eye toward decreasing levels of morbidity and mortality in Africa. The initiative has made local communities largely responsible for identifying problems and distributing and managing local health care resources. Cost recovery is a key component of the Bamako Initiative. The adoption of a policy of decentralization in which the immediate providers and users of PHC services are responsible for the recovery of costs was recommended. Chad and Cameroon decentralized its health services in 1990 and 1992, respectively. With onchocerciasis one of these 2 countries' most important public health problems, the 2 governments decided to base onchocerciasis control efforts upon the mass distribution of Mectizan (ivermectin, MSD) integrated into the local PHC systems and including cost recovery. Community participation must now be developed to ensure the sustainability of treatment programs in both countries. In both Cameroon and Chad, studies have found that the introduction of cost recovery has had no significant effect upon treatment coverage in hyper- and meso-endemic communities. In fact, those charged for Mectizan treatment often believe that the drug must be worthwhile because they have to pay for it.
The challenge of establishing community-directed treatment with Mectizan in Uganda.
Onchocerciasis is a major public health problem in Uganda, affecting 17 of the country's 39 districts. 1995 data indicate that of the 19 million Ugandans, 1.8 million were at risk of infection and 1.36 million were already infected. 1.3 million Ugandans in 2255 villages are currently being targeted for annual treatment with Mectizan (ivermectin, MSD). 74% of the targeted villages are hyperendemic and 18% are meso-endemic for the disease. The control of onchocerciasis in Uganda through the mass distribution of Mectizan began in the early 1990s, as a result of collaboration between the Ministry of Health and 4 nongovernmental development organizations. With the aim of eliminating onchocerciasis as a public health problem in Uganda, the national program now reaches all communities known to be affected by the disease in all but 1 district, and achieved a mean treatment coverage of 75% in 1995 and 1996. However, with results of a 1996 World Health Organization study suggesting that community-directed treatment should be the main method of onchocerciasis control in Africa, Uganda's national onchocerciasis task force must now reorient its current program from community-based to community-directed treatment. This latter approach gives communities a greater role in distributing Mectizan.
HIV infection in children: the widening gap between developing and industrialized countries.
The HIV/AIDS pandemic began approximately 20 years ago. Since then, there has been considerable progress in research on the mother-to-child transmission of HIV with regard to its epidemiology, immunology, transmission-associated factors, clinical syndromes, and prevention. While much of this research has taken place in developing countries with international support, HIV/AIDS-affected mothers and children in these countries have thus far benefitted little from their involvement in research efforts. This is especially so with regard to the administration of antiretroviral drugs during pregnancy, the early diagnosis of HIV infection in children, prophylaxis against Pneumocystis carinii pneumonia (PCP) in early infancy, and facilities for the general support of affected families. In industrialized countries, the heterosexual spread of HIV occurs mainly among the poor and minority populations. However, in developing countries, HIV affects all levels of society. The author reviews the epidemiology of perinatal HIV infection, antenatal clinic HIV surveillance, vertical transmission, breast-feeding by HIV-infected mothers, clinical factors of HIV infection, social aspects of HIV infection, and preventing the vertical transmission of HIV from mother to child.
Prevention of congenital syphilis in X: the "supposed to" syndrome.
Syphilis is a systemic, chronic infectious disease transmitted through sexual intercourse, from mother to infant during pregnancy, and through the transfusion of infected blood. Untreated maternal syphilis infection may lead to abortion, stillbirth, infant prematurity, or congenital syphilis. However, syphilis infection is easy to detect and fully curable, at least since the advent of penicillin in the 1940s. Antenatal screening for syphilis serology is a national health policy in country X, with pregnant women found to be seropositive for syphilis referred to a STD clinic for treatment. However, a survey conducted in 10 MCH clinics found that an adequate syphilis screening had been conducted in only less than 10% of pregnant women. Efforts were subsequently taken to strengthen the syphilis control program in the country's capital. Findings are presented from an evaluation of the program in 13 MCH clinics across the city. 3-4% of pregnant women in the capital of country X are seroreactive for syphilis. Furthermore, approximately half of the antenatal attenders do not undergo blood screening, despite optimal logistic support, and alternative approaches such as screening and testing at antenatal clinics followed by prompt treatment, or mass treatment from a certain prevalence rate, should be considered.
Findings are presented from a community-based study of experiences with modern contraceptive methods in urban and rural Cambodia, and user preferences for various technical attributes, including effectiveness, mode of administration, secrecy, and the rapid return of fertility. Findings are based upon 12 focus group discussions held with 95 poor, reproductive-age, married women; 3 focus groups with 25 urban, married men; and 2 group discussions with 15 urban female prostitutes. Women who use modern contraceptive technologies want highly effective methods of birth control. Cambodian women are mainly interested in longer-acting methods, perceive weight gain positively, and are less concerned about a rapid return to fertility upon method discontinuation or secrecy from their partners. The women reported a high level of method side effects and considerable variation between side effects and each modern method used. The data also indicate that women may switch from a modern method associated with negative side effects to a less effective traditional method, to either take a break from unwanted side effects or discontinue modern method use altogether in the absence of an alternate, acceptable method. Efforts therefore need to be made to develop and provide a broad array of modern contraceptive methods, together with improved information on how methods function in vivo and the expected side effects of use.
Bangladesh has considerable national experience promoting and providing family planning services through home visits to reproductive-age married women by paid female community workers. Since 1978, the government has trained and employed 24,000 such workers, known as Family Welfare Assistants (FWA), while nongovernmental organizations (NGO) have trained and employed an additional 7000 field workers to carry out similar activities. NGO field workers are considered to be part of the national family planning program. Findings are presented from an assessment of the quality of family planning services provided by community-based field workers in zone 3 of Dhaka City, Bangladesh, and are based upon a large household survey of a representative sample of clients, direct field worker observation, and interviews with field workers and clients. Areas in greatest need of improvement include the frequency of contact with clients who are nonusers or who have special needs, client education about family planning methods, and counseling about side effects and warning signs.
Determinants of childhood mortality in slums of Karachi, Pakistan.
Pakistan has an infant mortality rate (IMR) of 90.5/1000 live births, and the country's child mortality level of 117.5 is worse than in other South Asian countries. Rapid population growth combined with rural-to-urban migration has led to the creation of urban slums in which morbidity levels are usually higher than in rural populations. A study was conducted in January 1993 in 6 slums of Karachi where the Aga Khan University has operated primary health care programs since 1985. Researchers recorded the deaths of 347 children under age 5 years old due to diarrhea and acute respiratory infections (ARI) during 1989-93. 235 mothers of these children were interviewed. The following are discussed as risk factors for under-5 child mortality: the use of traditional healers, poor nutritional status, incomplete or no immunization, the quick change of healers, inappropriate child care arrangements, mother's literacy, who decides about outside treatment, short birth interval, bottle feeding, and nuclear family structure. Maternal autonomy, appropriate health-seeking behavior, and child-rearing processes identified in the study point to the need for intervention strategies which go beyond the usual primary health care initiatives and involve communities in developing social support systems for mothers.
Knowledge of HIV / AIDS among migrants in Delhi slums.
Over the past decade, there has been a sharp increase in the reported and estimated numbers of HIV/AIDS cases in India. The UNAIDS estimates that up to 3 million people in India may be infected with HIV, of which 70-80% were infected through unprotected heterosexual activity. Findings are presented from an assessment of HIV/AIDS-related knowledge and awareness among slum dwellers in Delhi, India, and which factors affect that knowledge. To explore the links between socioeconomic, health, and migrant status generally, a survey was conducted in 1996 among 150 slum households from different parts of the city. The slum dwellers were all migrants from other states, living for at most 15 years in Delhi. All 361 adults in the selected households were interviewed. Despite significant investment in IEC activities by the State AIDS Cell over the past decade, respondents were found to be poorly informed about HIV/AIDS and how it is spread. The probability of having better knowledge about HIV/AIDS was higher among younger, more educated individuals, as well as among those who owned televisions and lived in certain zones.
Improving family planning program performance through management training: the 3Cs paradigm.
Action research was conducted in Bangladesh to determine whether a high level of fertility control behavior can be attained in a country of very low socioeconomic status, including very low levels of literacy and women's status, and if management training help can improve the performance of service delivery systems. 20 family planning officials participated in a 14-week, non-degree, management training program conducted in Dhaka. The research found that competently executed determined effort is a far faster and more effective alternative to socioeconomic development-led contraception in a developing population. A carefully designed and executed intervention can achieve a high level of contraceptive use, and thereby control fertility, without waiting for significant improvement in a country's socioeconomic indicators. For example, in the 19 experimental thanas, the contraceptive prevalence rate increased by an average of approximately 10 percentage points within 12 months of training. These findings demonstrate how a task-focused, well-designed, and properly conducted management training, backed by well organized and managed follow-up, can effect major improvement in a system's effectiveness and productivity, even if that system is staffed by a demoralized and apathetic work force.
Feasibility of local condom production examined.
Despite Africa being the world region worst affected by the HIV/AIDS pandemic, there is only 1 condom manufacturer on the continent, in Johannesburg. Hundreds of millions of condoms are donated and imported annually. For example, 500 million units were donated in 1996, of which 212 million came from the US Agency for International Development. A recently released study commissioned by the European Union's HIV/AIDS Program for Developing Countries determined that it would be technically viable to manufacture condoms in not only South Africa, but also in Mauritius, Cote d'Ivoire, and Kenya. All that is required is a factory, work force, water, and electricity, with the raw materials to be imported from Malaysia or Thailand regardless of where the factory is located. The financial returns of such an operation would depend upon the cost of labor, the type of factory and its output, and market demand. Benefits would include employment creation, potential exports, and foreign exchange savings. A typical condom plant, operating 24 hours a day with 2 production lines, can produce 160 million condom units per year. However, should such a factory be built and put into operation, managers must ensure that any condoms produced are of high quality.
Voluntary HIV counseling and testing (VCT) is an entry point to a range of HIV prevention and care interventions. Given recent breakthroughs to help people with HIV/AIDS, there is considerable reason to promote such services. However, despite the particular need for VCT in developing countries with high prevalences of HIV infection, VCT is rarely available. One exception to this general lack of HIV testing and counseling services in Africa is the AIDS Information Center in Uganda, where more than 450,000 people have received VCT. Zambia's first VCT center, Kara Counseling and Training Trust, was established in November 1992, and offers a range of support services outside the workplace or medical center. Fear, the lack of available medical help for HIV-infected people, and stigma associated with having HIV are discussed as some of the reasons why people decline to be tested for HIV infection.
In summer 1999, the Religious Consultation on Population, Reproductive Health, and Ethics will host a meeting of international scholars in Philadelphia for the first of 2 conferences on the right to family planning, contraception, and abortion in 10 world religions. The project is being funded by a grant from the David and Lucile Packard Foundation. The Consultation project hopes to uncover and disseminate the neglected resources within religious traditions which can justify, on religious grounds, the moral right to family planning, including contraception and abortion. The project's aim is to foster the introduction and consideration of more progressive religious views on family planning, contraception, and abortion in ongoing international debates. A list of attending scholars is presented. Academic papers developed from the consultation will be published first in an academic volume, then in a popular volume targeted to policy-makers, population workers in the field, and the general public. Chapters of the popular volume will be translated into several non-English languages, and the project's scholars will maintain a permanent task force to present briefings, engage the media, and contribute to policy debates in the US, at the UN, and abroad.
U.S. moves forward on international promises.
The United Nations Population Fund (UNFPA) is wholly funded by voluntary contributions from UN members to improve the quality and accessibility of voluntary family planning services in the most poor regions of the world. In 1997, UNFPA provided support services to 168 countries for reproductive health, including family planning, the prevention and treatment of sexually transmitted infections, HIV/AIDS, infertility, and maternal and child health care. In 1997, extremist US Representative Chris Smith, a Republican from New Jersey, led a movement in Congress to defund US contributions to UNFPA, citing China's coercive reproductive health practices even though no UNFPA funds were used to support coercive practices and UNFPA strongly opposes them. In March 1999, a bipartisan group of Senators introduced a bill in the US Senate to restore UNFPA funding. The bill, which has already passed the House International Relations Committee by a vote of 23-17, authorizes the appropriation of $25 million to UNFPA for fiscal year 2000 and $35 million for the following year, while also addressing important public health and human rights concerns.
Gender, refugee status and permanent settlement.
The size of the world's refugee population has grown considerably during the past 25 years due to social, economic, and political instabilities associated with factors such as the formation of new nation-states after the end of colonial rule, the end of the Cold War, and the legacies of earlier military action and foreign policies of industrial countries. In many cases, women outnumber men in these forcibly displaced populations. Yet, the over-representation of women in refugee flows reverses to under-representation in claims and/or settlement in the world's industrial countries. Women are also under-represented as asylum claimants. This paper examines how gender is implicated in the stages of defining a refugee, the refugee determination process, and the act of final settlement. After a general overview of the situation, specific relevant details are presented for Canada. Canada admits refugees for permanent settlement, and has been the first country to develop gender-sensitive guidelines and to participate in the resettlement of women at risk of harm. However, the available data indicate that women are under-represented in humanitarian-based flows to Canada. When they enter Canada, they are more likely than men to be married and to enter as spouses rather than as principal applicants.
Bringing order to chaos. A framework for understanding and treating female sexual abuse survivors.
This article presents a framework that can help clinicians treating survivors of sexual abuse understand the interactions among the past abuse, the survivor's present symptoms, and the treatment process. After an introduction sketching the problems faced by therapists who treat survivors of abuse, the article focuses on specific difficulties caused by the fact that therapists often exhibit a strong countertransferential response to survivors of abuse. The next section gives an overview of the framework that uses four boxes to describe effect, general symptoms, symptoms of transference, and symptoms of countertransference. This framework is then fleshed out for the following effects of sexual abuse: stigmatization, early sexualization, and lack of trust. It is concluded that the framework offers therapists a way to control the very intense feelings and dynamics that are present during sexual abuse therapy. Thus, therapists can better understand their clients' feelings and their own countertransference tendencies. This will help therapists avoid retraumatizing their clients.
Working toward freedom from violence. The process of change in battered women.
This article proposes using the transtheoretical model of behavior change to improve understanding of how battered women change their lives so that eventually these changes can be systematically and quantifiably measured. After a brief introduction, the article reviews currently applied outcome measures and notes that they fail to measure the internal changes that allow battered women to change. The next section reviews what is known about the process of change, pointing out that it is no easier for a battered woman to leave her abuser than for a person to adopt any other seemingly simple health-giving behavior (cessation of smoking, exercise, dietary change). This section notes that some agencies for battered women have intuitively developed programs that respond to the stages the women must go through when changing their lives. The article continues with a description of the transtheoretical model of behavior change, which assumes that behavior change is dynamic and is constructed with a recognition of stages of change, processes of change, decisional balance, and self-efficacy. Each of these constructs is discussed and applied to the situation faced by battered women. The article concludes that, while the model as it exists addresses many of the issues that battered women face in their attempt to overcome abuse, to be as useful as possible, researchers must determine what must be added to or changed in the model to make it completely relevant to this application.
Public health targets teens' private acts.
During the 1998 annual meeting of the American Public Health Association, most of the research on adolescent health focused on ways to reduce risk behavior. One researcher reported that when physicians discussed abstinence and condom use with boys 12-15 years old undergoing general examinations, condom use increased, but 8% of the respondents noted at follow-up that they believed the physicians thought it was acceptable for them to engage in sexual intercourse. Selection bias due to only 50% participation by eligible respondents may have skewed these results. Other researchers underscored the difficult but essential task of involving adolescents in research. In a study involving longterm follow-up of adult-led and peer-led risk-reduction interventions for 659 Black adolescents at risk of contracting HIV, one intervention stressed abstinence, one stressed condom use, and one dealt with nonsexual health behavior. The abstinence education led to respondents being less likely to report engaging in intercourse at the three-month follow-up, but this effect disappeared by six months. Condom promotion had a consistent positive effect. There were no differences among groups facilitated by adults or by peers. A survey of the television habits of 240 Black adolescent females 14-18 years old revealed that the viewing of television shows depicting women as sexual objects and those depicting violence was associated with adolescent pregnancy and sexual behavior that placed the adolescents at risk of becoming infected with HIV.
A battered woman needs more than biological help.
Violence against women can take many forms and is widespread, but incidences are difficult to quantify because women suffer in silence or fail to realize that the violence they experience is unacceptable. In India, a survey of 1842 rural women of reproductive age revealed that both men and women consider wife beating acceptable and that 40% of all wives have been beaten by their husbands. Indian women who have a good education, are married at later ages, and have control over economic resources are less likely to experience domestic violence. Females can suffer from violence throughout their life cycle. Fetuses may be aborted just because they are female; infants may be killed because they are female; girls may be neglected or subject to various other types of abuse; adolescents may be raped; married women may be beaten, raped, or killed by their husbands; and widows may be neglected and abused. The health effects of this violence, thus, range from death to psychological trauma. In response to this situation, women's organizations have focused worldwide attention on violence against women as a human rights violation and are beginning to hold accountable governments that were party to the Convention on the Elimination of All Forms of Discrimination Against Women. Training medical personnel on how to deal with women who are obvious victims of domestic violence will be an important strategy.
Are newspapers a viable source for intentional injury surveillance data?
This study sought to determine the accuracy of previous reports claiming that newspaper accounts were a reliable adjunct to surveillance of the prevalence of unintentional injury. Data were collected through an in-depth analysis of every issue of the two largest daily newspapers published in Alabama in 1991. Published accounts of 422 assaults, homicides, suicides, and rapes occurring in Jefferson County were compared with data available from the coroner's office and the justice system. It was found that the newspapers underreported cases of suicide, rape, and assaults. While 88% of the assaults covered in the newspapers involved firearms, firearms were actually used in only 23% of all assaults in the county. While 18% of homicides and 20% of assaults occurred with knives, the newspapers only reported 7% and 6% of these incidences, respectively. It was concluded that editorial policy leads to exclusion of much information of potential value for injury surveillance purposes, and newspapers are neither a valid nor a reliable data source for injury surveillance.
Third trimester abortion: is compassion enough?
One comprehensive ethical framework that can be applied to cases of third trimester abortion is based on the following notion: patient trust depends upon physicians developing specific virtues and basing their professional actions on these virtues. One such virtue, as described by Dr. John Gregory in 1772, is sympathy for the distress of others that overcomes self-interest. This application of sympathy and desire to relieve suffering can justify late term abortion in some cases. The compassionate response to sympathy forwarded by Gregory, however, must be properly regulated by reason, as Gregory himself recognized. Thomas Percival (1740-1803), author of the classic text "Medical Ethics," charged physicians with uniting "tenderness" (Gregory's "sympathy") with "steadiness." This combination of virtues reoccurs in the contemporary work of bioethicists Edmund Pellegrino and David Thomasma. The intellectual component of compassion requires physicians to exhibit compassion towards their patients, and this includes fetal patients. Thus, third trimester abortion is only justified in cases where fetal abnormalities are associated with the certainty or near certainty of early death or of a complete absence of cognitive developmental capacity. Most anomalies fail to meet these criteria, and physicians must exhibit the virtues of self-effacement and integrity to make rigorous, clinical, ethical judgements and properly balance the interests of the pregnant woman and the fetus.
Investing in the World Health Organization [editorial]
The World Health Organization (WHO) has been at the forefront of efforts to promote global health since its inception. The US has always considered that its support of the WHO promotes humanitarian goals and national self-interest. Under the new leadership of Gro Harlem Brundtland, the WHO is revamping its programs so that it will be even more effective in setting priorities and meeting goals. However, as of May 1999, the US was more than $35 million in arrears in assessed dues to the WHO and has taken a position of resistance to even nominal increases in its assessment. The WHO is funded through its assessments and through extrabudgetary contributions. The agency's ability to function has been jeopardized by the fact that its purchasing power has declined approximately 20% in the past decade. In 1998, the US gave the WHO $46.1 million in extrabudgetary contributions, but the US ranks eighth in contributing nations when its contribution is calculated on both a per capita basis and as a share of gross domestic product. A mere 3.7% increase in assessments would allow the WHO to cover price increases and exchange rate fluctuations. The WHO has been exemplary in adopting reforms to increase efficiency; this year, it reduced administrative costs by 15%. The US must pay its arrears and enlarge its financial commitment to this important institution.
Ensuring students' well-being as they learn to support victims of violence.
As medical schools in the US incorporate domestic violence into their curriculum, they must also create mechanisms to assist medical students who have personal histories of domestic violence. In addition, all students must receive the support they will need to confront the psychological difficulties of working with survivors of domestic violence. It is only within the past decade that the extent of domestic violence and its effects on health have been recognized. The few surveys that have examined the prevalence of a history of domestic violence among health care providers have revealed that figures for this population mirror those for the general population. One reason for this is that more women are becoming medical students, and significantly more women than men have violence in their histories. Because it is a caring profession, medicine also attracts those who were exposed to family violence. Some of these individuals become high achievers to alleviate their pain but find it impossible to maintain perfectionism in medical school. When survivors are ultimately unable to feel good about themselves, they are unable to deal with patients objectively. As patients begin to discuss experiences of violence with medical students, the students may react by withdrawal, denial, or "intrusive" actions such as rescue attempts or boundary violations. These situations may be particularly problematic for medical students who have survived violence. Medical schools, therefore, should offer self-care training as they address the presence of family violence experiences among their students.
The disastrous results of condom distribution programs.
Distributing condoms to adolescents in an effort to protect them from pregnancy and HIV infection is a prescription for disaster because adolescents are too impulsive and undisciplined to use condoms properly. A 1988 survey showed that 27% of never-married, low-income, adolescent females became pregnant in their first year of depending upon condoms for birth control. A program of condom distribution in San Francisco's Balboa High School led to nearly double the number of sexually active students using condoms and a 25% increase in the school's overall pregnancy rate, despite graphic demonstrations of proper condom use. A school-based program of condom distribution in St. Paul, Minnesota, resulted in a 33% increase in pregnancy rates (from 22/1000 to 29), while condom distribution at an inner-city school in Dallas, Texas, resulted in an 11.2% pregnancy rate, a 47% increase from the rate of 7.6 in a control school. Studies have shown that even among adults with HIV-positive partners, counseling on proper condom use is not always effective. With this evidence that condom distribution only worsens the consequence of adolescent sexual activity, another approach must be found to protect adolescents from pregnancy, sexually transmitted diseases, and HIV infection.
The Church Partnership Program.
In 1996, Black religious groups in the US acknowledged that adolescent pregnancy is a serious problem for Black churches and that the churches have a responsibility to address reproductive health concerns. These statements bolster the collaboration between clergy and faith communities and Planned Parenthood of Metropolitan Washington (PPMW) that began in 1992 when PPMW entered into a partnership with the Mt. Airy Baptist Church to prevent HIV infection. As new congregations entered the Church Partnership Program, the focus changed to the prevention of adolescent pregnancy. The program offers to ministers and lay leaders training workshops that incorporate a curriculum adapted for multiple denominations. PPMW also holds a series of monthly ministerial breakfasts to reach additional clergy and congregations. During the training and breakfasts, ministers are introduced to short-term programs offered by PPMW, such as parent-child communication workshops, forums for teenagers and younger children, and use of PPMW's resources. Longterm programs include an adolescent pregnancy prevention program, called the "Sursum Corda Youth Program," that provides life skills to 62 children from ages eight to 18. Other longterm efforts include establishment of a church-based reproductive health clinic and incorporation of an educational youth theater troupe. PPMW is currently producing a video describing this innovative partnership in order to promote its replication nationwide.
Handling information in public health planning [editorial]
This editorial highlights two papers that focus on the challenge of coordinating the flow of information between neighboring countries in southeastern Asia in order to enhance public health. One paper uses geographical mapping to display data on malaria control in China's Yunnan Province that are of relevance to bordering Myanmar, Laos, and Viet Nam. The other paper addresses data collection issues related to disease dispersal in the Greater Mekong Subregion caused by international migration. Both papers illustrate the need to extend data collection beyond standard sources, especially since such sources have evolved to document stable populations with predictable disease patterns. The effect on health of increased population movement is both positive, from resulting economic development, and negative, due to increased pressures on health systems and disease dispersal that can trigger epidemics. This public health context highlights the essential role of effective, continuous data collection and of displaying data in ways that are readily interpretable by planners. Geographic information systems that allow data to be mapped on macro and micro scales are a powerful tool. While the maps are only as valuable as the data on which they are based, it is important to begin the process with available data to stimulate the development of improved data collection systems.
Japanese experts positive on Vietnam.
During a study meeting of the Japan International Cooperation Agency's Viet Nam Project, two experts reported on recent visits to the reproductive health project in Nghe An Province, Viet Nam. Dr. Shoko Nagaya made advisory visits to the project in June and November 1998. He observed activities in 7 of the 8 districts covered and 1 of the 11 districts not covered. He was especially interested in the effects of project training on the staff of the 244 Commune Health Centers (CHCs) who oversee prenatal care and delivery. He found that the training of the mobile team members of the District Health Centers (DHCs) resulted in positive supervisory support to the CHCs. He also spoke to key personnel at the provincial Maternal and Child Health and Family Planning Center (MCH/FPC) to encourage them to achieve project sustainability. His overall impression was that the project should be expanded nationwide. Dr. Michiko Chosa made three visits to the project to transfer hospital management techniques to the MCH/FPC. In particular, he taught personnel a five-point Japanese system of making priorities, putting things in order, practicing self-hygiene, cleaning, and creating habits. Chosa found that his efforts were increasingly accepted by the staff, which was eager to become a model for the DHCs and CHCs.
Regional Technical Committee meeting.
In January 1999, the 7th Regional Technical Committee of the Asia Regional Project, which seeks to strengthen community-based delivery of reproductive health (RH) care and family planning (FP), met at JOICFP. The 15 participants from Bangladesh, Laos, Nepal, the Philippines, the UN Population Fund, and the International Planned Parenthood Federation (IPPF) reviewed project activities during 1996-98 and finalized a work plan for 1999, reviewed evaluation outcomes, drafted a set of guidelines for the implementation of community-based RH programs, and consolidated plans to ensure program sustainability beyond 2000. The delegates from each country reported on their accomplishments and future challenges, and these experiences will be incorporated into manuals that will be useful tools for policy-makers and grassroots activists alike. A representative of the IPPF recommended continued sharing of accumulated project experience, sharing IEC (information, education, communication) materials with other nongovernmental and governmental organizations, fostering site visits to expand projects, and involving local governments to raise local resources. She noted that the IPPF would explore ways to continue project support. The UNFPA representative called for increased regional activities in the areas of adolescent sexual and RH education and services, quality of care training, advocacy, and furthering male involvement.
To highlight the advantages that can be gained by distinguishing between anger and hostility in attempts to understand domestic violence, this article analyzes the literature on anger and hostility exhibited by men who commit acts of domestic violence. After a brief introduction that notes the complexity of the relationship between the experience of anger and hostility and the expression of aggression, the review opens by defining hostility and anger and the relationship between the two. The next section considers methods that are commonly used in marital violence research to assess hostility (the Buss Durkee Hostility Inventory, the Hostility and Direction of Hostility Questionnaire, and the Hostility Scale of the Brief Symptom Inventory) and anger (the Novaco Anger Scale, the Multidimensional Anger Inventory, the State Trait Anger Expression Inventory, single-item rating scales, and affect/verbal content coding systems). The article continues with a review of empirical studies that have used these assessment tools to investigate anger and hostility in maritally violent men. The analysis concludes that theoretical inconsistencies, measurement confounds, and methodological inadequacies in the studies prevent sound conclusions about the role of anger and hostility that can be used to devise interventions. The conclusion also explains the advantages of differentiating between anger and hostility and the necessity of improving the assessment of anger through the use of instruments, such as a spouse-specific anger scale, derived from a theoretical model of anger.
Date and acquaintance rape. Development and validation of a set of scales.
Increasing recognition of the prevalence of date/acquaintance rape (DAR) in the US, especially among college women, has led to an understanding that the techniques needed to fend off attacks from friends and acquaintances differ from those used to prevent rape by strangers. This study developed and tested the reliability and validity of the following DAR constructs: perceived vulnerability (underestimation of vulnerability discourages adequate self-protection), self-efficacy, relational priority (neglecting self-interest to save a relationship), rape myth acceptance (subscribing to myths about rape allows women to avoid facing their own vulnerability), and commitment to self-defense. These constructs were also correlated with scales measuring masculinity, self-esteem, and degree of belief in a "just world." Data were gathered to test these constructs via a questionnaire administered to 800 female undergraduate dormitory residents (47% response rate). Analysis of the data allowed refinement of 50 items into 25 items that constitute reliable scales of perceived vulnerability, self-efficacy, and self-determination and a marginally reliable scale of victim-blaming (rape myth). Support was found for 5/6 predicted correlates between DAR scales and 3/5 hypothesized correlations between DAR scales and convergent/discrimination validity scales. Research into this rape prevention tool will continue.
The Massachusetts-based Women's Rights Network (WRN) was founded in 1995 in response to the need to develop collaborative, crosscultural, and international strategies to eliminate domestic violence. The WRN initiated meetings with local advocates to identify the most pressing issues facing the US battered women's movement and then began to contact advocates for battered women throughout the world. To date, the WRN offers a resource center documenting strategies used around the world to end domestic violence, gives workshops and presentations to increase public education and awareness about domestic violence, organizes international strategy sessions between women's advocates in Massachusetts and those in other countries, facilitates one-on-one partnerships between groups for battered women in Massachusetts and sister organizations in other countries, and participates in the annual "16 Days of Activism Against Gender Violence." The WRN also plans to publish a biannual journal.
"The war against women". Media representations of men's violence against women in Australia.
This article analyzes how a newspaper in Victoria, Australia, represented violence against women in a special series entitled, "The War Against Women." True to the series title, the series appropriated all of the metaphors of war and dealt with violence against women in much the same fashion as it would report a war, speculating as to its causes, mapping its prevalence, reporting deaths, and referring to "explosions" of violence. As in war coverage, the series included findings of a poll of public opinion, told a story of contrition from an enemy who surrendered (a man in counseling), and offered editorials. While it drew attention to one of society's most pressing and intractable social problems, the paper ignored its own previous reports on domestic violence to gain the shock value of the "new" and, therefore, perpetuated a pattern of "discovery, forgetting, and rediscovery" of violence against women. The paper also failed to apply the feminist notion of a continuum of male violence or to breach the chasm between feminist and public understanding of male violence. Finally, the paper used editorial disclaimers to minimalize men's responsibility and distance itself from feminists. Thus, it placed its critique of men's pervasive violence against women within the hegemonic narratives of gender relations, which hold that women acquiesce in domestic violence, feminists vilify men, and men are a much-maligned group not responsible for the bad behavior of a minority. The paper, thus, conveys that idea that this war will not be won.
This article analyzes how religion influences the way in which the medical profession, legislators, and the public in Latin America think about assisted reproductive technologies (ARTs). Opposing views consider ARTs, and indeed most technology, to be either an artificial form of life or an expression of nature based in culture (and, therefore, something people have a right to use as a tool that can be considered a gift from God to be used to make God's work more effective). The dilemmas that ARTs pose are based on the myriad of choices available and on the need of some social actors to impose their own views and moralities on the rest of society, in effect attempting to exercise a moral dictatorship. The reproductive mandates of Catholicism have been specifically directed to legislators, who then refuse to implement laws that would respect moral diversity while individual citizens follow their own consciences instead of church dictates. The 1995 Latin American consensus offers minimal ethical guidelines on the various aspects of ARTs in the absence of legal regulation. It is important that ARTs be officially accepted, even if this entails restrictions. For the foreseeable future, access to ARTs in the region will, unfairly, be restricted to those who can afford private treatment.
The "illegitimacy bonus" and state efforts to reduce out-of-wedlock births.
In 1996, the US Congress responded to a dramatic increase in out-of-wedlock births (now a third of all US births annually, mostly to women not receiving welfare) by mounting a nationwide campaign against "illegitimacy." The hallmark of the campaign is a program that divides an award of up to $100 million annually among as many as 5 states for 5 years beginning in 1999 for achieving the greatest declines in out-of-wedlock births and abortions. While some states are making formal efforts to win the award, others are attempting to reduce these births despite their acknowledgement that they have little chance of winning the bonus. State programs and policies are attempting to: 1) increase contraceptive usage among low-income women by promoting family planning (FP) and expanding FP access, 2) prevent adolescent pregnancy, and 3) reach adults and adolescents. Funding for many programs is coming from "Temporary Assistance to Needy Families" (TANF) welfare block grants, which can be used for this purpose. In some cases, states are passing on small and substantial grants to communities to encourage local initiatives to reduce out-of-wedlock fertility. Initiatives undertaken since the illegitimacy bonus was announced will likely have no effect on the winners in the first or even the second years. Even when the results of the new efforts are in, it may be difficult to establish cause and effect. It is clear that the incentive has sparked activity, especially given the flexibility of available TANF funds to support this activity.
AIDS now world's fourth biggest killer.
In May 1999, the World Health Organization released figures indicating that AIDS is now the fourth leading cause of death in the world (moving up from seventh in 1998 rankings). The previous first three causes, ischemic heart disease, cerebrovascular disease, and acute lower respiratory disease, remain the same. In Africa, AIDS is the number one killer and was responsible for 1,830,000 deaths last year, twice as many as were caused by malaria. The change in AIDS ranking was partially due to improved methods of estimating the mortality caused by diseases, but the new figures vindicate UNAIDS warnings in 1998 that the epidemic is still out of control. UNAIDS estimates that 6 million more people are infected with HIV each year, but the international community is only investing $150 million each year to prevent and control HIV in Africa.
Why men like or dislike condoms.
In a double-blind, crossover study to determine how men decide if they like a specific type or brand of condom, 194 men rated 3765 condoms as 61% favorable, 31% neutral, and 8% unfavorable. The men found less favor with condoms that were too loose, too tight, too short, or too hard to apply. Unfavorable ratings were also given if the condom slipped or broke. In general, men with larger penises rated condoms less favorably. Condoms that seemed to be well-lubricated throughout use found more favor. The study concluded that resistance to adoption of consistent condom use could be reduced through better condom design and manufacture.
Public health issues in Hong Kong and China [editorial]
The 1997 return of Hong Kong to Chinese jurisdiction has created public health opportunities and challenges. Public health problems attendant upon industrialization and urbanization on the mainland include environmental pollution, food contamination, and increasing occupational injuries and traffic accidents. Major problems in Hong Kong have included outbreaks of infectious diseases and food poisoning. Chronic diseases in both areas have been caused by socioeconomic changes that led to lifestyle changes, such as increased tobacco use. With smoking rates already over 30% in China and 15% in Hong Kong, there is concern that multinational tobacco companies will attempt to increase their market in developing countries to compensate for losses at home. A further concern is the increase in incidence of sexually transmitted disease. The reunification of Hong Kong and China, however, presents opportunities for joint research in areas of medicine and public health of common interest; joint training of health care workers; and cooperation in the prevention, control, and surveillance of infectious diseases and in environmental protection. Challenges include securing the necessary government support and resources to implement new activities, mobilizing the community to improve community health, enlisting the support and cooperation of other sectors, and revamping the outdated organizational structure of government agencies dealing with public health issues.
French-led therapy fund kicks off in Africa.
The antiviral drugs used to treat HIV infection successfully in developed countries are priced out of the reach of most infected individuals in the most effected areas of the world. To reduce this global inequity, in 1997 the Minister of Health and the President of France created the Fund for International Therapeutic Solidarity to subsidize the cost of anti-HIV therapies in developing countries. The Fund's first project will be to provide about $1.7 million over 4 years to help prevent maternal-child transmission of HIV in the Ivory Coast. To date, the only contribution to the fund has been $4 million in seed money donated by France. There is hope for an additional $3.3 million from the European Commission, and talks are underway with the World Bank. The Ivory Coast project will subsidize "bitherapy" for 500 patients and will support testing and therapeutic follow-up for 20,000 pregnant women and their families in Abidjan. The women who test positive for HIV will be offered a "short course" of antiviral drugs to prevent maternal-child transmission, and mothers in advanced states of HIV will be offered triple therapy. Health officials in the Ivory Coast welcome the project but point out that it will have only a small effect. UNAIDS officials counter that it is better to begin than to wait until the perfect intervention is available. Meanwhile, other African nations are seeking assistance from the Fund, and new programs will soon start in Uganda and Morocco.
A future free from violence: a world where all women enjoy their human rights.
The executive director of the UN Development Fund for Women (UNIFEM) opened her address to the 42nd session of the UN Commission on the Status of Women by affirming a vision of hope for creation of a world where women can enjoy their human rights. To further this vision, UNIFEM is working at the national level to: 1) help women's organizations increase their capacity and develop networking, leadership, and advocacy skills; 2) focus attention on needed changes in pivotal criminal justice and legal systems; and 3) explore ways that governments, international agencies, and civil institutions can create conditions that will foster peace. UNIFEM administers the UN trust fund in support of actions to eliminate violence against women, which has supported 45 innovative initiatives in 40 countries, and coordinates the Latin America and Caribbean Campaign on Women's Human Rights: A Life Free of Violence. In addition, UNIFEM has developed an array of initiatives to encourage universal ratification of the Convention on the Elimination of All Forms of Discrimination against Women. UNIFEM's work in the area of peace-building and conflict resolution includes the African Women's Crisis Program, which enables UNIFEM to support women who have been victimized by armed conflict and other emergencies, the launching of the Federation of African Women Peace Networks, and help in establishing the Mogadishu Peace Market initiative. These efforts reflect UNIFEM's understanding that without peace and women's human rights there can be no sustainable communities or development.
A Safe Space Created by and for Women: sexual and gender-based violence program phase II report.
This report covers the second phase of a Sexual and Gender-Based Violence Program being implemented by the International Rescue Committee among Burundian refugees in Tanzania. This phase involved applying the findings of a needs assessment survey so that the refugee community could be engaged in reducing the incidence of sexual and gender-based violence. The report is introduced with an overview of the history of the conflict in Burundi and an update of the Tanzanian context. The next section summarizes the methods used and results obtained during the first phase of the project. Then the report describes the community mobilization effort undertaken as the second phase of the project moved through the steps of disseminating survey results, establishing drop-in centers, building the capacity of women leaders, and involving block leaders and security leaders. The report then reviews efforts to deal with emerging topics such as managing staff stress, expanding the program's focus to include children under 18 years of age, dealing with violence against men, and creating interagency networks. The report concludes by noting that the program depends upon the existence of trust between survivors and staff and that the program will continue to progress with the lessons learned in one camp transferred to work done in the others. The guiding principles of this program are that it is community run and owned (and, therefore, sustainable) and that the experience gained by the women will help them improve their overall position in society.
Clandestine abortion in Latin America: provider perspectives.
This report details in-depth interviews with 10 clandestine abortion providers in Latin American cities. The introduction notes that unsafe abortion is thought to cause 24% of maternal deaths in Latin America and is known to strain public health resources. Because most of the abortions occur in women with children, the high mortality rate causes adverse effects in surviving children. Efforts to redress this situation have focused on reducing the number of unwanted pregnancies by providing high quality contraceptive services, improving postabortion health care, and changing the legal prohibition on abortion. The article continues by discussing the factors that led the abortion providers to begin their clandestine work, such as experiencing a sense that they were called to help women in this way, a personal experience with abortion, and a commitment to social change. Next, the article considers the major difficulties this work causes in the personal and professional lives of providers as they deal with a lack of medical support; the need for secrecy; and threats of violence, extortion, and prosecution. Finally, the article reviews what gives the providers satisfaction in their work, such as the feeling that they are saving women's lives and empowering women while meeting a challenge.
The Musasa Project, in collaboration with the University of Zimbabwe and the London School of Hygiene and Tropical Medicine, conducted action research to document the magnitude and health consequences of violence against women (VAW) and to explore strategies for action. In 1997, they reported their findings at the Musasa Project Workshop, held at the Monomotapa Hotel in Zimbabwe. This report contains the text of speeches and papers delivered at the workshop and excerpts from discussions. The first day of the workshop was devoted to an analysis of the current situation in Zimbabwe. It featured an opening speech by the Deputy Minister of Health, who described VAW as an emerging health issue in Zimbabwe. Papers showed VAW to be a global health problem, sketched the magnitude and health consequences of violence against women in Zimbabwe, presented community attitudes that perpetuate VAW in Zimbabwe, and presented Musasa's experience in meeting clients' counseling needs. On day two, papers were given on the following topics: options for community action in confronting abuse, strengthening Zimbabwe's health sector response to address violence, lessons learned from the establishment of victim-friendly courts, community intervention strategies dealing with gender issues, and counseling women who are experiencing violence. Workshop participants then made specific recommendations calling for appropriate responses to domestic violence and additional research into the effectiveness of interventions.
Philippine migration policy: dilemmas of a crisis.
Philippine migration policy is traced from the early 1970s to the present. The main migration trends in the 1990s are described. An assessment is made of the efficacy and appropriateness of present migration policy in light of the economic crisis. A regional approach to migration policy is necessary in order to encourage placing migration as a greater priority on national agendas and in bilateral agreements. In the Philippines, migrants are considered better paid workers, which diminishes their importance as a legislative or program priority. Santo Tomas (1998) conducted an empirical assessment of migration policies in the Philippines, but refinement is needed. Although migration is a transnational experience, there is little dialogue and cooperation among countries. Philippine migration policy defines its role as an information resource for migrants. Policy shifted from labor export to migrant management in the public and private sectors. Predeparture information program studies are recommending a multi-stage process that would involve all appropriate parties. There is talk of including migration information in the education curriculum. There are a variety of agendas, competing interests, and information resources between migration networks and officiating agencies. The Asian financial crisis may have a mild impact, but there are still issues of reintegration, protection, and employment conditions
The Singapore state's response to migration.
Migration trends in Singapore are traced since 1819. Immigration has been encouraged to advance economic development. Local and international factors fuel migration to Singapore. Singapore depends upon foreign labor. Population growth has been mainly due to migration from China, India, Malaysia, and countries surrounding Singapore. Independence in 1965 led to policies aimed at controlling high population growth. Policies became pronatalist after 1987. Foreigners in 1998 were over 18% of the total population, which was six times the number in 1970. About 2000 Singaporeans per year emigrated during the 1990s. Singapore is encouraging overseas industrial development. In 1997, the Prime Minister called for recruitment of foreign talent in order to meet the challenges of an increasingly globalized world, low fertility, and an aging society. Economic planners recommend short-term migration of unskilled foreign workers who would be a revolving pool to fill jobs natives do not want. Singapore is promoting arts and culture in order to keep people in Singapore. The government has issued assurances that natives will have first priority on jobs, education, and training. Singapore's ability to absorb workers will depend upon its economic performance.
The Malaysian state's response to migration.
This paper aims to provide a profile of migration trends in Malaysia since 1970 and to analyze public policy on migration in the context of economic growth and the labor market. The discussion centers on the impact of the Asian financial crisis. There is long history of immigration to Malaysia. The development strategy of the 1970s and 1980s was to create more jobs and restructure employment to meet equity goals. Labor shortages on plantations and construction booms led to a more organized, sustained effort to import labor. Recession in the mid-1980s led to unemployment, but many Malaysians were unwilling to work on plantations, in construction, or in low paying jobs. Economic growth during 1987-96 was very high, and labor shortages spread to service and manufacturing sectors. Migration policy has shifted over the decades. Both the market and the government's promotion of export-based industrialization require access to low cost migrant labor. Public and official recognition of the large number of migrants was not made until 1995. The financial crisis in 1998 led to enforcement of a new migration policy on illegal migrants and greater outflow of migrants. The economic crisis has increased job and income inequities in the region; this encourages continued migration. It is argued that it would be best for Malaysia to maximize short-term gains while minimizing long-term economic, social, and political costs.
Thailand's responses to transnational migration during economic growth and economic downturn.
This paper gives an historical overview of immigration to Thailand since the 1970s and emigration since the 1960s. It describes migration policies since the 1930s. Final discussion focuses on the impact of economic contraction on migration. Immigration to Thailand dates back to the 1760s when a huge wave of Chinese emigrated to Thailand. The flow continued until about 1850 and resumed during 1905-17. The next big waves of immigrants were after 1975, when refugees fled Indochina, and in the 1990s, when migrants flocked from neighboring countries drawn to the booming economy. Thai professionals left in the 1960s for the USA. During the 1980s, many left for work in the Middle East. During the 1990s, Thai migrants moved within the East and Southeastern Asian countries and the USA or Europe, and they included many women and illegal migrants. Emigrants leave as arranged by the government, by employers, by recruitment agencies, and as trainees. The first official act was in 1950 and revised in 1979. Many work permits were approved in the 1990s, especially for unskilled labor. There are supports for Thai migrants abroad, but little is offered to foreigners at home. By 1997, the country's recession led to nonrenewal of many work permits. The 1998 economic crisis led to a new labor policy that deported illegal and unskilled migrant workers in order to create jobs for Thais. Policy encouraged Thais to seek work overseas.
On-the-job training through follow-up visits to improve the quality of family planning services.
This follow-up study evaluates the effectiveness of an on-the-job training program for health professionals in Turkey. The family planning training program was launched in 1992 in medical schools. Interns received further training during clinical practice at family planning clinics. National Family Planning Guidelines were established in order to create uniformity in in-service and pre-service training. Follow-up visits were conducted at 16 Maternal and Child Health/Family Planning Centers, which collaborated with universities for pre-service training. Follow-up visits included observations of actual clinical practice and performance ratings using a standard checklist on interpersonal interaction and method-specific counseling. Findings indicate that 55% of the 130 in the sample were midwives, 35% were general practitioners, and 7% were interns. 3% were specialists. Most of the clinics were in maternity hospitals with an average patient load of 25-35 clients per day. Clinics offered a range of methods. Quality of family planning improved with on-the-job training. Counseling, IUD insertion, and genital tract infection services improved with training. The evaluation did not measure improvement in motivation of health professionals or client satisfaction.
An exploratory study of Korean fathering of adolescent children.
This 1996 exploratory study uses an ecological model (Bronfenbrenner, 1989; DeLuccie, 1995; Belsky, 1984; and Barnett and Baruch, 1987) to assess variation in fathering styles among adolescents in Seoul, Korea. It examines determinants of fathers' involvement (task share, frequency of father involvement, and warmth). Data are obtained from a sample of 129 Korean families who had children aged 11-14 years in one of three middle schools. 66 families had low socioeconomic status (SES). Fathers' mean age was 41.8 years. 73% had two children. 13.2% of fathers had graduated from middle school. 41.1% had graduated from high school. 40.3% had attended some college. 25.7% of low SES fathers had attended college. Analysis of variance indicated that there was no significant effect of the three measures by child gender. Warmth of fathering and task share of father involvement varied by SES. Low SES fathers showed less warmth and shared significantly more tasks. Paternal support given to the mother was the strongest predictor of warmth of fathering. 42% of variance in frequency of father involvement was explained by warmth of mothering and paternal support. Task share was explained by maternal education, father's education, frequency of mother involvement, and SES.
Pediatric care and immunization among Jordanian children.
This 1983 study examines immunization coverage and use of health services for 4533 children among a national sample of ever married women aged 15-49 years in Jordan. Data are obtained from a household survey conducted among households with children born in the preceding three years before the survey. Findings indicate a high level of immunization coverage but a low level of use of pediatric care. Sex was not associated with health care use or preferential treatment of male children in this study. This finding differs from other study findings. Immunization did not vary by socioeconomic factors, with the exception of female schooling. Higher education was associated with higher immunization coverage. Findings suggest that a mother's understanding, motivation, and decision making were associated with use of health services. Pediatric care was affected by socioeconomic factors: residence, average space per dwelling, average education, and maternal education. Findings suggest that outreach services and integrated maternal and pediatric services would improve the use of health services. 83% of the sample were immunized. Knowledge of exact date of birth was associated with immunization status.
This study describes mortality among 12 reporting states in the USA in 1984: Colorado, Georgia, Kansas, Kentucky, Maine, Missouri, Nebraska, Nevada, New Hampshire, Rhode Island, South Carolina, and Wisconsin. Data are obtained from the Vital Statistics Cooperative Program of the National Center for Health Statistics. Data are described by occupation and industry on the death certificate, cause of death, and preliminary mortality ratios (PMRs). Reliability and accuracy of the reported information from reported studies did not indicate any simple generalizations. The ten highest statistically significant PMRs for males in occupations were extractive occupations, followed in descending order by accidents in extractive occupations, forestry and fishing, teachers, farm and other agricultural occupations, electricians, health diagnosis and treatment occupations, military, and painters and construction. The highest PMRs for females in occupations were for machine operators, followed by professional specialty occupations, precision food production occupations, health services, food preparation, motor vehicle accidents among other handlers and cleaners and laborers, military, administrative support occupations.
Maternal mortality: the state of the art.
This paper discusses some issues of measurement of maternal mortality. Maternal mortality differences between developed and developing countries are much greater than differences in infant mortality. Reductions in maternal mortality require multiple solutions. Solutions require at least medium levels of technology. Infant and maternal mortality are similar in that both occur near the time of birth. Measurement must include a large sample size. Maternal mortality is highest in countries without adequate vital registration systems. Maternal mortality in any country may be underreported by at least 25% up to 100%. Research study samples up to 10-15 years ago were hospital-based. The exceptions are studies by Chen et al based in Matlab, Bangladesh, and studies in England and Wales. Now there are a number of population based studies, such as those in Addis Ababa, Ethiopia; Ananthapur district in South India; the Menoufia Governorate and three other governorates in Upper Egypt; and Jamaica. Another recent change in research methods is the focus on cause of death due to multiple causes, including social ones. Examining only clinical causes in developing countries denies the influence of access to medical care, transportation, and other obstacles to care. Measures have changed from measurement of obstetric risk with the maternal mortality ratio to rates as a proportion of maternal deaths out of the reproductive age population. Researchers are now demographers as well as clinicians.
Report on baseline survey in Uttar Pradesh. Volume III. Trained dais.
This report establishes benchmark data on family planning and maternal and child health services in Uttar Pradesh state in India. Data are obtained from a sample of trained dais (traditional birth attendants, TBAs) in rural areas of Uttar Pradesh during 1991. Findings indicate that 16% of Dais were aged younger than 35 years. About 41% were aged over 50 years. Most were married. 25.6% were widows. Only 1.2% were never married. 72% were illiterate. 91.5% were Hindus. 73% belonged to Scheduled Castes. 70% were self-employed. 59% only had the skills for being a Dais. Dais had worked an average of 17 years. 27% had worked under 10 years. An average of 9 years had passed since the last training. Most received training at subcenters. Average length of training was 8 weeks. Dais remembered that training focused on personal hygiene and sanitation, cord cutting, and sterilization of equipment. Few remembered training in detection of high risk pregnancy, family planning, or nutrition. 59% considered the training useful. 32% did not receive a delivery kit after training. 28% of 82 Dais valued retraining. A high percentage provided advice on tetanus toxoid, nutrition, iron deficiency, and prenatal care and referred cases. Referrals to subcenters occurred an average of 8.6 hours after pain started. Some postnatal care was provided. 44% counseling about family planning. Many were untrained for complicated deliveries and wanted more training, more money per delivery, and restocked kits. Many Dais without kits used sterilized equipment.
This study aims to determine whether use-effectiveness has changed during 1990-96 in Egypt. Data are obtained from the 1995 Egypt Demographic and Health Survey among 8274 married women who had a birth in the last 5 years; a subsample of 6209 who had used a method before or after the last delivery; and 5280 who had used a method only after the last delivery. The study sample compared to the larger sample of 13,583 married women was similar but younger and with more ever users. This study examines parity at first use of contraception, timing of use after delivery, contraceptive methods chosen, duration of use, reasons for discontinuation, extended use failure by method, birth intervals, and the relationship between contraceptive use and use of maternal and child health services. 48% of currently married women used contraception; only 2% used traditional methods. Key findings are that family planning has successfully marketed the benefits of contraception among younger women, which has increased use effectiveness. More women discontinuing use for spacing reasons means better family planners. Extended use failure improved during 1992-95. Only 16% of discontinuers used a method for fewer than the ideal 24 months after delivery. Findings from the subsample suggest greater promotion of effective use and adoption at lower parity among rural Upper Egyptian women. Women should be reminded of a late, high risk pregnancy at older ages.
Mother's employment and infant and child mortality in India.
This study examines the influence of mother's employment on child survival in India. Data are obtained from the 1992-93 National Family Health Survey among 89,777 ever married women aged 13-49 years. Employment effects are evaluated for mothers who were not employed, employed at home, employed at home without cash earnings, and employed outside the home with cash earnings. Findings indicate that infant mortality did not vary by mother's employment status. Mother's employment had a negative impact on infant survival, especially male infants, if the mother worked away from home for cash, lived in an urban area, or lived in the south of India. Infant girls' survival chances were better in rural areas and worse in urban areas. Maternal employment negatively affected child survival. Male child mortality was greater among mothers working away from home. Female child mortality was greater among mothers working at home. Lower total infant and child mortality in the south and east regions was due to lower female mortality. In the north, mothers' employment was not significantly associated with increased risks of infant and child mortality, except among infant boys. In the south, mothers' employment was associated with increased risks of mortality among boys aged 12-47 months. In the east, it was associated with increased risks for girls. The interaction between birth order and same sex siblings at birth and mothers' employment was unable to be determined.
The prevalence of domiciliary deliveries in Khayelitsha, Cape Town.
This brief article presents the findings of a survey among maternity wards and family planning clinics that ascertained the prevalence of home deliveries in South Africa. The survey was conducted during 1991-94 in Khayelitsha Township with its large informal settlements in Cape Town. The sample included 3394 patients cared for at Khayelitsha Midwife Obstetric Unit (MOU) who were admitted prenatally; 29,2200 women admitted to the MOU labor ward; a one in ten sample of the 5260 children with vaccination cards from three clinics; and women who were offered family planning at clinics during 1992-96. Findings indicate that 8% of the sample had home deliveries, which indicates a stable level. The number of contraceptive acceptors increased by 89% during 1992-94. The number of patients cared for at Khayelitsha MOU declined by 17%. The decline is attributed to a successful family planning program and a low number of deliveries in Khayelitsha.
Benin 1996: results from the Demographic and Health Survey.
This summary report presents statistical tables of findings from the 1996 Benin Demographic and Health Survey among 5491 women aged 15-49 years and 1535 men aged 20-64 years. Findings indicate that 70.8% of women had no formal education. 19.8% had a primary education. Fertility during 1991-96 was 6.3 children/woman, a decline from a stable level of fertility of 7.1. Fertility was 7.0 in rural areas and 5.2 in urban areas. Fertility was 7.0 among women with no formal education, 5.0 among women with a primary education, and 3.2 among women with some secondary or higher education. Ideal fertility was highest among older women. High parity women had a high ideal number of children desired. 58.6% of women with 6 children desired a stop to childbearing. 23.0 of all women in a union desired a stop to childbearing. 73.6% of births in the preceding 3 years were wanted. 19.3% were wanted later. 5.7% were unwanted. Contraceptive prevalence was 11.6% for traditional methods and 3.4% for modern methods. Contraceptive use was highest among women aged 20-24 years and 35-39 years. 43.5% obtained methods from the public sector. 29.2% obtained methods from the private sector. 26.7% obtained supplies from other sectors. 76.2% knew at least one method. Women were most knowledgeable about the pill, injectables, condoms, and traditional methods. 25% of young children were moderately stunted. 14.3% were moderately wasted.
The world food problem: tackling the causes of undernutrition in the Third World. 2nd ed.
Undernutrition continues to compromise physical health and size, learning capabilities, and labor productivity in developing countries. Since the 1992 publication of the first edition of this analysis of the world hunger problem, significant advances in knowledge and understanding have occurred. This second edition integrates current knowledge from a range of disciplines (economics, demography, nutrition science, biology, chemistry, health science, geography, agronomy, history, anthropology, philosophy, and public policy analysis) and presents the most recent data in tabular form. Part 1 addresses the definition, impact, and measurement of malnutrition. Part 2 focuses on the economic, demographic, agricultural, environmental, and health-related causes of malnutrition. The authors advocate a food security equation approach that conceptualizes the hunger problem as a result of the interplay of household food consumption requirements, the level of household food production, the price of food, and income and liquid assets available for food purchase. Part 3 explores public policy alternatives for nutrition planners, including public health program reform, land reform, food subsidies, and famine and disaster relief. There is general agreement among experts that policy initiatives should seek to reduce the rate of population growth, invest in improved agricultural productivity, protect soil and water resources, and encourage economic growth among the poorest.
Choosing unsafe sex: AIDS-risk denial among disadvantaged women.
The links between inner-city African-American women's low condom use rates and their conceptualizations of heterosexual relationships were investigated in an anthropological study conducted in Cleveland, Ohio, during 1991-93. Low-income women seeking care at five urban health care centers associated with the Cleveland Maternity and Infant Health Care Program were recruited for interviews and focus group discussions. The typical participant was 28 years old, had completed the eleventh grade, and had two children. Although the women had been exposed to education on safer sex and HIV/AIDS prevention, they did not personalize their AIDS risk or comply with condom use recommendations. This AIDS-risk denial was not related, as is widely assumed, to financial dependence on men, but rather to the cultural meanings and psychosocial ramifications associated with condom use and AIDS. Unsafe sex is the norm among socially isolated women who derive self-esteem and status mainly from having conjugal partnerships with men. Women have an emotional investment in continuing to view themselves as wise and their partners as monogamous. Because condoms are associated with infidelity and deception, their use implies that partners do not truly care for one another and thus threatens the monogamy narrative. Avoidance of HIV testing or nondisclosure of HIV seropositivity is motivated by a desire for intimacy and the fear of rejection. AIDS education programs that are grounded in simple materialist models of Black female sexuality and ignore the enormous impacts of culturally conditioned social and emotional factors are doomed to failure.
Contraceptive technology. Seventeenth revised edition.
Reproductive health care in the US has expanded in content to include a wide range of risk factors that influence women's health, and the broader public health impact of reproductive health has been recognized. Family planning services now address issues such as infertility, reproductive tract infections, and menopause. This 17th edition of "Contraceptive Technology" presents practical information for both providers and users of reproductive health services on a spectrum of salient concerns. Its 31 chapters address topics such as sexuality and reproductive health, female genital tract cancer screening, menstrual problems, menopause, HIV/AIDS, reproductive tract infections, education and counseling, abstinence, coitus interruptus, emergency contraception, fertility awareness methods, male condoms, vaginal spermicides, vaginal barriers, combined oral contraceptives and other hormonal methods, IUDs, male and female sterilization, postpartum contraception and lactation, future fertility control methods, preconception care, pregnancy testing and management of early pregnancy, impaired fertility, abortion, adolescent sexuality and pregnancy, contraceptive efficacy, and the dynamics of reproductive behavior and population change.
Emergency contraception: the user profile.
Although emergency contraception has been promoted in Sweden since 1994, little is known about the characteristics of women who request the regimen. During a 4-month period in 1996, 794 consecutive women who presented to youth health centers and a large family planning clinic n Uppsala, Sweden, for emergency contraception were asked to complete a questionnaire covering demographic characteristics, sexual history, previous contraceptive use, and the context in which the need for a postcoital method arose. 762 women (96%) completed the questionnaire. The mean age of respondents was 19.8 years (range, 13-48 years); 80% were high school or university students. Intercourse had taken place within the past 24 hours for 50%, within 25-48 hours for another 33%, and within 49-72 hours for 17%. 667 women were previous condom users and 390 had taken oral contraceptives. The 214 women who had previously used emergency contraception were significantly more likely than those without such a history to be smokers and to have had an abortion. Friends were the main source of knowledge about emergency contraception. 20% of emergency contraception seekers had used alcohol in connection with the unprotected intercourse and 37% had not discussed contraceptive use with their partner prior to coitus. A review of the factors underlying the current need for emergency contraception revealed five general categories: condom breakage (47%), coitus interruptus (12%), unprotected intercourse (20%), poor compliance with the pill (2%), and general worries about pregnancy (18%). Over-the-counter availability of specially packaged emergency contraceptive pills should be considered to make this method of pregnancy prevention even more accessible to young women.
The traditional approach to evaluating how well a barrier method of contraception prevents pregnancy must be reassessed now that the availability and acceptability of emergency contraception are increasing. It is possible, for example, that a woman may use emergency contraception to lessen the impact of an observed or suspected failure of a barrier method (e.g., dislodgement of a cap-like device or condom breakage)--an act with implications for efficacy estimates. Omission from efficacy analyses of cycles with nonstudy barrier use implies omission of cycles with a higher underlying risk of pregnancy than other cycles. This omission will produce estimates of the cumulative pregnancy probabilities that are lower than would be expected if the nonstudy method were not available and the degree of consistency of use of the study barrier did not vary with frequency or timing of intercourse. The first step in designing a barrier method efficacy trial now becomes deciding whether the primary outcome of interest is the probability of pregnancy expected among users of the barrier alone or the barrier with emergency contraception back-up. It must be kept in mind that women who would not use emergency contraception as a back-up in the event of barrier failure may differ from other study participants in ways related to pregnancy risk.
Emergency contraception update.
Two recent studies have provided important new information on emergency contraceptive use. The first, a World Health Organization study of 1998 women at 21 centers worldwide, found that levonorgestrel-only emergency contraceptive pills (two doses of 0.75 mg) have fewer side effects and are more effective in preventing pregnancy than the Yuzpe regimen. Women randomized to receive the levonorgestrel regimen had one-third the risk of pregnancy compared with women who were assigned to the Yuzpe group (relative risk, 0.36; 95% confidence interval, 0.18-0.70). The effectiveness of both regimens declined with increasing time since unprotected intercourse. The second study compared contraceptive use patterns in 1000 Scottish women; 500 received only information about emergency contraception and 500 were given both information and an advance pill supply. At the 1-year follow-up, use of regular contraceptive methods did not vary significantly between groups, and women who received advance supplies were not more likely to use emergency contraception repeatedly. These findings imply that, where available, the levonorgestrel-only emergency contraception should be the regimen of choice.
Levonorgestrel is a better emergency contraceptive than the combination pill.
A comparative study conducted at 21 centers in 14 countries found that women who use a levonorgestrel-only emergency contraception regimen are about one-third as likely as women who use the standard Yuzpe regimen to become pregnant after treatment. They are also less likely to experience nausea and vomiting. A total of 1998 women who had had unprotected intercourse within the past 72 hours were enrolled in the study and randomly assigned to receive either levonorgestrel (2 0.75-mg doses) or the Yuzpe method (2 50-mcg tablets of ethinyl estradiol and 2 0.25-mg tablets of levonorgestrel). At the follow-up visit 1 week after expected resumption of menses, 42 women (31 from the Yuzpe group and 11 from the levonorgestrel-only group) were pregnant. The pregnancy rate was 3.2% for women using the Yuzpe regimen compared with 1.1% in the levonorgestrel-only group (crude risk ratio, 0.36). The risk of pregnancy increased significantly as the number of hours between unprotected intercourse and use of either method of emergency contraception increased. When the treatment was initiated within 24 hours of unprotected sex, the failure rate was 0.4% in the levonorgestrel group and 2.0% in the Yuzpe group; when treatment was commenced 49-72 hours after intercourse, these rates were 2.7% and 4.7%, respectively. 51% of women assigned to the Yuzpe regimen, compared with 23% of those in the levonorgestrel group, experienced nausea; the incidence of vomiting was 19% and 6%, respectively. On the basis of these findings, it is recommended that levonorgestrel replace the Yuzpe regimen as the standard emergency contraception method.
Emergency contraceptives bring a little peace of mind.
Although emergency contraceptive pills have been prescribed to US women since the discovery of the birth control pill, this regimen has been termed "America's best-kept secret." For fear of legal liability, many providers have been unwilling to prescribe oral contraceptive pills for a purpose other than that for which they are labeled on the packaging. There are indications, however, that access to emergency contraception in the US is improving. PREVEN, the first product to be approved by the US Food and Drug Administration specifically for emergency contraception, was released in 1998. The kit includes a step-by-step information booklet, a pregnancy test, and four birth control pills. In Washington State, collaborative drug agreements between volunteer pharmacists and licensed prescribers enable pharmacists to prescribe emergency contraception pills directly--a move that is estimated to have prevented 207 unintended pregnancies and 103 abortions in less than one year. Planned Parenthood has developed two programs to increase the use of emergency contraception. The first allows clinicians to discuss emergency contraception over the phone with clients (even new ones) and to call in prescriptions to local pharmacies; the second provides women with emergency contraceptive kits to keep on hand in advance of a need for the regimen.
Potential molecular mechanisms for the contraceptive control of implantation.
The implantation process has come to be regarded as the most relevant limiting factor for successful pregnancy. A simplified approach to implantation prevention seeks to interfere with cytokines that trigger adhesion of the blastocyst. This article reviews current knowledge on the role of cytokines in human implantation. Four such molecules are salient: colony stimulating factor-1 gene, leukemia inhibitory factor, interleukin-1 receptor antagonist, and heparin-binding epidermal growth factor. The endometrium is an active site for cytokine-growth factor production and action, and the embryo is able to communicate with the endometrium using the same cytokine-growth factor-receptor language. The hormonally driven cytokines regulate each other in a cascade process. It is now possible to think in terms of more organ-specific paracrine acting-molecules as opposed to endocrine hormones with less endocrine action. A system for delivering these polypeptides must be local and as specific as possible while avoiding hormonal interference. Potential clinical applications include naturally occurring antagonists such as interleukin-1 receptor antagonist or synthetic derivatives with antagonistic function or blocking receptor antibodies administered as vaginal pills during the implantation window in cycles when coitus occurred in the luteal phase.
Hormonal contraception, IUDs, and HIV risk.
Family planning providers should inform their clients that hormonal contraceptives, IUDs, and other long-term methods do not confer protection against sexually transmitted diseases (STDs), including HIV/AIDS. Risk assessment questionnaires can help health care providers to raise this issue and gain an understanding of their clients' personal situations. Not only do nonbarrier methods fail to protect against STDs, but also there is tentative evidence that they increase the risk of infection. The progesterone contained in hormonal methods may cause endometrial, cervical mucus, and bleeding changes that serve to increase susceptibility to STDs/HIV. Moreover, estrogen-induced changes in the degree of cervical ectropion may enhance vulnerability to certain infections. Although studies have documented an increased risk of HIV among sex workers who use hormonal contraception, studies involving low-risk women have not recorded any increase in risk. Despite concerns that increased menstrual bleeding and possible increases in upper genital tract infections place IUD users at increased risk of HIV, this has not been confirmed in either high- or low-risk women.
Awareness of non-hormonal contraceptive (SAHELI) among subjects using MTP services [letter]
A survey conducted at the family planning clinic of Indira Gandhi Medical College, Kamala Nehru Hospital, in Shimla, India, documented a need to improve awareness of the steroid-free oral contraceptive pill SAHELI. 200 consecutive women who presented to the clinic for induced abortion were interviewed, and only 41 (20.5%) were aware of the method. Just 5.2% of illiterate women, compared with 65.3% of college graduates, knew about SAHELI. Women whose major source of knowledge about contraception was the mass media were most knowledgeable about SAHELI, while those who relied on doctors for contraceptive information were least aware. Increased communication about this new contraceptive option on the part of health care providers is essential if Indian women are to have freedom of choice.
Oral-contraceptive use and risk of hip fracture: a case-control study.
Hormone replacement therapy prevents the decrease in bone density that accompanies menopause and reduces the risk of hip fracture. A population-based case-control study conducted in Sweden sought to determine whether premenopausal exposure to the estrogen in oral contraceptives (OCs) has a similar protective effect on hip fracture risk. 1327 women 50-81 years of age with fractures of the proximal femur were identified from clinical records or hospital operation registers for the period 1993-95 and matched by age with 3312 healthy controls drawn from population registers. 130 cases (11.6%) and 562 controls (19.1%) reported ever-use of OCs; 120 cases (9.0%) and 456 controls (14.0%) were taking hormone replacement therapy. Overall, the risk of hip fracture was 25% lower in ever-users of OCs than in never-users (odds ratio (OR), 0.75; 95% confidence interval (CI), 0.59-0.96). This risk reduction persisted even after adjustments for major hip fracture risk factors and other potentially confounding factors, including hormone replacement therapy. Women who had used high-dose OCs (estrogen dose of 50 mcg or more of ethinyl estradiol) had a 44% lower risk of hip fracture than never-users (OR, 0.56; 95% CI, 0.42-0.75). No overall trend was observed with duration of OC use or time since last use. However, use at older ages was associated with lower relative risks than use at earlier periods of life. The ORs for hip fracture were 1.26 (95% CI, 0.76-2.09) for use before age 30 years, 0.82 (95% CI, 0.57-1.16) for use at 30-40 years of age, and 0.69 (95% CI, 0.51-0.94) for use after 40 years of age. These findings indicate that OC use can reduce the risk of hip fracture, especially if prescribed late in a woman's reproductive life.
Depression has been recognized as a rare side effect of oral contraceptive (OC) use. It has been suggested that OC-related psychological changes are a result of pill-induced deficiencies of vitamins B-6 and B-12, folate, and iron. Deficiencies in these nutrients can produce anemia, which, in turn, influences mental status. The present study measured both psychological and nutritional status in 23 Canadian university students who took a triphasic OC (Triphasil 21 Cyclette) for 6 months. Study subjects had never used OCs before study entry and had no personal or familial history of psychological disorders. No significant changes were recorded during the study period in serum levels of iron, ferritin, folate, vitamin B-12, or B-6-aldehydes. After 6 months of OC use, slight fluctuations from baseline were noted on the Hysteria, Depression, and Psychotic Deviation scales of the Minnesota Multiphasic Personality Inventory, but none of the changes was statistically significant. Since nutritional status was not affected by OC use, these minor changes could not have been biased by nutritional deficiencies. The low hormone dose in the OCs currently in use may exert less of an effect on mental status than was the case with earlier high-dose formulations.
In response to studies reporting an excess of thrombotic events in women who used oral contraceptives (OCs) containing third-generation progestins, the Planned Parenthood Federation of America (PPFA) launched a retrospective review of clients at all PPFA-affiliated centers during 1993-95. During the 3-year study period, 2,265,087 woman-years of OC use were recorded in clinic drug sale records. All OCs prescribed in this period contained 30 or 35 mcg of estrogen and either norgestimate (21.0%), desogestrel (8.9%), norethindrone (46.6%), or levonorgestrel (23.6%) as the progestin. 70 major thrombotic events among clients using OCs (3 vascular complications per 100,000 woman-years of OC use) were reported to PPFA's risk management division during 1993-95; these included 25 cases of deep vein thrombosis, 20 cases of pulmonary embolism, 22 cerebrovascular accidents, and 3 myocardial infarctions. There were 5 deaths (0.22/100,000 woman-years of use), all from pulmonary emboli. The thrombotic event rates were calculated as the relative risk of complication, comparing the risk of each event for one progestin relative to the other three classes of progestins. The overall risk varied from a low of 1.895 events/100,000 woman-years for norgestimate OC users to a high of 3.969 events/100,000 woman-years for desogestrel OC users, but these differences were not statistically significant. In the progestin comparison, desogestrel users showed elevated risks for pulmonary emboli and fatalities, norgestrel use was associated with an increased risk of deep vein thrombosis, and norgestimate an increased risk of deep vein thrombosis and pulmonary embolism. Generally, these four groups of low-dose OCs appear safer than any previously published study has indicated. In part, this may reflect PPFA's careful prescribing guidelines. In addition to following US Food and Drug Administration contraindications, PPFA affiliates do not provide OCs to women over 35 years of age who smoke more than 15 cigarettes a day.
Contraception and cardiovascular disorders.
Prescribing contraceptives for women with underlying medical conditions requires careful attention from practitioners. This article reviews current knowledge on the metabolic effects and cardiovascular risks associated with use of combined oral contraceptives (OCs). OCs exert effects on lipids, high- and low-density lipid cholesterol, serum triglycerides, hemostasis, insulin resistance and hyperinsulinemia, and hypertension, all of which may have implications for ischemic heart disease, cerebrovascular accidents, and venous thromboembolism. Also discussed are alternative contraceptive methods for women with contraindications to OC use. Preconception counseling is especially important to provide women with information on the likely impact of their disease on pregnancy outcome and of pregnancy on their disease.
Oral contraceptives and the risk of subarachnoid hemorrhage: a meta-analysis.
Both case-control and cohort studies have evaluated the risk of subarachnoid hemorrhage (SAH) among oral contraceptive (OC) users and identified relative risks as low as 0.5 and as high as 6.5. To determine whether OC use is indeed a risk factor for SAH after accounting for the variability in study designs and results, a meta-analysis was conducted of the 11 salient independent studies included in the research literature. The summary estimate of effect for all studies was a relative risk (RR) of 1.42 (95% confidence interval (CI), 1.12-1.80). There was a trend toward smaller RRs in the most recent studies, presumably as a result of decreases in the estrogen dose of modern OCs. In the 6 studies that controlled for both smoking and hypertension, the summary RR was 1.49 (95% CI, 1.20-1.85). Only 2 of the 11 studies found a protective effect of current OC use on SAH risk, and it was nonsignificant. Taken together, these studies support a weak positive association between OC use and SAH risk. In the US, an additional 430 patients each year with OC-related SAH would be expected. For most women, the SAH risk is inconsequential in evaluating the decision about OC use. However, for women at high risk of SAH due to unruptured aneurysms, a strong positive family history, smoking, or hypertension, it may be advisable to consider alternative contraceptive methods until more data are available.
Although weight gain has been identified as the most common single reason for discontinuing oral contraceptive (OC) use, the few studies that have addressed this issue have found little or no OC-related weight change. The present study analyzed the daily weights of 128 US women, 18-35 years of age, over the course of 4 cycles of use of a triphasic OC (Tri-Norinyl). The mean weight change between study start and completion was 0.0 pounds. 52% of study participants experienced no weight change (defined as remaining within 2 pounds of their starting weight) and an additional 33% experienced a gain or loss of less than 5 pounds. Overall, 72% of subjects had either no weight gain or lost weight. These results did not differ for the various age, race, and parity groupings. Analysis of daily weight measurements indicated that women tended to gain a small amount of weight (about one-half pound) during the first few weeks of each treatment cycle and to lose approximately the same amount during menstruation. Thus, at least some change in weight blamed on OC use may be attributable to normal cyclic fluctuations. Contraceptive counseling should stress the fact that the empirical research has failed to document weight gain as a side effect of OC use.
Oral contraceptives and colorectal tumors. A review of epidemiological studies.
It has been suggested that the decline in colorectal cancer mortality recorded among women but not men in developed countries in the last two decades reflects a protective effect of the use of exogenous female hormones. The present report reviews the literature on the association between oral contraceptive (OC) use and colorectal neoplasms. A total of 19 studies was located. Reduced risk in OC ever-users was found in 3 of the 4 cohort studies on colorectal cancer and was significant in the 1 based on colorectal cancer mortality; the fourth cohort study showed no difference. All 11 case-control studies also failed to document a significantly elevated colorectal cancer risk and 5 reported a lowered risk among ever-users of OCs. An attenuation of the apparent protection 5-15 years after cessation of OC use was suggested. The 1 cohort study and all 3 case-control investigations that focused on colorectal adenomatous polyps also failed to document any increased risk with OC use. Future confirmation of a favorable effect of OC use on colorectal cancer risk could have a substantial influence on assessments of the risks and benefits of OC use.
A retrospective cohort study of 904 Latinas (Hispanic women) with gestational diabetes mellitus assessed whether exposure to low-dose oral contraceptives (OCs) increases the risk of developing type 2 diabetes mellitus. Study subjects were attending the High-Risk Family Planning Clinic at Los Angeles County (California, US) Women and Children's Hospital and were followed from their initial postpartum visit in 1987-94 through the end of 1994. At the first postpartum visit, 443 women selected a nonhormonal fertility control method, 383 received a combination OC, and 78 breast-feeding women were supplied with a progestin-only OC for the duration of lactation. A total of 169 women developed diabetes during the follow-up period. The unadjusted average annual incidence rates of type 2 diabetes mellitus were 8.7% for women using nonhormonal methods, 10.4% for users of combined OCs, and 26.5% for users of progestin-only OCs. After adjustment for potential confounding factors, use of progestin-only OCs almost tripled the risk of type 2 diabetes mellitus compared with equivalent use of a low-dose combined OC (relative risk, 2.87; 95% confidence interval, 1.57-5.27). The magnitude of this risk increased with duration of uninterrupted progestin-only OC use. Women who were breast feeding but using a nonhormonal contraceptive method were not at increased risk of diabetes. The low-estrogen state associated with breast feeding may enhance any diabetogenic effects of progestin-only preparations. Progestin-only OCs should be used with caution, if at all, by breast-feeding women with a history of gestational diabetes mellitus. By contrast, low-dose combined OCs can be used safely in women with recent gestational diabetes mellitus.
Women with gestational diabetes mellitus face a greater than 50% risk of developing type 2 diabetes over the next 10-20 years. This article reviews the available literature on the effects of subsequent pregnancy, hormonal contraception use, and hormone replacement therapy during menopause on diabetes development. Subsequent pregnancy in women with prior gestational diabetes mellitus appears to triple the risk of developing type 2 diabetes mellitus, at least in Hispanic women, possibly through accelerating the decline of beta-cell function. Low-dose combined oral contraceptives (OCs) and hormone replacement therapy have not been shown to increase this risk. Hormone replacement therapy may be especially suitable for postmenopausal women with gestational diabetes because it reduces cardiovascular mortality by 30-50%. In general, exposure to repeat pregnancy appears to pose a greater risk for subsequent development of diabetes than either low-dose combined OCs or hormone replacement therapy. However, women on these regimens should be provided with careful follow-up and metabolic surveillance.
To enhance understanding of the interaction between smoking and oral contraceptive (OC) use with respect to thrombogenesis, urinary levels of the stable metabolites of prostacyclin and thromboxane A2 were compared in 30 smokers and 30 nonsmokers who were taking combined low-dose OCs. Study subjects (age range, 19-32 years) were divided into 3 groups of 20: OC users who smoked, OC users who did not smoke, and a control group of 10 smokers and 10 nonsmokers. Each OC treatment group was randomized to receive a formulation containing 20 or 30 mcg of ethinyl estradiol in addition to 1 mg of norethindrone acetate daily for 3 months. Neither the absolute nor the percent change in both 6-keto-prostaglandin F1-alpha (PGF1-alpha) and thromboxane B2 (TxB2) levels changed significantly from baseline to post-treatment in any of the 6 subgroups defined by smoking status and ethinyl estradiol dose. Also, no significant differences were found in each subgroup with respect to changes in the 6-keto-PGF1-alpha/TxB2 ratios. Large intersubject variability in urinary 6-keto-PGF1-alpha and TxB2 levels were observed in all subgroups, however, making it difficult to determine whether there are significant differences between the 2 ethinyl estradiol doses. These findings suggest that low-dose OCs containing 20-35 mcg of ethinyl estradiol may not have as great an effect on coronary artery thrombosis as earlier formulations containing 50 mcg or more of estrogen.
Anaerobic and aerobic bacteria were isolated from the vagina and pouch of Douglas (POD) in 43 women who presented with pelvic inflammatory disease (PID) to the University College of Medical Sciences and Guru Tegh Bahadur Hospital in Shahdara, Delhi, India. In addition, high vaginal swabs were taken from 20 healthy controls. In the PID group, a positive culture was achieved in 42 of 43 cases. Anaerobic and aerobic bacteria were isolated from 37 (86%) high vaginal swab and 31 (72%) POD specimens. Of the 26 PID cases in which both vaginal swab and POD specimens were positive, 18 (72%) had different microflora at the two sites. In 5 additional cases, high vaginal swabs were negative for organisms detected by POD aspiration. A total of 100 aerobic and 10 anaerobic bacterial strains were recovered from both the sites. Coagulase negative staphylococci, Escherichia coli, and Streptococcus faecalis predominated. Polymicrobial flora were detected in 27 specimens from women with PID, but only 5 of these contained a mix of anaerobes and aerobes. Among controls, a total of 10 aerobic and 3 anaerobic strains were recovered from 10 specimens. These findings confirm that POD aspiration provides a more accurate picture of the microbial population of the fallopian tubes than high vaginal swab and has a definite role in the management of PID patients.
Incidence of Trichomonas vaginalis among women having vaginal discharge, in Manisa, Turkey.
The incidence of Trichomonas vaginalis was investigated in 207 women 18-45 years of age who presented to Celal Bayar University Hospital in Manisa, Turkey, with vaginal discharge. In 27 women (13.1%), T. vaginalis was detected by both direct microscopy of saline wet mount preparations and the microscopic examination of Giemsa stained smears. After cultivation of the vaginal discharge samples in CPLM media, T. vaginalis reproduction was seen in 21 samples (10.2%). All women with T. vaginalis as well as their spouses were treated with 2 g of Secnidazole and complete recovery was observed at follow-up 1 week after treatment ended.
Review of current research on breastmilk and mother-to-infant transmission of HIV.
A review of the available literature suggests that breast feeding doubles the risk of vertical transmission of HIV infection. There appears to be a continuous, additive risk of HIV infection throughout the period of lactation. When primary maternal HIV infection occurs during pregnancy or in the breast-feeding period, the risk of HIV transmission is further increased. Moreover, coming off of antiretroviral drugs such as zidovudine may produce a rebound in maternal viral load, with implications for breast feeding. Overall, understanding about the nature of the HIV transmission process through breast milk remains limited. Some of the proteins in breast milk have been shown to bind and inactivate HIV under experimental conditions, but the effectiveness of any immune responses against HIV in human milk requires further study. Infection of the infant through breast feeding seems to be a two-way process dependent as much upon the infant gut as on the milk. It remains unknown whether HIV enters the infant through normal gut mucosal cells or breaches of mucosal integrity. The strategy of advising women not to breast feed requires, first, that safe alternative infant foods are available and, second, that HIV infection has been confirmed. Local statistical models must be developed to demonstrate the age at which the risk of HIV transmission exceeds the decrease in child mortality associated with breast feeding. Such models will help to ascertain the timing for early weaning and use of formula in different countries.
Coitus-dependent family planning methods: observations from Bangladesh.
In-depth interviews conducted with 150 women and 141 men (128 matched couples) from rural Bangladesh as part of a survey of contraceptive use patterns revealed many inconsistencies between partners, especially in terms of use of condoms, the safe period, and withdrawal. In general, respondents who used coitus-dependent methods had difficulties answering survey questions on method use. Although many couples are known to use a combination of coitus-dependent methods (e.g., condoms during the fertile period of the cycle and coitus interruptus on days considered to be associated with a lower probability of conception), the interviews did not reflect this pattern. If one coitus-dependent method was mentioned by the woman and another by the man, investigation showed that, in most cases, the couple was using a combination of all the coitus-dependent methods they had mentioned. In some cases, the method mix employed by a couple changed from month to month. As a result, different aspects of a couple's regular sexual practice might be reported by each partner. Occasional unavailability of condoms was another reason for multiple method use. Overall, these findings indicate that inconsistencies in reported use of coitus-dependent methods of family planning are not due to careless or misleading responses to survey questions. These methods are so often used in combination, in order to enhance contraceptive effectiveness, that the combination itself is really the method being used. More accurate assessment methods are needed to capture use of coitus-dependent methods.
Measuring true contraceptive efficacy. A randomized approach -- condom vs. spermicide vs. no method.
Traditional contraceptive trials that evaluate the pregnancy rate of different methods over a 6-12 month period are limited in their ability to assess a method's inherent protection by ethical concerns related to withholding contraception from a control group. This paper describes a randomized approach that seeks to overcome this obstacle by enrolling women who desire pregnancy but are willing to postpone conception by 1 month. By measuring the risk of pregnancy after a single act of intercourse on the day of ovulation, potential problems with self-reported data on the frequency and timing of intercourse are surmounted as well. The feasibility of this approach was tested in 54 women from 3 US sites who were enrolled at the beginning of their menstrual cycle and asked to abstain from intercourse until ovulation, as determined by a urine luteinizing hormone home ovulation test. They were randomly allocated to use no method (n = 17), a male latex condom (n = 19), or a nonoxynol-9-containing vaginal contraceptive film (n = 18) at that intercourse. Both written diaries and daily phone calls to an automated toll-free number were used to record information about menses, coitus, and ovulation. The pregnancy rate was 12% (95% confidence interval (CI), 1-36%) for the group using no method and 11% (95% CI, 1-35%) for women using the vaginal film; no pregnancies occurred in the condom group (95% CI, 0-18%). As a result of the small sample size of this pilot study, no conclusions can be drawn about the relative efficacy of the methods. However, this study design does appear to enable measurement of the true effectiveness of barrier methods, and its implementation on a wider scale as a complement to traditional contraceptive trials is recommended.
Acceptability and efficacy of the female condom: a new barrier method.
The female condom offers women the potential both to prevent pregnancy and to protect themselves from sexually transmitted diseases, including HIV/AIDS. This article reviews the findings of international clinical trials on the efficacy and acceptability of this method. These trials have addressed the extent of protection and experience of current family planning users and their partners, the degree of vaginal discomfort and effect on vaginal flora, durability, use-effectiveness, and viral leakage. Consistent, correct use of the female condom is the most important determinant of contraceptive efficacy. Whether the female condom is used consistently over time seems to depend, in turn, on its availability and affordability, perceptions of personal risk, and ongoing insistence on and belief in protection of self and others.
User acceptability of a female condom (Reality) in Shanghai.
User acceptability of the Reality female condom was assessed in a 1998 study of 30 Chinese couples recruited from the Shanghai Institute of Family Planning Technical Instruction and Shanghai Baoshan Family Planning Commission Clinics. Each couple was instructed to use 10 condoms and to document their experiences separately after each use on a questionnaire. No pregnancies occurred during the 300 episodes of use. Overall, 90.0% of couples considered the female condom an acceptable method, and 55.2% preferred it to the male condom. 80.0% of wives and 73.3% of husbands rated the effect on sexual pleasure as improved or no different compared to the male condom. 76.3% of wives and 80.7% of husbands reported that Reality did not cause any discomfort in the majority of coital acts, although 38.7% of women and 34.0% of men felt the condom's inner ring. Evaluations related to comfort and sexual pleasure improved significantly between a couple's first 5 and second 5 coital acts. For example, the proportion of women who stated they did not like the female condom dropped from 40.0% in the first 150 collective coital acts to 27.3% in the last 150 acts; among men, the decline was from 34.7% to 23.3%. This finding suggests that the female condom may require extensive education and accumulated experience before it attains standing as an important contraceptive option.
Self-efficacy to use condoms in unmarried Latino adults.
Enhanced understanding of barriers to condom use that are specific to US Latinos could contribute to the development of targeted interventions aimed at reducing this group's high rates of sexually transmitted diseases (STDs), HIV/AIDS, and unwanted and adolescent pregnancy. This article describes the development and psychometric properties of a 20-item self-efficacy scale designed to generate data about a range of circumstances surrounding condom use by Latinos. The scale was evaluated in random-digit-dial telephone interviews with 1600 unmarried male and female Latinos 18-49 years of age from 10 states with large Hispanic populations; to be eligible, respondents had to report at least 1 heterosexual partner in the 12 months preceding the survey. 18 items were found to measure 5 intercorrelated factors: Condom Discussion, STD Thoughts, Partner Resistance, Regular Partner, and Impulse Control. Men who always used condoms had a mean condom self-efficacy score of 4.40 compared to 3.84 for men who never used then; among women, these means were 4.61 and 4.05, respectively. Three aspects of condom self-efficacy--Regular Partner, Impulse Control, and Partner Resistance--were significantly related to condom use in men and two--Impulse Control and Regular Partner--were significantly related to condom use in women. In each case, higher levels of self-efficacy were associated with more frequent condom use. The most formidable barriers to condom use were related to impulse control when under the influence of drugs or alcohol. Few differences were found in scale scores across gender, age, and ethnic subgroups; however, less-educated men and women had lower self-efficacy to discuss condom use, manage partner resistance, use condoms with a regular partner, and control impulses.
Testing of latex condoms in factories and regulatory laboratories for pinhole defects, embedded particles, and thin regions represents a major strategy for ensuring condom reliability. A new optical method for testing condoms could supplement or even replace existing, less powerful electrical test techniques that require extensive manual handling. Optical techniques provide quantitative data on the condoms tested rather than simple accept/reject decisions, thereby enabling detailed monitoring of production or lot characteristics. This paper presents initial findings on the optical testing of 1813 nonlubricated latex condoms purchased in US retail stores. An extremely high level of correlation was found between the optical test results and the outcomes of standard leak-and-burst testing. Optical screening followed by leak testing produced 12 confirmed failures in this series. The majority of confirmed leaks resulted from holes substantially larger than the detection limits of both testing systems. The large pinhole and thin-region defects identified optically are of serious public health concern, even if the defects were incipient and only realized after handling.
Men's attitudes toward vaginal microbicides and microbicide trials in Zimbabwe.
Female-controlled methods of HIV/AIDS and sexually transmitted disease prevention, specifically vaginal microbicides, may be more successful in Zimbabwe than the male condom. Since in Zimbabwe men make most decisions regarding sex, the ultimate acceptability and effectiveness of a vaginal microbicide will depend on men's attitudes and beliefs about the practice. These issues were explored in five focus group discussions with Zimbabwean men. The majority of participants were married taxi drivers and farm workers from the Harare area. They indicated that women can protect themselves from HIV by being hygienic, faithful, and responsive to their husband's sexual needs; there was no mention of the fact that many women are at risk of acquiring HIV as a result of their partner's extramarital sexual activity. Almost all participants said that a woman would need her partner's permission to use a microbicide. They were skeptical about product safety, concerned that it would lead to infertility or at least prevent pregnancy. They further expressed concerns that a microbicide would cause excessive vaginal lubrication and interfere with sexual pleasure. The discussions indicated that, if vaginal microbicides are to find acceptance in Zimbabwe, they must neither substantially lubricate the vagina nor act as a contraceptive. If clinical trials are to be conducted, both men and women need to be informed about the safety and mechanism of action of the microbicide and assured that treatment for side effects will be available. The study guidelines should be explained to male partners as well as to women enrolled in the trial to minimize domestic conflicts and ensure compliance with the protocol.
Data from the US Collaborative Review of Sterilization were used to assess the long-term effectiveness of the most widely used methods of tubal occlusion. The analysis was based on 10,685 women who entered the prospective, multicenter observational study during 1978-86. Silicone rubber band application was the most common sterilization technique in this series (31.2%), followed by bipolar coagulation (21.2%), postpartum partial salpingectomy (15.3%), clip application (14.9%), and unipolar coagulation (13.4%). 143 women had pregnancies classified as true sterilization failures. Of these, 21 (14.7%) ended in spontaneous abortion, 26 (18.2%) in induced abortion, 41 (28.7%) in delivery, and 47 (32.9%) in ectopic pregnancy. The 10-year cumulative life-table probability of failure was 18.5/1000 procedures (16.6/1000 when pregnancies ending in self-reported spontaneous abortion were excluded). The most effective methods were postpartum partial salpingectomy and laparoscopic unipolar coagulation (each 7.5 pregnancies/1000 procedures) and the least effective was laparoscopic spring clip application (36.5 pregnancies/1000 procedures). After adjustment for age, race/ethnicity, and study site, three methods--interval partial salpingectomy, spring clip application, and bipolar coagulation--were significantly more likely than postpartum partial salpingectomy to result in sterilization failure. After adjustment for sterilization method, race/ethnicity, and study site, women sterilized at 34 years and older were at significantly less risk of sterilization failure than women sterilized at 28-33 years of age. After adjustment for sterilization method, age, and study site, Black, non-Hispanic women were at significantly greater risk for sterilization failure than White, non-Hispanic women. These findings confirm the importance of the concept of cumulative risk of pregnancy after sterilization, especially for women sterilized at a young age.
Migration of sterilisation clips: case report and review.
Both Filshie and Hulka Clemens sterilization clips are capable of migration, although this is a rare event with no reported serious sequelae. This paper reports the case of a 43-year-old UK woman who presented with a 5-week history of painful swelling around the umbilicus. A firm, tender 2 x 2 cm subumbilical mass was palpated. She had undergone laparoscopic sterilization with Filshie clips 3 years earlier. The provisional diagnosis was incarcerated omentum in an umbilical hernia. A midline incision was made over the mass and a Filshie clip was found in the subcutaneous tissue. There was no evidence of a hernia. Migration of a sterilization clip into the umbilicus has not been previously reported. In this case, it is possible that slow peritonealization caused the clip to fall off and escape through unhealed defects in the peritoneum and rectus sheath. There is no evidence that one type of sterilization clip is more likely to migrate than another.
Ovarian pregnancy; relationship to an intrauterine device.
The etiology of primary ovarian pregnancy is unknown, although an IUD is frequently implicated. This paper presents two cases of primary ovarian pregnancy diagnosed at Dokuz Eylul University in Izmir, Turkey, in 1995 and discusses the pathogenesis in relation to the IUD. In the first case, the woman had used a copper-releasing IUD for 3 years and had had it removed 1 month before presentation. The second woman had been using a Lippes Loop device for 16 years. Ovarian pregnancy was diagnosed only after pathologic examination of the specimen. Both pregnancies were located within the corpus luteum, suggesting that fertilization and nidation occurred at the ovulation site. Although the IUD protects against ectopic pregnancy in the first 24 months of use, the risk increases over time as the reversible foreign-body histologic changes associated with IUD use become established in the Fallopian tube. The preoperative diagnosis of primary ovarian pregnancy is very difficult. It should be kept in mind, however, that ovarian pregnancy is more frequent in ectopic pregnancies associated with IUD use.
The efficacy, safety, and acceptability of use of the Multiload Cu 375 SL IUD for emergency contraception were investigated in 515 Chinese women who had the device inserted within 5 days of unprotected intercourse. 428 women (83.1%) were parous. The most commonly used contraceptive methods were condoms and periodic abstinence. Contraceptive failure (e.g., condom breakage or failure to withdraw) was the reason for the request for emergency contraception in the majority (57%) of cases. The average interval between unprotected sex and IUD insertion was 45.7 hours. Two pregnancies were reported in this series (0.39/100 women), one of which was considered to represent user failure. The efficacy rate was 92.4%. The most common side effects were pain and bleeding. No pelvic infections occurred. 14.9% of nulliparous and 3.5% of parous women requested IUD removal after the resumption of menses. This study is ongoing and will eventually encompass 1000 women presenting to family planning clinics in China for emergency contraception.
IUDs: do new devices reduce bleeding and expulsion rates?
The Copper-Safe 300 and Copper-Fix IUDs, two newly developed devices, appear to be associated with a reduced incidence of bleeding, pain, and expulsion while maintaining a contraceptive efficacy comparable to that of the Copper T 380A. The arms and stem of the Cu-Safe 300 device are thinner and more flexible than those of other T-shaped IUDs, making insertion and removal easier and less painful. Removals for bleeding and pain are significantly lower than those for the TCu 380A. The two studies that assessed expulsion rates associated with the Cu-Fix IUD produced discrepant results. It appears that provider skill and experience in insertion techniques both influence this rate. Both devices have been approved for marketing in all European Community countries for use of up to 5 years.
The costs and benefits of IUD follow-up visits in the Mexican Social Security Institute.
A prospective study conducted at 8 clinics of the Mexican Social Security Institute during 1992-93 compared the health benefits of follow-up visits for IUD users with the program costs of such care. 1713 new IUD users were instructed to return for either 2 or 4 visits in the first 12 months after IUD insertion. The total number of follow-up visits was 1135 in the 4-visit group and 710 in the 2-visit group. Only 11% of women in the 4-visit regimen and 19% in the 2-visit regimen made at least the required number of visits. 83% of follow-up visits were scheduled. In both regimens, 21-22% of visits involved a serious medical intervention, primarily the prescription of antibiotics for suspected genital tract infection. 53 scheduled visits in the 4-visit group and 29 in the 2-visit group involved women who were asymptomatic but required a serious medical intervention. Assuming that the program provides about 250,000 IUDs annually, costs would total US$1.7 million for the 4-visit regimen and US$900,000 for a 2-visit schedule. The 4-visit approach would generate 8387 more visits involving medical interventions than the 2-visit regimen, at a cost of US$48 per visit. Although these findings indicate that the practice of scheduling frequent revisits for IUD users aids in the detection of situations requiring medical attention, the Mexican Social Security Institute has decided that the costs of such a regimen are prohibitive. Program managers have concluded that only 1 follow-up visit, 1 month after IUD insertion, is necessary.
In the first year of use, 4-14% of IUD users have the device removed because of pelvic pain or bleeding. Identification of women at risk of removal for these reasons would enable targeted counseling and treatment, thereby reducing the frequency of removal requests. The hypothesis that problems reported at the 1-month follow-up visit can help to predict eventual IUD removal for pain or bleeding was investigated through use of data from a randomized controlled trial of IUD acceptors from 18 centers in 14 countries in Asia, Africa, and Latin America, who were followed for 1 year. The present analysis was restricted to 2536 women who received Copper T-380A or Multiload 250 IUDs. There were 89 removals for pain or bleeding during the study period. When baseline acceptor characteristics were considered, breast-feeding status was the most significant predictor of removal. Women not breast feeding at the time of IUD insertion were 2.8 times (95% confidence interval (CI), 1.5-5.2) as likely as those who were breast feeding to undergo removal for pain or bleeding in the 12 months after insertion. The following variables reported at the 1-month follow-up visit were significant predictors of removal: intermenstrual bleeding since last menses (odds ratio [OR], 1.9; 95% CI, 1.4-5.9), excessive menstrual flow (OR, 3.5; 95% CI, 1.4-9.2), and cessation of breast feeding since IUD insertion (OR, 2.2; 95% CI, 0.9-5.6). Although intermenstrual pelvic pain, spotting, and menstrual flow of more than 1 week's duration increased the risk of removal, they were not statistically significant predictors in this sample. Women who report intermenstrual bleeding or excessive menstrual flow at their 1-month follow-up visit may benefit from counseling and, in some cases, treatment with nonsteroidal anti-inflammatory drugs to reduce their risk of early IUD discontinuation.
Analysis of contraceptive failure data in intrauterine device studies.
Life-table estimates of net and gross rates, widely used in the past three decades for analyses of contraceptive failure, result in a loss of information about fertility control behavior at intermediate stages and overlook the interdependence of reasons for method termination. The application of modern techniques of competing risks to contraceptive studies enables estimation of cause-specific termination rates. This paper applies these methods to data from two studies reporting IUD failures in women from Finland, Sweden, and Hungary who were using the Nova T and levonorgestrel-releasing devices. Cumulative termination rates due to five causes--pregnancy, expulsion, amenorrhea, bleeding and pain, and hormonal reasons--were developed based on data on individual termination times and their reasons. The uses of cumulative incidence functions, which are essentially the quantity given by Potter's net rate, and cause-specific hazard rates were stressed. Terminations due to amenorrhea and hormonal reasons were important in users of the levonorgestrel-releasing IUD, while bleeding/pain was most significant category among Nova T users. When failure times are recorded exactly and life-table estimates are replaced by corresponding continuous time estimates, the role of monthly adjustments on the risk sets disappears completely. Unlike the life-table method, which requires grouping of data into intervals and a subsequent loss of information, modern competing risk techniques offer a natural way to study different termination reasons jointly and carry out comparisons between them.
There is evidence of an increase in the number of polymorphonuclear leukocytes in the endometrium after insertion of a copper IUD. When activated, these macrophages secrete two groups of toxic metabolites that interact with each other: reactive oxygen intermediates (ROI) and reactive nitrogen intermediates (RNI). The mechanism of action of the copper in copper IUDs as an antimicrobial agent is not well understood. The present study measured ROI and RNI levels in 20 copper IUD users from Chandigarh, India, before and 1, 4, and 12 weeks after insertion. A statistically significant decrease in RNI levels was observed at each postinsertion time. In contrast, ROI levels showed an initial fall at 1 week postinsertion followed by a rise at 4 and 12 weeks. Control of infection has been found to be associated with this pattern of a rise in ROI and fall in RNI. (The initial fall in ROI at 1 week observed in the present study is assumed to be an anomaly related to the introduction of microbials during IUD insertion.) The copper in a copper IUD could be responsible for limiting pelvic inflammatory infection.
Uterine histopathologic changes after Cu-Fix intrauterine device insertion.
A study conducted at Chulalongkorn University in Bangkok, Thailand, investigated uterine histopathologic changes in 10 women fitted with the Copper (CU)-Fix IUD after cold conization for a suspicious Papanicolaou smear. All 10 women were diagnosed with carcinoma-in-situ of the cervix and underwent hysterectomy 6 weeks after IUD insertion. The findings of preoperative ultrasonography for localization of the IUD were compared with hysterectomized specimens, with emphasis on the anchoring site of the device's nylon knot. Slight mononuclear cell infiltration in the myometrium was observed in only 1 woman; normal findings were seen in the remaining patients. Histopathologic analysis revealed diffuse mononuclear cells as well as plasma cell infiltration during the proliferative phase of the menstrual cycle in all 10 women. This finding showed evidence of foreign body reactions similar to those described after insertion of other types of IUDs. No patient had signs or symptoms of pelvic infection. Overall, these results confirm there is no increased risk of uterine infection when the IUD is fixed in the muscle of the fundus.
Successful use of levonorgestrel intrauterine system in a HIV positive woman.
The case presented in this paper suggests that the levonorgestrel intrauterine system may be an excellent contraceptive method for HIV-positive women. At presentation to a UK family planning clinic, a 32-year-old nulliparous woman was using Depo-Provera for contraception; however, she was bleeding irregularly and complained of acne and lack of vaginal lubrication. The Mirena intrauterine system was considered because it offered lighter menstrual periods or amenorrhea, no need for regular clinic visits, reliable contraception, and fewer systemic side effects than other progestogen-only methods. At follow-up 6 weeks after Mirena insertion, the woman reported one light period, pain on the day of fitting only, and no progestogenic side effects. The reduced blood loss associated with this method is beneficial if mild anemia is present and may reduce exposure of an HIV-negative male partner to infected blood. Moreover, the system's effectiveness is not compromised by the broad-spectrum antibiotics or liver enzyme-inducing drugs taken by women with HIV/AIDS.
Clinical acceptability of an ethylene-vinyl-acetate nonmedicated vaginal ring.
The acceptability of a newly designed vaginal ring was evaluated in an open, randomized study conducted at Atrium Medical Center in Kerkrade, the Netherlands. 65 healthy women 18-45 years of age were assigned to use 1 of 3 types of nonmedicated vaginal rings made with ethylene-vinyl-acetate with the same diameter (54 mm) but varying cross-sectional thicknesses (3, 3.5, or 4 mm). Women were instructed to insert the ring on day 5 of the menstrual cycle and use the device for 21 days. Temporary removal of the ring was permitted during intercourse or for rinsing with water after vaginal bleeding. 59 women (91%) completed the study. 41 women (66.1%) reported at least 1 adverse effect, most frequently foreign body feeling (8 women) and vaginal discharge (15 women), but all side effects were mild. No major differences were recorded between the 3 types of rings other than a sensation of expulsion, which was more common in women assigned the ring with the smallest cross-sectional thickness. 1 woman in the 3.5 mm group experienced complete expulsion during intercourse. The ring was judged to be easy to insert and remove. The device was felt during intercourse by 5 women in the 3.5 mm group but by only 1 woman each in the 2 other groups. Although 35-50% of male partners could feel the ring during intercourse, only 11-15% cited this as a reason for disliking the device. Further development of an active combined contraceptive ethylene-vinyl-acetate ring with a cross-sectional diameter of 4 mm is recommended.
When Norplant implants are inserted too deeply and cannot be palpated, or if they are located close to the neurovascular structures of the upper arm, radiologic guidance may be needed to locate and remove the implants without injury to surrounding structures. This paper describes a case in which digital subtraction fluoroscopic guidance was helpful in removing an implant located close to a major nerve near the axilla. This technique enables both localization and direct image-guided removal. The patient, a 36-year-old US woman, requested implant removal 18 months after insertion because she desired pregnancy. At removal of the sixth capsule, the patient reported pain suggestive of nerve stimulation. Soft tissue x-ray indicated the capsule was located deep in the tissues near the area of the brachial artery and nerve. Fluoroscopic-guided removal was successful in removing this capsule in 30 minutes.
Research, introduction, and use: advancing from Norplant.
An April 1997 workshop, convened by the US Institute of Medicine, reviewed data on Norplant's efficacy, safety, and use; considered lessons learned from the method's development, introduction, and market experience; and explored approaches based on these lessons that could improve the environment for contraceptive research and development and facilitate market entry for new contraceptive technologies. A review of clinical experience with Norplant suggested the importance of delivery in a medically controlled environment, provider training in insertion and removal techniques, intensive client counseling, and free choice. Negative mass media coverage and litigation have had an adverse impact on Norplant use patterns. Nine areas were identified for consideration or action: clinical research on hormonal effects, market research and regularized interactions with industry, a preintroductory phase permitting various assessments in advance of full-scale product introduction, mechanisms to ensure informed decision making, postmarketing surveillance, provider credentialing, core guidelines for long-acting contraceptives, cost analyses, and product liability legislation. Dialogue at the workshop provided evidence of a paradigm shift toward a woman-centered contraceptive research agenda.
Norplant failure: an adolescent case study and review of the literature.
Norplant use in adolescents may be associated with unique risk factors. This paper presents the case of a 15-year-old US adolescent who became pregnant 19 months after Norplant insertion. She had two previous pregnancies--the first related to noncompliance with oral contraceptives and the second due to delayed presentation for Depo-Provera injection. A review of the available literature on Norplant use in adolescence indicated that women 25 years of age and under, obese women, and those who experience regular menstrual cycles during Norplant use have significantly higher rates of method failure. All three of these risk factors were present in the case presented in this paper. These factors should be considered in initial adolescent patient selection, education, and postinsertion medical supervision. The long duration of subdermal implant action tends to make adolescent users less motivated to keep appointments for annual follow-up visits and examinations, and health care providers may develop a false sense of security when they provide Norplant. In this patient, extensive education on timing and frequency of contraceptive administration, barrier method use, intensive patient tracking, follow-up reminders, and counseling on relationship issues would be helpful.
Young women's attitudes toward injectable and implantable contraceptives.
The potential acceptability of contraceptive implants and injectables was assessed in a cross-sectional study of 328 US women 13-21 years of age who were awaiting medical care at 3 clinical sites: an elite women's college health service (n = 126), a coeducational state university health service (n = 111), and an inner-city hospital-based adolescent clinic (n = 91). 83% were sexually active (mean age at first intercourse, 15.6 years) and, of these, 21% had been pregnant. 62% of respondents indicated they would accept injectable contraception, and there was little variation in this rate according to sexual or pregnancy history. Only 24% would consider subdermal implants, but ever-pregnant young women were significantly more likely to agree to implant use than their never-pregnant counterparts (33% and 21%, respectively). This finding may reflect the fact that 37% of young women wanted to have a baby within the next 5 years. 74% of respondents indicated they would stop using a contraceptive method that caused irregular menses and 65% would discontinue use of a method that induced amenorrhea. 50% were willing to accept a method-related weight gain of up to 5 pounds if the method was highly effective. Finally, 39% preferred a method that others did not know they were using, and 56% would accept a method that required parental consent. The uniformity of most of these responses across study sites, despite striking differences in socioeconomic status variables, was unexpected and suggests that the mass media is the predominant influence on attitudes about contraception.
Weight variation in users of the once-a-month injectable contraceptive Cyclofem.
Weight gain has been shown in numerous studies to be an important reason for discontinuation of injectable contraception. The effect of Cyclofem injection on body weight was investigated in an introductory collaborative study of 3183 women from Brazil, Chile, Colombia, and Peru. A Cyclofem injection contains 25 mg of medroxyprogesterone acetate and 5 mg of estradiol cypionate. Women were divided into 5 groups on the basis of their weight at study entry: under 50, 50-54, 55-59, 60-64, and over 64 kg. The trend in weight gain over the 13-month study period was inversely proportional to admission weight. The weight increase was highest in women who weighed less than 50 kg at study entry; they averaged a 2.8% weight increase 4 months after injection, and this increase reached 7.7% at 13 months. Women who weighed more than 64 kg at admission showed no weight change at 4 months and an increase of only 1.7% after 13 months. Method discontinuations due to weight gain also were proportional to admission weight. This rate was 15.5% in women who weighed more than 64 kg at admission compared with 5.4% among those who weighed less than 55 kg and 10.1% among women with an entry weight of 55-64 kg.
Bone density in long term users of depot medroxyprogesterone acetate.
The effects on bone density of long-term depot medroxyprogesterone acetate (DMPA) use were investigated in a cross-sectional study of 185 clients 17-52 years of age at family planning clinics in Portsmouth and Manchester, England, who had been receiving contraceptive injections for 1-16 years (median, 5 years). Dual energy x-ray measurements of bone density of the femoral neck and lumbar spine, as well as venous blood samples, were taken prior to the women's next DMPA injection (1994-96). 153 women had serum estradiol levels under 150 pmol/l--the value considered adequate to maintain bone density. The mean bone density of the lumbar spine compared with the population mean for women 20-59 years old yielded a Z score of minus 0.332 (95% confidence interval, -0.510 to -0.154; p < 0.001). There was a weak, nonsignificant correlation between lumbar spine Z score and years of DMPA use. Mean density of the femoral neck did not differ significantly from the normal population mean. There was no significant correlation between serum estradiol level and either bone density score. Overall, these findings provide no evidence that DMPA-induced amenorrhea places women at significant risk of further bone loss or that supplemental estrogen is required.
Bone density among long-term users of medroxyprogesterone acetate as a contraceptive.
Family planning programs that offer depot medroxyprogesterone acetate (DMPA) cannot be indifferent to the risk of lowered bone density. A study conducted at the Family Planning Clinic of the State University of Campinas (Sao Paulo, Brazil) compared bone densities in 72 women who had been using DMPA for at least 1 year (mean duration, 42 months) and 64 regularly menstruating nonusers. Mean age was 31 years in both groups; there were no significant differences between the 2 groups in terms of ethnicity, body mass index (BMI), or smoking. Mean serum estradiol concentrations were 55.7 +or- 40.5 pg/ml for DMPA users and 149.9 +or- 88.2 pg/ml for nonusers (p < 0.001). The mean length of amenorrhea was 26.5 +or- 23.8 months among DMPA users. The mean bone density in DMPA users was significantly lower than that of controls at all sites evaluated (i.e., lumbar spine, femoral neck, Ward's triangle, and trochanter). 38 DMPA users, compared with only 17 controls, had a T-score in the lumbar spine lower than -1 standard deviation (p = 0.014). Multiple regression analysis identified BMI and DMPA use as variables significantly associated with bone density in the lumbar spine; in the femoral neck, these variables were BMI, age, and length of amenorrhea. Periodic bone densitometry should be considered for women over 40 years of age with low BMI who have more than 2 years of continuous amenorrhea.
Long-term depot-medroxyprogesterone acetate and bone mineral density.
The effect of long-term use of depot medroxyprogesterone acetate (DMPA) on bone mineral density remains controversial. The present study compared bone mineral densities in 67 long-term (5 years or more) DMPA users recruited consecutively from the Hong Kong (China) Family Planning Association with those in 218 age-matched controls recruited from 8 family health service clinics in Hong Kong. Mean age was 42.8 years (range, 34-46 years) in the DMPA group and 40.0 years (range, 34-46 years) among controls. Body mass index, calcium intake, and smoking were similar in both groups. The median duration of DMPA use was 6 years (range, 5-15 years). Long-term DMPA users had significantly lower bone mineral densities than controls at the lumbar vertebra (0.93 vs. 1.03 g/sq. cm), neck of femur (0.69 vs. 0.83 g/sq. cm), trochanter (0.59 vs. 0.71 g/sq. cm), and Ward's triangle (0.58 vs. 0.78 g/sq. cm). The percentage of bone loss in L2-4 was more pronounced with increasing age. For each year of DMPA use, the decrease in bone mineral density was estimated to be 0.011 g/sq. cm (1.1%) in L2-4, 0.0193 g/sq. cm (2.3%) in the neck of femur, 0.0169 g/sq. cm (2.4%) in the trochanter, and 0.0277 g/sq. cm (3.5%) in Ward's triangle.
A hospital-based case-control study conducted in Korea confirmed that the risk factors for cervical cancer are similar to those found in other countries. Enrolled in the study were 203 women with histologically confirmed invasive cervical cancer diagnosed at Seoul National University Hospital during 1992-95 and 827 women who visited the hospital's Department of Gynecology and Obstetrics during the same time but had normal Pap smears and no history of any malignancies. Information on risk factors was obtained from self-administered questionnaires and interviews. Multiple linear logistic analyses revealed a significantly higher risk of cervical cancer in women with an early sexual debut and those whose husbands had a history of high-risk sexual behaviors. Compared to women whose first intercourse was at 19 years or under, those whose sexual debut was at age 25 or over were a third less likely to have cervical cancer (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.20-0.68; p = 0.002). Compared to women whose husbands had a history of high-risk sexual behavior, women whose husbands did not have such a history had a cervical cancer risk of 0.69 (95% CI, 0.62-1.44; p = 0.07). Other significant independent risk factors were having a spouse who was not educated beyond the primary school level (p = 0.0003), height of 154 cm or less (p = 0.02), age 19 years or under at first full-term pregnancy (p = 0.0005), and 3 or more full-term pregnancies (p = 0.006).
A mobile unit: an effective service for cervical cancer screening among rural Thai women.
A mobile cervical cancer screening campaign was conducted in both 1993 and 1996 in all 54 rural villages in Mae Sot District, Tak Province, in northern Thailand. The impact of the program on women's knowledge of cervical cancer and uptake of Pap smear testing was evaluated in 3 rounds of survey of women 18-65 years of age from the area served by the mobile unit. 1603 women were interviewed in 1991 before program implementation, another 1369 women were surveyed in 1994, and 1576 were enrolled in the 1997 survey. Awareness that cervical cancer can be asymptomatic increased from 19.5% in the baseline survey to 52.8% in 1994 and 63.9% in 1997. The proportion of women knowledgeable about Pap smears increased from 20.8% in 1991 to 57.3% in 1994 and 75.5% in 1997. The proportion of women who had ever had a Pap smear rose from 19.9% in 1991 to 58.1% in 1994 and 70.1% in 1997. Screening by the mobile unit accounted for 85.2% of all cervical intraepithelial neoplasia (CIN) III and all invasive cancers detected by Pap smear in the study area during 1992-96. The rate of CIN III was 3.5/1000 smears in the mobile screening program compared with 0.7/1000 in the maternal-child health/family planning clinic and 1.8/1000 in the annual 1-week mass screening campaign. These findings confirm that a mobile unit is an effective tool in rural areas where existing screening activities cannot reach all the women at risk of cervical cancer.
Breast cancer in Maori and non-Maori women.
National statistics collected in New Zealand since the mid-1960s have identified higher rates of breast cancer in Maori women under 40 years of age than their non-Maori counterparts, despite their low socioeconomic status and high fertility. Data from a nationwide population-based case-control study of breast cancer in New Zealand women 25-54 years of age were used to compare the age-adjusted distribution of reproductive and other risk factors for breast cancer in self-identified Maori (n = 89) and non-Maori women (n = 1771) from the control group. Compared with women with no Maori ancestors, women 25-39 years old with at least half Maori ancestry had a two-fold higher risk of breast cancer after adjustment for known risk factors (odds ratio, 2.2; 95% confidence interval, 1.2-4.2). However, when data from the control group were analyzed, Maori women had a significantly more favorable profile in terms of breast cancer risk than their non-Maori counterparts in terms of education level, socioeconomic status, age at first full-term pregnancy, parity, and duration of breast feeding. The only exception to this pattern was body mass index. 62.1% of Maori controls 25-54 years old, compared with 23.1% of their non-Maori counterparts, were in the highest quartile of recent body mass index (p < 0.001). The excess of breast cancer in young Maori may reflect unknown genetic factors that increase susceptibility.
Timing of HIV interventions on reductions in sexual risk among adolescents.
The effectiveness of a small-group HIV/AIDS prevention intervention was assessed in 151 US adolescents 13-24 years of age who were randomly assigned to seven 1.5-hour sessions, three 3.5-hour sessions, or no intervention. The study participants were recruited from a community-based agency in New York, New York, that serves high-risk Black and Hispanic youth from neighborhoods with high HIV seroprevalence rates. The cognitive-behavioral intervention emphasized role-playing for social skills development and HIV-related beliefs, perceptions, and norms. Regression analysis indicated that over the 3-month study period, the numbers of sexual partners and sex acts unprotected by condoms were significantly lower in the 7-session group than in the other 2 groups. Compared with youths in the 7-session group, those in the control condition reported an average of 7.9 more risk acts and those in the 3-session group had an average of 7.2 more risk acts. The factors mediating risk reduction behavior changed in a complex manner. For example, perceived vulnerability increased more among those with initially lower vulnerability scores among youth in the 7-session group and self-approval of condom use was higher for those with initially low scores in the 7-session compared to the 3-session regimen. Self-efficacy for both risk avoidance and condom use was significantly higher in the 3-session condition for those with initially low scores, however. On the role-play measure, those with higher baseline scores in the low-pressure situation improved significantly only in the 3-session intervention; in the high-pressure situation, adolescents reported significantly higher scores in the 7-session condition and those with higher scores improved the most. These findings support an HIV/AIDS intervention strategy of shorter educational sessions spread over a brief span of time.
Reproductive health needs: comparing women at high, drug-related risk of HIV with a national sample.
The extent of the unmet need for reproductive health services, including HIV/AIDS programs, among US women who inject drugs or have injection drug-using sexual partners is unknown. Large-scale national surveys that estimate drug use tend not to include reproductive health variables and surveys that are designed to inform reproductive health care policy in the US generally do not address drug use. This paper compares baseline data (1989-91) from three Perinatal HIV Reduction and Education Demonstration Activities (PHREDA) projects (New Jersey; Philadelphia, Pennsylvania; and San Francisco, California) and data from the 1988 National Survey of Family Growth (NSFG) to illustrate the gaps in knowledge of women's needs created by the current practice of regular surveillance of only one of the populations. PHREDA recruitment included the use of snowball techniques that relied on personal referrals from women with HIV risk behaviors as well as personal eligibility screenings of women in drug treatment centers and street-based locations in high-risk neighborhoods. The 1635 PHREDA respondents were significantly more likely than the 8220 NSFG respondents to be older, homeless or in transient situations, less educated, unmarried, unemployed, members of a minority group, on general assistance, to use less effective contraceptive methods, to have a history of sexually transmitted diseases, to be sterilized, to have had an abortion, to be daily alcohol drinkers, and to use heroin and cocaine. Since the NSFG is used to set national standards for reproductive health policy and practices, including HIV/AIDS, its failure to include women at greatest risk of HIV has serious implications. To ensure greater representation of high-risk women, national surveys of reproductive health must expand their methodologies and sampling designs to identify and target settings where such women are likely to be recruited.
Sexual practices in a cohort of US women with and without human immunodeficiency virus.
The hypothesis that HIV-infected women are less sexually active than women without infection was investigated through use of baseline data from the US HIV Epidemiology Research Study. This multicenter, prospective study began in 1993 and is following 873 HIV-infected and 438 HIV-negative women from 4 US cities every 6 months for at least 5 years. Among seropositive women, 170 (23%) had learned of their serostatus within the previous 6 months, including 97 women who received this result through screening at study entry. HIV-positive women were significantly more likely than their seronegative counterparts to have injected drugs during the past 6 months, live in households with monthly incomes under US $500, have less than 12 years of education, and to be Black. 77% of infected women and 89% of HIV-negative women reported at least 1 sexual partner in the 6 months before study entry. Seropositive women were more likely to report fewer than 10 sex partners as opposed to 10 or more sex partners in the past 5 years (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.57-3.11). Compared with seronegative women, HIV-infected women who were sexually active in the past 6 months were 2.8 times more likely to have had only 1 recent sexual partner (95% CI, 1.99-3.92) and 2.5 times more likely not to have had any sexual partner in the 6 months before study entry (95% CI, 1.77-3.44). Reasons for sexual abstinence were fear of infecting partner, decreased sex drive, no one around to have sex with, and too depressed. HIV seropositivity remained associated with sexual inactivity even after controls for alcohol and drug use, history of sex for drugs or money, and living with children (OR, 2.28; 95% CI, 1.44-3.71). Finally, HIV-infected women with CD-4 counts of less than 200 were 2-4 times more likely to have been sexually inactive during the 6 months before study entry than those with counts above 500. These findings confirmed the study's hypothesis and suggest a need for counseling for HIV-positive women who stop engaging in sexual partnerships.
Cesarean childbirth in Puerto Rico: the facts.
Puerto Rico's cesarean section rate is the highest in the world. Since 1989, information on the type of delivery has been included on birth certificates in Puerto Rico. This report assesses trends in cesarean section delivery derived from birth certificates for the period 1989-94. The cesarean rate was 29.9% in 1989, 30.7% in 1990, 31.3% in 1991, 31.0% in 1992, 31.3% in 1993, and 30.9% in 1994, suggesting a trend of stabilization. The level of repeat cesarean section deliveries fluctuated between 41-43% of cesarean deliveries during the study period. The cesarean section rate was lowest among adolescents, unmarried mothers, and those with low socioeconomic status. It was highest among women 30 years and over, married women, those with 16 years of education or more, working mothers, and women whose husband/partner was a white-collar worker. Mothers who began prenatal care in the first trimester, made the most prenatal visits, and had adequate scores on the Kessner Index also had higher cesarean section rates. Chronic hypertension and uterine bleeding were the most common pregnancy-related medical indications for cesarean childbirth, while cephalopelvic disproportion was the most common delivery-related factor. Finally, in 1994, the cesarean delivery rate was 46% in private hospitals, compared to 20% in public institutions. A partial correlation analysis indicated that the type of hospital was the best predictor of cesarean delivery.
Vesico-vaginal fistula in Benin City, Nigeria.
A total of 49 women with vesicovaginal fistula were admitted to the gynecology ward of the University of Benin Teaching Hospital (Benin City, Nigeria) during 1992-97. The mean age at presentation was 31 years (range, 20-65 years). Mean parity was 3 (range, 1-11); 27% of the patients were primiparae. The average duration of the antecedent labor was 3 days (range, 2-7 days). 65.2% of patients had forceps, vacuum extraction, or emergency lower-segment cesarean section delivery. 13 patients (27.08%) had vesico-uterine fistula, 15 (31.25%) had mid-vaginal fistula, and 11 (22.92%) had juxtacervical fistula. The repair success rate was 81.3%. This series stands in contrast to the typical profile of vesicovaginal fistula: a young teenager presenting in her first pregnancy after prolonged obstructed labor. The poor quality of obstetric care at clinics, maternity homes, and medical centers and hospitals in Benin City is assumed responsible for the present cases.
South Africa's Perinatal Education Program (PEP) provides in-service training for health workers from peripheral areas involved in the care of pregnant women and their infants, with the goal of reducing perinatal mortality. This program was evaluated in a study conducted in 3 midwife obstetric units in the Mpumalanga health district; volunteer midwives from 2 of these units were exposed to PEP. Patient files from a 3-month period before and after PEP exposure were compared with findings from the unit where there was no intervention. All 8 midwives who completed the PEP obstetric manual showed improved knowledge scores. However, this improved knowledge was not translated into clinical practice. The outcomes measured included documentation of estimated fetal weight, pelvimetry, blood pressure, urine, head above pelvis, fetal heart rate, contractions, plotting of cervical dilatation, and whether appropriate action was taken when a problem was detected. Case notes of 303 obstetric patients from the 3 clinics failed to reveal any changes in referral patterns as a result of the PEP. Obstetric history was well documented, but responses to detected problems were unsatisfactory at all 3 study sites. Overall, appropriate action was taken in 0-12% of cases, with no association with training. Performance deficiencies were especially marked for pelvimetry, estimated fetal weight, and urine analysis.
Imbalance between lipid peroxidation and antioxidant status in preeclampsia.
Some investigators have suggested that pre-eclampsia may be associated with variations in the oxidant-antioxidant balance of the placenta and plasma. To address this issue, plasma and placental lipid peroxides were measured in 17 women with pre-eclampsia and 10 age- and parity-matched women with uncomplicated pregnancies who presented for labor and delivery to the Department of Obstetrics, Medical Faculty of Istanbul (Turkey). Before delivery, a significant increase in thiobarbituric acid reactive substance (TBARS) and significant decreases in total thiol (t-SH) content and superoxide dismutase (SOD) activity were observed in the plasma of pre-eclamptic women compared with controls. Vitamin C levels and glutathione peroxidase (GPx) activity did not differ between the two groups. In placenta before delivery, TBARS levels were significantly elevated and glutathione levels, vitamin C levels, GPx, glutathione S-transferase, and SOD activities were decreased. After delivery, the elevated TBARS values decreased significantly and the reduced SOD activity and t-SH contents increased significantly. These findings lend support to the hypothesis that pre-eclampsia is associated with an imbalance between lipid peroxides and the antioxidant system.
The association between prenatal care and postpartum health behavior was explored in a cross-sectional study conducted in 1995 in 30 randomly selected rural areas served by health subcenters in Salem District, Tamil Nadu, South India. 95% of respondents attended for prenatal care at least once during their pregnancy, with a median number of 4 visits (range, 0-51). The fifth month of pregnancy was the median time for initiation of prenatal care. 615 women (48%) gave colostrum to their infants. Feeding of colostrum was significantly more likely among women who had 7 or more prenatal visits (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.06-2.07), initiated prenatal care in the first trimester (OR, 1.40; 95% CI, 1.06-1.85), or received information about breast feeding at prenatal visits (OR, 1.66; 95% CI, 1.29-2.14). 265 women (21%) commenced breast feeding within 2 hours of delivery. Only women who received information about breast feeding were significantly more likely to initiate early breast feeding (OR, 1.81; 95% CI, 1.34-2.43). Finally, 765 women (58%) consumed the same amount or more food during the first postpartum month as before pregnancy. Use of prenatal care was not associated with maternal diet in the first postpartum month. Further research is urged to explain the gap between the objectives of prenatal care and the actual outcomes of such care. It is suggested that a greater emphasis should be placed on the content of prenatal visits rather than only on their frequency and timing.
Low birth weight and associated maternal factors in an urban area.
The prevalence of low birth weight and its association with maternal factors was assessed in a 1994 study of 201 pregnant women from an urban area in Nagpur, India. 61 women (30.3%) delivered a low-birth-weight infant. Multivariate analysis identified the following maternal risk factors for a low-birth-weight delivery: anemia (odds ratio [OR], 4.81), low socioeconomic status (OR, 3.96), short birth interval (OR, 3.84), tobacco exposure (OR, 3.14), height (OR, 2.78), maternal age (OR, 2.68), body mass index (OR, 2.02), and primiparity (OR, 1.58). These findings suggest that a greater emphasis should be placed on encouraging adequate birth intervals, weight gain during pregnancy, avoidance of tobacco chewing and exposure to passive smoke, and prevention of adolescent pregnancy.
Maternal mortality in Guinea-Bissau: the use of verbal autopsy in a multi-ethnic population.
The use of verbal autopsy to ascertain the cause of maternal deaths was assessed in a cohort of 15,832 women of reproductive age from 100 clusters in Guinea-Bissau. There were 350 deaths in this cohort during the 6-year study period. Diagnostic algorithms for the most common causes of maternal mortality were employed in interviews with close relatives and birth attendants. 111 (32%) of the deaths occurred during pregnancy or within 42 days after delivery. 78 (70%) of these deaths could be further categorized as direct obstetric, indirect obstetric, or coincidental mortality and, in 69 cases, a possible or probable gynecologic-obstetric diagnosis could be made. The most frequent diagnoses were postpartum hemorrhage (42%), obstructed labor (19%), and puerperal infection (16%). The recall period averaged 2.4 years (range, 1 month to 7.8 years). Informants were most often husbands (28%), older male relatives (26%), or co-wives (18%). Multivariate analysis indicated that the sex of the respondent, the respondent's presence in the village during the terminal phase of the woman's illness, and time after delivery were significantly associated with the risk of not reaching a specific diagnosis after a maternal death through verbal autopsy. Women were less likely than men to provide adequate information for a diagnosis (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.2-8.1). Respondents who did not reside in the village during the woman's illness or delivery carried equal risk of not reaching a conclusion (OR, 3.1; 95% CI, 1.1-9.1). Deaths occurring more than 1 week after delivery also were less likely to be classified (OR, 6.1; 95% CI, 1.7-22.0). The verbal autopsy method is both economical and technically feasible in areas where health workers have only minimal training in determining causes of death.
Women's satisfaction with medical termination.
Women's satisfaction with medical abortion was assessed in a survey of 100 women 14-43 years of age (mean age, 24.6 years) who undergone this procedure at Bedford Hospital (UK). 45 women had not heard of medical abortion before presentation to the hospital. 30 women stated they were not given a choice between medical and surgical abortion. 85 women had already had at least 1 prior pregnancy termination and 30 reported 2 or more prior procedures. Women were given 200 mg of oral mifepristone and returned to the gynecology ward 48 hours later for a 1 mg gemeprost vaginal pessary. A satisfaction questionnaire was distributed before discharge. Women used a visual analogue scale with scores from 0 to 10 to assess staff helpfulness, the appropriateness of the information they received, and overall satisfaction. The amount of bleeding was deemed heavy by 51 women and acceptable by another 42 women. 70 women did not require pain killers. The mean score for overall satisfaction was 8.19 out of a possible 10. When women with a previous surgical abortion were asked to compare it with the medical procedure, the mean value was 7.63, favoring the medical option. Satisfaction with the staff and the informational leaflet was high. The greatest dissatisfaction centered around the adequacy of the counseling women received. The high rate of repeat abortion indicates a need for improved contraceptive counseling before and after pregnancy termination.
Young adults' knowledge, attitudes, and behavior about abortions in young women.
Abortion-related opinions and decision-making strategies were investigated in 89 male and 215 female students from two colleges in New York State, United States, during routine visits to the campus health center. Study respondents were predominantly White and of high socioeconomic status. 30 students (12%) reported that they or their partner had been pregnant and, in 26 of these cases, an abortion was obtained. The vast majority supported abortion for a woman under 18 years of age in cases of rape (92%), incest (90%), or danger to a girl's health (90%). There was less acceptance of pregnancy terminations for reasons of fetal abnormalities (55%), economic hardship (51%), and single marital status (55%). Abortion was considered acceptable regardless of the circumstances by 46% of students (52% of females and 31% of males) and never acceptable by 18% (24% of females and 16% of males). 90% agreed that the outcome of an unplanned pregnancy for a girl under 18 years of age should be decided by the girl herself; only 30% believed that parents should participate in the decision-making process. Nearly one-half erroneously believed that current New York state law requires parental notification and one-third thought that parental consent was required. 75% of Catholics and 95% of non-Catholics believed that abortion should remain legal. 45% of respondents stated they would seek abortion if they or their partner became pregnant. 19% (22% of females and 13% of males) would seek an illegal abortion if necessary. Respondents' feelings about abortion for girls under 18 years old were shaped primarily by their personal values (96%), with significant input from parents (50%), friends (45%), and religious beliefs (36%).
Safety, efficacy and acceptability of mifepristone-misoprostol medical abortion in Vietnam.
Mifepristone-misoprostol medical abortion may be an appropriate option in developing countries with a high demand for abortion services. The safety, efficacy, and acceptability of medical abortion were assessed in 393 women attending two urban clinics in Viet Nam (Hanoi and Ho Chi Minh City) during 1995-96. A trained provider explained both surgical and mifepristone-misoprostol abortion and women were given a choice of regimens. 260 women chose medical abortion and 113 opted for a surgical procedure. Women who selected the medical method were slightly younger, had more years of schooling, were more likely to be unmarried, and were more likely to have been using a contraceptive method than women in the surgical abortion group. Women who opted for medical abortion did so to avoid pain, to avoid surgery or anesthesia, or because they believed it was the safer option. Those who chose surgical abortion perceived it to be simpler, faster, safer, and more effective than medical abortion. The success rate was 96% for medical abortion and 99% for surgical abortion. Side effects such as nausea, vomiting, cramping, pain, diarrhea, and bleeding were more common in the medical abortion group. 97% of women who underwent medical abortion and 95% of those in the surgical abortion group were satisfied with their experience. 96% of medical abortion patients, compared with only 52% in the surgical abortion group, would select the same method again if necessary. Prolonged heavy bleeding was most commonly cited as the worst feature of medical abortion, while pain was the worse aspect of surgical abortion. These findings confirm that mifepristone-misoprostol medical abortion can complement available surgical services and help meet the pressing need for safe, effective abortion in Viet Nam.
Pregnancy termination in a rural subdistrict of Bangladesh: a microstudy.
Interviews with 41 married women from Bangladesh's Abhoynagar Thana identified in the Sample Registration System database as having had a pregnancy termination during 1990-95 probed the reasons for the terminations, the decision-making process, and the consequences of the procedure. Most terminations were sought because women did not desire any more children or wished to space births. Virtually all respondents emphasized that the termination was necessary for the family's economic welfare. Public opinion and religious morality were not salient concerns. Only 5 respondents had been using a contraceptive method (condoms) at the time they became pregnant. Another 12 women had discontinued contraceptive use because of actual or anticipated side effects. 24 women obtained the procedure from a family welfare visitor, nurse, or physician. For the 13 women who approached an untrained provider and the 4 who conducted their own terminations, the risks were viewed as minor compared with advantages such as proximity, familiarity, confidentiality, trust, and privacy. 7 of the 13 women who obtained abortifacients from untrained providers did not have a complete abortion and subsequently went to a trained provider. 14 women reported moderate to severe complications. The risks inherent in use of untrained providers should be publicized so that women can make safer choices.
Early, effective treatment plays an important role in reducing the risk of ascending chlamydia infection after induced abortion. The departments of genitourinary medicine, obstetrics and gynecology, and microbiology in Nottingham, England, have adopted a screen-and-treat policy. 78.6% of abortion seekers or women with genitourinary symptoms who are screened and notified of a positive result return for treatment, and 73.6% have at least 1 contact treated. Of the male contacts, two-thirds have 1 or more generally asymptomatic genital infection. In the first half of 1997, 34 of the 39 women (87.2%) with chlamydia infection identified at pre-abortion screening returned for treatment, as did 70.6% of their sexual contacts. These findings suggest the feasibility of a policy of chlamydia screening and treatment for all abortion patients, preferably before the procedure. Those who are positive should be referred to the genitourinary department for follow-up and the initiation of contact tracing and treatment.
Vaginal misoprostol for pre-abortion cervical priming: is there an optimal evacuation time interval?
The optimal evacuation time interval for vaginal misoprostol administration for cervical priming before first-trimester pregnancy termination was investigated in a prospective study conducted at the National University of Singapore Medical Institute. 60 healthy nulliparous women requesting pregnancy termination at 6-11 weeks of gestation were randomly assigned to receive either 400 mcg or 600 mcg of misoprostol. Vacuum aspiration was performed after 3 hours in the 400 mcg group and after 2 hours in the 600 mcg group. The degree of cervical dilatation before the procedure was measured through use of a Hegar's dilator. Only 5 women (16.7%) in the 600 mcg group, compared with 28 women (93.3%) in the 400 mcg group, achieved a cervical dilatation of 8 mm or more. When the 400 mcg group was used as a baseline, the odds ratio for successful dilatation (8 mm or above) was 0.014 (95% confidence interval, 0.003-0.080) for 600 mcg of misoprostol. Mean cervical dilatation was 8.1 mm for 400 mcg and 6.6 mm for 600 mcg (p < 0.001). Despite the shorter evacuation time interval, the 600 mcg misoprostol dose was associated with an increase in side effects such as vaginal bleeding, abdominal pain, and fever above 38 C. These findings indicate that 400 mcg of misoprostol with a minimal evacuation time interval of 3 hours is most effective. However, a further evaluation with a larger sample size with adequate power to evaluate side effects is recommended.
Uganda's National Institute of Allergy and Infectious Diseases is sponsoring the first HIV vaccine trial to take place in Africa. The vaccine, which introduces three HIV genes to a weakened version of the canarypox virus, has undergone safety testing in the US and France with no serious adverse effects reported in approximately 800 people. The Uganda phase I test will enroll 40 healthy HIV-negative adults who will be randomly assigned to receive four injections of the vaccine or of a placebo. The main purpose of the trial is to assess safety, but the vaccine's potential to trigger the production of neutralizing antibodies against HIV or HIV-specific cytotoxic T lymphocytes will also be assessed. The HIV genes included in the vaccine are those found in clade B viruses, while the predominant HIV subtype in Uganda is caused by clade A and clade D viruses. If the vaccine elicits a response to the African HIV clades, larger trials will be conducted. If it does not, then a vaccine based on the African HIV clades must be developed.
Peer education: a successful strategy with some constraints.
The use of peer education programs to promote sexual health has been widely accepted because of the potential of such programs to be implemented in a cost-effective manner in various settings and because peers are considered more convincing than outsiders. In addition, the thousands of people who have received training to become peer educators constitute a new generation of social work and health professionals who are not embarrassed by sexuality. Problems encountered by peer health education programs include sustainability of volunteers and funding, difficulty in assessing the impact of a program (especially cost-effectiveness), and the lack of appropriate monitoring and evaluation indicators. Given the large turnover of peer educators and the resources needed to provide week-long residential training courses, new methods of training are needed that are less labor intensive and more cost effective. Another problem is that many facilitators of peer health education programs lack a background in health promotion, and sometimes peer education programs for similar audiences compete or send contradictory messages because of a lack of coordination.
Planning peer education programmes in the workplace.
In Guatemala, the HIV/AIDS epidemic is expected to have a vast negative impact on private enterprises as employees battle the disease in themselves and in family members. In response, the Guatemalan Association for the Prevention and Control of AIDS (AGPCS) developed a program to train private sector employees in peer health education. The program began by informing employers about the potential impact of HIV/AIDS on the private sector. Then AGPCS designed a workshop consisting of 11 two-hour weekly modules to provide up to 30 participants with information on sexually transmitted diseases, AIDS, and related issues. The first business to take advantage of the program was a 7000-employee clothing factory that continues to implement HIV prevention strategies. However, concern about the loss of employee time impeded other companies from participating. AGPCS, therefore, increased its flexibility and gave employers the option of sending employees to fewer seminars on topics the employers choose. This new approach led to 31 workshops in 1997 and 28 by August 1998. Also, in 1998, one company hired AGPCS to present 20 workshops to all of their employees. Efforts are made to evaluate workshop effectiveness and to facilitate follow-up activities. Peer education is an important part of the program, and potential peer educators are provided with a manual, extra training, and follow-up help. The training has helped companies develop work-place AIDS policies, and the AGPCS project has become sustainable.
In Zimbabwe, a survey was conducted among 197 students at secondary schools that had FLAG clubs in operation for at least three years (the FLAG program promotes sexual abstinence). Data were gathered via a questionnaire and via focus group discussions with 65 of the students. It was found that most of the students felt they or their peers were at risk of acquiring HIV. The students learned about HIV from teachers (37%), nongovernmental organizations (15%), and families (4%). The students reported that they could protect themselves against HIV by practicing abstinence, being faithful to a sex partner, and using condoms. However, they indicated a lack of understanding of the term "abstinence." They also expressed the misconception that condoms had tiny holes in them that allowed passage of HIV. The students knew where to get condoms but said they would be too embarrassed to request them.
Impact of peer education on HIV infection in Zimbabwe.
The Zimbabwe AIDS Prevention Project (ZAPP) conducted a randomized trial to investigate the effectiveness of peer education in preventing HIV infection. Initial research revealed that if health education could successfully promote a reduction in the number of sex partners and condom use, HIV risk could be greatly reduced. In 1993, ZAPP began enrolling men working at 40 factories in a study. The men were tested for sexually transmitted diseases (STD) and HIV every six months and had access to a ZAPP clinic for counseling, testing, and STD treatment. In June 1994, ZAPP randomly chose 20 factories to receive an additional peer education intervention. Educators were trained for a week and were given refresher courses every six months. Comparison of the incidence of HIV between the control and intervention groups was measured by determining incidence for all individuals and by comparing overall incidence at each factory. Of the 2219 men who were HIV negative after the introduction of peer education, 78% completed one follow-up, and HIV incidence was 2.52%/year. Controlling for time enrolled in the program revealed that the peer education resulted in significantly fewer new HIV infections. Because the voluntary testing and counseling were available at factories with control and intervention programs, this study exposed the independent impact of peer education. It is concluded that peer education, condom distribution, and treatment of STDs should be the cornerstone of HIV prevention policies.
In Brazil, GTPOS, a nongovernmental organization conducting sexuality research and interventions, held a party for two groups of peer health educators who trained adolescents to promote safer sex. One group worked with youth in a slum community, and the other trained students 14-21 years old to conduct workshops in public schools. When the two groups met, they suggested formation of a prevention network. The trained adolescents, who become "Teen Leaders," provide sex education and encourage other adolescents to fight for their rights as citizens and to intervene in their communities in a positive way. The Teen Leaders have learned to organize activities, to plan and evaluate proposals, and to work cooperatively in groups. All of this has had a positive impact on their self-esteem. Another important aspect of the program is that it has brought together youth from different socioeconomic backgrounds. One factor contributing to the success of the GTPOS project is that it has linked Teen Leaders to groups of adult leaders.
In Austria, Germany, Italy, and the Netherlands, the Transnational AIDS/STD (sexually transmitted diseases) Prevention Among Migrant Prostitutes in Europe Project (TAMPEP) is working with 23 groups of female and transgender sex workers who have migrated from Africa, Eastern Europe, Latin America, and Southeast Asia. TAMPEP uses cultural mediators and peer educators and also offers prostitutes seminars, workshops, and other field activities to empower them and create an environment that supports safer sex behavior. Because sex workers migrate, new peer educators are continuously trained. The most successful peer educators are leaders of their target group; exhibit some knowledge of health, educational talents, and excellent communication skills; and are highly ambitious and motivated. TAMPEP spends 2-3 months selecting, training, and following-up peer educators. Peer educators receive a small fee while undergoing training, and they participate in course design. The peer educators receive a certificate upon completion of the course. Cultural mediators conduct follow-up by supporting the peer educators as they assume their new role, providing additional information and materials, and facilitating contacts with public health personnel. Lessons learned the program's first five years reveal that peer education programs should: 1) be part of a broader effort to improve conditions for migrant sex workers, 2) be conducted by autonomous community-based organizations, and 3) continuously adapt to change.
The World Health Organization (WHO) estimates that the death rate from unsafe abortion in Africa is 110/100,000 live births, the highest in the world. In the US, the death rate from abortion is 0.6/100,000. The WHO has concluded that reducing unwanted pregnancies in Africa would dramatically reduce the number of deaths from unsafe abortion. Death from unsafe abortion is the easiest to prevent and treat of all of the causes of maternal mortality. In Ghana, complications of unsafe abortion are the primary causes of death among women of reproductive age, claiming approximately 1200 each year. In response, the government is training community-based midwives to use manual vacuum aspiration to clear the uterus of fetal remains after a woman has a spontaneous miscarriage or unsafe abortion.
Exploring the impact of domestic violence on reproductive health.
Domestic abuse of women is widespread and not linked to race, class, or educational status. Recognizing the impact of domestic violence on reproductive health, AVSC and the Planned Parenthood Association of South Africa have been developing a men's reproductive health program since 1997. At baseline, almost half of the men surveyed indicated that women suffer rape because they dress provocatively, and 58% asserted that marital rape is impossible. Thus, violence against women was prioritized in the program, which is training community health workers in ways to educate men. Trained workers are now educating men in seven provinces. Challenges faced by the program include a lack of social and legal support for violence elimination, the difficulty of intervening in a violent relationship, social definitions of male power that are based on the subjugation of women, and the financial dependence of women and children on men. Health care providers can help survivors of domestic violence by questioning patients about violence in a nonjudgmental way, helping clients increase their awareness that abuse is not to be tolerated, documenting the signs of abuse in medical records, and referring clients to local resources or helping create such resources.
Improving quality: one step at a time.
The notion that health care workers have the power to improve the quality of their services is a key to AVSC's efforts worldwide. The COPE process, AVSC's low-cost intervention for improving quality at service sites, brings together supervisors and staff at all levels to identify barriers to quality services and helps them find solutions they can implement with their own resources. For example, a hospital in Tanzania had tried unsuccessfully to obtain the funds to repair or replace broken equipment. Using the COPE process, the hospital used available funds to send a technician for training in maintenance and repair. Now everything from blood pressure equipment to bedsprings is repaired promptly, and quality has improved. Another hospital in Tanzania coped with the problem of broken bedsprings (patients were putting mattresses on the floor) by using readily available wire mesh to make repairs. In Kenya, the lack of running water forced staff to collect water from a cistern, taking time from their other responsibilities. During a COPE meeting to resolve the problem the staff bemoaned the fact that they did not have the funds to replace the water system. Then the gardener told the group that all they needed to do was fix a broken pipe. The repair was made at minimal cost, and the water supply was restored. The COPE process reveals that health care staff not only can identify obstacles to quality, they often know the cause of the problem and can offer the best solutions.
The political challenges and educational opportunities around very early abortion.
In 1998, the US House of Representatives amended an appropriations bill to prohibit the US Food and Drug Administration (FDA) from approving abortifacients. While it would have had broader implications, this amendment targeted mifepristone, which has been used since 1988 in France to cause early medical abortions. The measure failed to gain the support of the Senate after opponents argued that it would represent an inappropriate interference of the Congress into scientific processes and pointed out that mifepristone is a promising treatment for other conditions, such as Cushing's syndrome and endometriosis. Mifepristone is just one of a number of emerging technologies that allow women to obtain abortions at very early stages of pregnancy. Most public support for abortion is directed to early abortion, and most US women have early abortions (50% in the first eight weeks, and 90% in the first trimester). A 1997 poll revealed that the US public is largely uninformed about drugs used for early abortion, such as mifepristone or the cancer-fighting drug methotrexate, which is being used off-label as an abortifacient. However, 4200 medical abortions were performed in the US in 1996, and this figure increased to 4300 in the first half of 1997. The public must be informed that the process of medical abortion is not as simple as "popping a pill" but requires several days of medical supervision. In France, the abortion rate has declined since mifepristone was introduced.
A rational approach to prenatal screening and intervention.
Improved testing procedures now allow prenatal screening for a wide range of congenital defects, including cystic fibrosis and muscular dystrophy. An emerging technique also allows diagnosis of congenital anomalies during the pre-implantation stage of in vitro fertilization. Thus, clinicians need an established criteria to use as a guide when counseling parents about what prenatal testing is possible, feasible, and desirable. For example, there are limits to prenatal testing for conditions like mutations in the breast cancer gene because affected individuals do not necessary develop the condition and a cure may be found by the time the condition develops. It is even questionable if parents should be given this information until the child reaches an appropriate age. One approach to development of guidelines is to classify congenital abnormalities according to severity, age of onset, and type (structural-functional versus mental). This system reveals anomalies that are clearly lethal, lead to moderate or severe disability with little or no prospect of improvement or cure, are characterized by early onset, and/or involve obvious mental retardation. This approach is particularly relevant in cases of trisomy 21, and progressively invasive screening techniques are available to detect this most common pattern of malformation in humans.
HIV among women in developing countries.
In South Africa, a pregnant woman infected with HIV took zidovudine to protect her fetus, but the child later developed HIV because the woman was not told about breast milk transmission. Women in developing countries have been hit hard by the AIDS epidemic because social inequalities that make it impossible for them to negotiate for safer sex or even to choose their sexual partners. In most developing countries, the only treatment women have access to is the zidovudine that is available only during their participation in clinical trials on prenatal transmission. Activists have expressed concern over programs that attempt to save the lives of babies with no regard for their mothers or other women. Women with HIV need access to health care, to information, and to counselors who can help them make choices. Women must be able to assess whether to risk breast feeding or attempt costly bottle feeding, which may lead to higher levels of infant mortality from bacteria in contaminated water. Women must also be educated so that they can protect their sexual health. In some settings, the topics of sex and sexuality still must be introduced into public discourse. Strong prevention programs are reducing HIV-infection rates among young women in parts of Tanzania, among pregnant women and prostitutes in Dakar, among prostitutes in Thailand and Nepal, and among street children in Brazil. Effective programs must consider AIDS a social issue and address education, equality, and information access.
Should the youth of Zimbabwe have access to condoms?
More than 150 people attended a March 1999 debate in Zimbabwe between two secondary schools and two teacher training colleges over whether young people should have access to condoms. After hearing from both sides, spectators were included in the discussion. It became clear that parents were promoting abstinence while young people were demanding the freedom to make informed choices about their sex behavior and have access to condoms. It is important to listen to youth in order to eradicate HIV. It is also important to remember that HIV is a lifestyle disease and can be eradicated if people reject promiscuity and address the despair that leads to drug abuse. Parents can do their part by setting a good example for their children.
Pacar and Tamu: Indonesian women sex workers' relationships with men.
This article reports on research on the multiple identities and behavior of female prostitutes in Indonesia as they relate to different players in their lives. It is introduced with a review of the literature, which reveals an underlying research bias that prostitutes are a hazard to society and a lack of attention to how they negotiate various aspects of their daily lives. The next sections review the various degrees to which Indonesian women engage in sex work and the concept of multiple identities. The prostitutes support their moves from one identity to another (mother, lover, daughter, sister, sex worker) with various rituals and codes that govern degrees of emotional involvement. The description of the study methodology notes that sex workers from Jakarta (486), Bandung (342), and Surabaya (658) were studied using a variety of means and that this report draws mainly on qualitative findings. The report then discusses why the women begin sex work, the problems that arise when the women attempt to keep their disparate roles discreet, relationships with casual clients and rituals performed with casual clients to enhance cleanliness and prevent disease, relationships with regular clients, relationships with boyfriends, and relationships of older women with men who consider them their "secret wives." The study concludes that the different roles and expected behaviors of these women must be understood to expose their sexual identities. Furthermore, programs to prevent disease must recognize that women who sell sex have complex identities and various types of relationships with men.
Commentary: self interest is not the sole legitimate basis for making decisions.
The treatment of cancer in pregnant patients involves difficult decisions about abortion, the best treatment options, and the potential benefits of treatment to the mother versus risks to the fetus. Most of the discussion about these decisions has focused on cases where a mother has refused an intervention that would potentially save her fetus, such as the case of Angela Carter, who was terminally ill with cancer and refused to undergo a Cesarean section at 26.5 weeks gestation. In this case, both mother and child died after a court-ordered Cesarean was performed. A higher court later overturned this ruling and stated that the pregnant woman should be allowed to decide on her treatment in virtually all cases. In a similar case, a mother with melanoma chose to continue her pregnancy even though this decision precluded some treatment options and caused her to refuse even the use of analgesics after bone metastases. While it is tempting to regard such a decision as the result of "internal coercion," it is important to recognize that people make many decisions based on the best interests of others. Thus, a decision to sacrifice treatment options in an attempt to salvage a healthy child should be considered voluntary and valid.
The interval between pregnancies and the outcome of subsequent births [editorial]
This editorial reviews a report in the New England Journal of Medicine that sought to determine the optimal pregnancy interval in humans. The researchers analyzed 173,205 birth certificates for 1989-96 in Utah and found that infants conceived less than 6 months postpartum had a 30-40% higher risk of low birth weight, premature birth, or small size for gestational age than infants conceived 18-23 months postpartum. The risk of these poor outcomes nearly doubled for infants conceived after an interval of 120 months. The women with these extreme birth intervals shared a high-risk demographic profile by being at the extremes of reproductive age, unmarried, smokers, and less educated. Had the available data allowed consideration of the impact of socioeconomic or psychological stress, the risks associated with the extreme intervals may have been reduced. In addition, the reasons why 10 years would pass between the birth of children may be important determinants of risk themselves. This study did not have access to data on the outcomes of the previous birth, which may provide the best markers of increased risk in subsequent pregnancies. This report indicates that health care providers should counsel women that they may become pregnant soon after delivery (27 days) and offer them a temporary supply of contraceptives. Also, women with extreme birth intervals should be considered at risk of potentially remediable medical and social conditions associated with poor pregnancy outcomes.
Title X family planning clinics confront escalating costs, increasing needs.
Since 1970, the Title X family planning program of the US Public Health Service act has helped low-income American women avoid unintended pregnancies, abortions, and unwanted births. In addition to averting a million pregnancies (and half as many abortions) each year, the 4400 Title X clinics provide an array of reproductive health services. Funding for the program, however, has never recovered from Reagan-era cuts, and President Clinton's proposal for a $25 million increase will only begin to allow the program to achieve Clinton-administration objectives. The clinics face a financial challenge in maintaining the full range of contraceptive choices, especially in light of the high up-front costs of long-acting contraceptives, such as Depo-Provera, which can consume 50% of a budget for 15% of the clients. New diagnostic technologies have made routine screening desirable but expensive, and clinics must struggle to maintain quality of care. Title X clinics also have a clear need to expand their service capacity to reach the million low-income women who continue to risk unintended pregnancy and to serve low-income salaried workers without health insurance. Currently, two-thirds of Title X clients are so impoverished that their care is totally subsidized, and only 20% are covered by Medicaid. A portion of the $25 million increase has also been earmarked to promote reproductive health among the hard-to-reach population, such as substance abusers and the homeless, and to expand service provision to males. While the increase is needed, it represents only a portion of the cost of facing these challenges.
"Cairo-Plus-Five" review is finding political will strong -- but funds lacking.
Last year, the UN Population Fund initiated a 5-year review of progress in attaining the goals of the 1994 International Conference on Population and Development (ICPD). The review included a series of meetings, including a forum in The Hague involving 2000 people, and will culminate in a special session of the UN General Assembly that will endorse the Secretary-General's progress report. The message that has emerged from these meetings is that countries have made a political commitment to implement the ICPD agenda but some of the largest donor countries, including the US, have failed to fulfill their pledges. The final report from the Hague Forum focuses on progress and constraints in: 1) creating an enabling environment for achieving sustainable development; 2) achieving gender equality, equity, and the empowerment of women; 3) promoting reproductive health and rights; 4) strengthening partnerships; and 5) mobilizing and monitoring resources. The Hague Forum was marked by a lack of controversy even though it recommended that: 20% of all donor allocations for reproductive health be earmarked for adolescent-oriented initiatives, postcoital contraception be promoted to reduce the incidence of unsafe abortion, and laws punishing women for undergoing illegal abortions be reviewed. The most significant obstacle to implementing the ICPD goals is the fact that total funding is only half of the $17 billion promised for the year 2000. To date, the US has provided only about a third of its pledged amount.
State efforts to expand Medicaid-funded family planning show promise.
The US government provides 90% of the cost of family planning (FP) services to people eligible for Medicaid, while states contribute the rest and set eligibility ceilings. In the past, only families on welfare received Medicaid, but broader eligibility criteria were created to cover low-income pregnant ("expansion") women until 60 days postpartum, and several states received waivers to extend services beyond this limit. Eight states offer expansion women an additional 2-5 years of FP services, one state offers FP services for 2 years to all women losing regular Medicaid, and four states extend FP services to all low-income women not previously covered by Medicaid. In addition, California provides solely state-funded FP services to women and men with incomes below 200% of the poverty level. Some of these approaches pose outreach challenges, and states have adopted different strategies to extend eligibility to the target population. Data on program enrollment indicate that the state efforts have the potential to reach large numbers of women and to support the work of nonprofit FP clinics. The next step, to expand the program to other states, would be facilitated if Congress obviated the need for states to seek an expansion waiver. Rhode Island's program quickly improved birth intervals for women with Medicaid-funded births so that they were virtually identical to those of privately-insured women and prevented 1443 Medicaid-eligible deliveries, saving $14.3 million through a program that cost $5.7 million from 1994 to 1997.
Light on population health status.
In response to a World Health Organization's Global Advisory Committee on Health Research initiative, a "visual health information profile" was developed that provides a quantitative description of and an assessment of multidimensional aspects of health in a population. The profile uses a hierarchy of indicators, with first-level domains covering: 1) disease conditions and health impairments, 2) the health care system, 3) sociocultural characteristics, 4) environmental determinants, and 5) food and nutrition. Indicators at all levels can be disaggregated. A decile reference method can be used to display indicators by country and to rank performance for specific years, thus allowing country and time comparisons. The circular visual health information profile has radial sectors representing health domains (with sectors representing the indicators in each domain). Scaling is arranged so that situations needing urgent attention are displayed on the periphery. With fixed reference points, comparisons can be made over time. A prototype of this profile is available via the World Wide Web at http://faw.uni-ulm.de/planet/health-profile/circle.html. The profile was evaluated by superimposing indicators for Tunisia for 1994 over those for 1966. Because of the immediate impact of the visual display of information, the profile, which can be applied to indicators at various levels, can contribute to the improvement of public health.
Guatemala -- strength is NGO cooperation.
In early 1999, representations of the UN Population Fund, JOICFP, and APROFAM met in Guatemala to monitor progress of an integrated program promoting reproductive health (RH) and family planning (FP) among Mayans in the Department of Solola. The team observed field activities, such as training, and assessed information, education, and communication (IEC) promotion; service delivery; institutional coordination; and adolescent health programs. The program is training traditional birth attendants (TBAs) to provide RH/FP and general medical services. At one site, a TBA acquires counseling for her clients from a physician via the telephone. This activity will be facilitated with the addition of radio receivers. Resources have been maximized by increasing collaboration among the project, the government, and local nongovernmental organizations. Referrals are being facilitated with improved communication tools and provision of a boat and ambulance for transporting clients. Cooperative efforts are also being made to promote community health and development, health education, and adolescent health.
Laos agencies coordinate on IEC materials.
In February 1999, a meeting was held in Laos to prepare for implementation of the reproductive health IEC (information, education, communication) master plan developed by four agencies that are cooperating members of the IEC Task Force. At the meeting, each agency shared its own IEC master plans, and the plans were combined so that implementation responsibility could be reassigned. The meeting allowed the agencies to learn from each other and avoid duplication of efforts. It was decided that reproductive health promotional materials would be developed for television, radio, and other media. Later in the month, the Lao Youth Union met to outline a manual that will provide comprehensive information for adolescents on sexual and reproductive health. In addition to providing factual information, the ground-breaking manual will address gender issues and the preservation of cultural traditions. A representative of the UN Population Fund served as an advisor to both groups.
Bahamas project gains valuable experience.
In December 1998, JOICFP and the Inter-American Development Bank entered into a contract to implement the Adolescent Reproductive Health Education Project in the Bahamas. Soon thereafter, three experts visited the Bahamas to provide short-term assistance in project development. Chizuko Ikegami, from Positive Living and Community Empowerment in Tokyo, evaluated the current status of HIV infection and responding national prevention activities. She concluded that the project should develop audiovisual material on HIV/AIDS/STDs (sexually transmitted diseases) using music popular with adolescents; expand on the available HIV/AIDS telephone counseling service; and incorporate material prepared by the World Health Organization for use in schools. Shirley Oliver-Miller, from the Margaret Sanger Center International, conducted a training course for project partners using an Experiential Learning Model. The training also involved choosing which existing materials could be adapted for field training in the Bahamas and adapting a prototypical "Christian Family Life Education" resource guide for facilitators. Hiroyuki Tanemoto, a computer consultant, determined which office equipment suppliers in the Bahamas could fulfill project requirements and conducted a computer training course for the project team. These consultations were coordinated by Harumi Kodama, acting JOICFP Coordinator, who also visited Mexico to observe programs there.
Dialogue and the negotiation of meaning: constructions of virginity in Mexico.
This article analyzes the social meaning assigned to virginity and sexual initiation in three areas of Mexico. The introduction: 1) notes that such a study may contribute to an understanding of constructs of sexuality, 2) reviews research in sexuality in Mexico, and 3) relates the current study to other qualitative studies of the cultural aspects of sexuality because it focuses on how sexual meanings are constructed. The next section explains how the study's conceptual foundation was influenced by social constructivist accounts of sex and sexuality and reviews the theory underlying the research process. The third section describes the field work conducted among an Indian community that is connected to the larger community, a rural subsistence agricultural village heavily influenced by Catholicism, and a working-class urban neighborhood. Data were gathered from 7 group discussions and in-depth individual interviews with 14 men and 13 women 15-30 years old. Next, the analysis is shown to have revealed recurrence of four major thematic categories that were analyzed in terms of narrative, metaphor, and rhetoric and in terms of dialogue and polyphony. An example is then provided to illustrate how deconstruction was used to interpret the dialogue. The discussion of findings points out that common constructions of meaning in the three communities proved to be as important as differences. The influence of Catholicism, urban culture, and formal education were recognizable and strong in all settings.
Mental and physical health effects of intimate partner violence on women and children.
This article reviews the literature on the effects of domestic violence on women and children. The introduction notes that domestic violence affects millions of women in the US each year, significantly increasing their health problems and their use of the health care system. The next sections review the incidence of mortality related to such abuse and women's physical health sequelae from battering. Consideration of women's mental health consequences focuses on the traumatic response framework that has been developed to conceptualize the psychological effects of domestic violence. The article then considers studies of abuse during pregnancy. Next, the article turns to the children of battered women, noting how they often fit the description of traumatized children but that there have been no studies to date of the existence among them of post-traumatic stress disorder. After looking at studies that marked children's responses to traumatic events and the effects of domestic violence on the children, the review examines work that revealed developmental differences in children from violent homes. The article then points to several limitations in prior research in the area of domestic violence and highlights the lack of experimental evaluation of treatments or interventions. Next, research into possible opportunities for routine screening and intervention is considered. The article concludes by documenting the need for a change in the health care system so that it can respond appropriately to the needs of battered women.
Sexual abuse in the health professions -- who's counting?
This article reviews the emerging literature quantifying the incidence of sexual exploitation of patients by their health care providers. The introduction notes that the ability of health care providers to provide appropriate care to patients may be compromised by their own childhood sexual abuse or by sexual harassment or contact at the hands of their teachers during their professional training. The next section considers whether sexual contact with patients is a breach of trust and concludes that it definitely is a breach of fiduciary duty. The article continues by examining what constitutes sexual violation of patients and concluding that sexual exploitation can take many forms and can occur without actual physical contact. Consideration of prevalence notes that a Canadian poll conducted in 1991 indicated that 8% of Ontario women suffered sexual harassment or abuse at the hands of physicians. Surveys of physicians reveal that as many as 9% have sexually violated a patient, with most of the interactions occurring between male physicians and female patients. Nurses surveyed reported witnessing verbal or physical abuse by other nurses of patients, but not sexual abuse. The first step in dealing with this problem is to provide health professionals with clear codes of conduct, which acknowledge that inappropriate sexual contact extends beyond sexual intercourse.
Two programs designed to support condom use.
Two programs that were described during the 1999 National Symposium on Overcoming Barriers to Condom Use have been successful in making condoms an accepted norm in their communities. In the first, condom use among Northern Illinois University (NIU) students has risen from 30% in 1989 to 61% by 1997, while rates of STD infection have fallen by 50%. Program coordinators think the success is due to a combined effort to increase condom availability and make condom use a social norm. Condom use is promoted in advertisements in the student newspaper proclaiming that typical NIU students use condoms for protection from sexually transmitted diseases (STDs). Condoms are not distributed on the campus but are made available at several locations on a free-choice basis along with printed health education material. During a 1996 campus survey, a significant positive correlation was found between students' perception of the condom use of other students and their own condom use. In the second program, ABCD Health Service in Boston distributes condoms at no charge through hair salons serving Hispanic women, barber shops, and auto body shops. The program currently distributes more than 11,000 condoms in this manner each month. ABCD health educators also make presentations in beauty salons and to community groups. They are now using state funds to train community women to host "Safety Net" home-based informational parties, where participants play games that convey safer sex messages and receive condoms as party favors.
[Family planning program evaluation: a step-by-step guide for managers and evaluators]
This clear and concise presentation of the entire process of evaluation is intended to allow family planning program administrators to improve the design and delivery of family planning services. In an era of declining resources for family planning and increasing demands for cost-effectiveness, donors are requiring quantified evaluation results. The basic principles of statistics and concepts of evaluation are explained. The first part introduces terminology, expounds on the importance of evaluation, and describes how evaluation measures the strengths and shortcomings of a project, when and how evaluations should be undertaken, and by whom. The second part identifies the steps involved in planning and directing evaluations, from conceptualization to design of methodology, data collection and analysis, presentation of results, and elaboration of budgets for evaluation. The final chapter presents a case study that applies all the information of the preceding chapters.
[Socio-demographic profile of induced abortion]
A study to identify the sociodemographic characteristics associated with induced abortion of the first pregnancy utilized data from a survey conducted in the Havana district of Diez de Octubre from 1991 through mid-1992. 659 women whose first pregnancies ended in induced abortion and 869 whose first pregnancies were carried to term formed the two study groups. The sociodemographic characteristics of the two groups differed significantly except for race. Nearly 60% who aborted the first pregnancy were under 20 years old and only 6% were 25 or over. 44% who carried the pregnancy to term were under 20 and 15% were 25 or over. 56% who aborted were single, while 70% who carried to term were married. 60% who aborted were not employed, but 64.5% who carried to term were employed. Women 20-24 years old had 2.1 times higher risk of aborting the first pregnancy and those younger than 20 had 3.3 times higher risk than women 25 and older; the relationship was statistically significant. Single women were at 9.5 times greater risk and women in union at 2.3 times greater risk of abortion than were married women. It was concluded that age under 25 and especially under 20 years and being single or in union rather than married were risk factors for abortion.
[1st National Reproductive Health Conference, Mexico City, March 15-17, 1995. Executive report]
This document contains the agenda, photographs of participants, examples of press coverage, conclusions, and various other materials from Mexico's First National Conference on Reproductive Health held in Mexico City in March 1995. The conference objectives were to analyze the holistic concept of reproductive health, identify its basic concepts, and establish principles for operating the new program. The 190 participants included heads of family planning and maternal-child health departments and other officials from throughout Mexico. The first day's program stressed the need for collaboration of all health institutions to improve reproductive health. A group of researchers and specialists then analyzed the various components of reproductive health, including the gender perspective. The structure of the reproductive health services and its 5 components was the topic on the second and third days. Substantive programs in family planning, perinatal and maternal health, adolescent reproductive health, and the men's program were all presented and discussed. The IEC strategies of the new programs were also reviewed.
Annual statistical reports of Bolivia's National Office of Epidemiology were the source of data for a survey of the evolution of the 10 most important transmissible diseases of 1980 over the next 10 years. In 1980, acute diarrheal disease was in first place, accounting for 33.3%, with 48,000 cases reported, followed by acute respiratory infection, accounting for 31.3% with 45,648 cases. Tuberculosis, malaria, and sarcoptosis were in third, fourth, and fifth places, accounting for 8.9%, 8.7%, and 5.5%, respectively. Measles, in sixth place, accounted for 2.4%, followed by whooping cough, gonorrhea, typhoid, and chicken pox. In the following decade, acute diarrheal disease was the primary cause every year except 1981 and 1989, when it was second after acute respiratory infection. Acute respiratory infection was in second place in all other years. Diarrhea and acute respiratory infection together accounted for 66% of the 10 causes in 1981 and 1989, but their combined share dropped to 47% in 1990, perhaps as a result of control programs. Tuberculosis was the third cause in 1981 and 1982 and the fifth cause in succeeding years. Malaria was third, fourth, or fifth in every year. Sarcoptosis moved into third place in 1990. Measles was among the first 10 causes only during 1980-81, 1983-84, and 1988. Mass measles vaccination campaigns began in 1983. Whooping cough disappeared from the list after 1985. The success of the Expanded Program of Immunization is evident from the declining incidence of the immunopreventable diseases.
[Abdominal pregnancy, institutional experience]
Abdominal pregnancy, a rare occurrence, is defined as implantation of the product of conception within the peritoneal cavity, excluding tubal, ovarian, or intraligamentary implantations. A retrospective study at Mexico's National Institute of Perinatology for the period 1989-96 revealed 6 abdominal pregnancies in 5 patients among 177 ectopic pregnancies and 43,644 births. The women ranged in age from 24 to 35 years and averaged 29 years. All were of low socioeconomic status. Gestational ages ranged from 15 to 32 weeks. The pregnancy at 32 weeks ended in a premature live birth, which resolved satisfactorily. In all cases the patients complained of diffuse abdominal pain, amenorrhea, and vaginal bleeding. The initial diagnosis was abdominal pregnancy in 4 cases, which were managed by laparotomy. The other 2 cases were initially diagnosed as deferred abortion. Only after failure of treatment was the abdominal pregnancy diagnosed. One woman underwent hysterectomy. The placenta was completely extracted in all cases. The woman with recurrent abdominal pregnancy had pelvic tuberculosis. There were no maternal deaths, but the perinatal mortality rate was 83.4%.
[Costs of maternal-infant care in an institutional health care system]
A study was conducted of the costs of prenatal care, delivery and puerperal care during 1996 in a primary care clinic and a general hospital belonging to the Mexican Institute of Social Security. The services utilized and type of actions carried out were defined and the intensity of utilization estimated. Fixed and variable costs were calculated separately for the health center and the hospital. The methodology and assumptions behind the calculation of costs are outlined, and the sources of data are broadly identified. The cost of prenatal care in pesos was $1205.33. The cost of labor and delivery was $3313.98, including hospitalization of the mother and child. The total cost of postnatal care was $520.43. The total cost of the 3 components of maternal-child care was $5039.74. The cost information is expected to be useful in future program planning.
[Food quality in children of 1-3 years of age (letter)]
Development of good dietary habits is an aspect of health promotion for which the mother is usually assigned the greatest responsibility. A survey of 100 mothers of children aged 1-3 years served by the Mexican Institute of Social Security health services was conducted at a family medical unit in the state of Mexico between April and October 1996. The mothers answered ten questions. The author concluded that children aged 1-3 are fed products of low quality and quantity, influencing the attainment of their full biological, psychological, social and emotional potential. The mothers were aware of the link between quality of the diet and intellectual capacity of the child. The constraints faced by families with limited resources should not be overlooked, but continuous promotion of nutrition and hygiene are also important.