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Pre-conception counselling for key cardiovascular conditions in Africa: optimising pregnancy outcomes.
Cardiovascular Journal of Africa. 2016 Mar-Apr; 27(2):79-83.The World Health Organisation (WHO) supports pre-conception care (PCC) towards improving health and pregnancy outcomes. PPC entails a continuum of promotive, preventative and curative health and social interventions. PPC identifies current and potential medical problems of women of childbearing age towards strategising optimal pregnancy outcomes, whereas antenatal care constitutes the care provided during pregnancy. Optimised PPC and antenatal care would improve civil society and maternal, child and public health. Multiple factors bar most African women from receiving antenatal care. Additionally, PPC is rarely available as a standard of care in many African settings, despite the high maternal mortality rate throughout Africa. African women and healthcare facilitators must cooperate to strategise cost-effective and cost-efficient PPC. This should streamline their limited resources within their socio-cultural preferences, towards short- and long-term improvement of pregnancy outcomes. This review discusses the relevance of and need for PPC in resource-challenged African settings, and emphasises preventative and curative health interventions for congenital and acquired heart disease. We also consider two additional conditions, HIV/AIDS and hypertension, as these are two of the most important co-morbidities encountered in Africa, with significant burden of disease. Finally we advocate strongly for PPC to be considered as a key intervention for reducing maternal mortality rates on the African continent.
BMJ Open. 2015; 5(10):e007004.OBJECTIVES: To explore whether the rule of law is a foundational determinant of health that underlies other socioeconomic, political and cultural factors that have been associated with health outcomes. SETTING: Global project. PARTICIPANTS: Data set of 96 countries, comprising 91% of the global population. PRIMARY AND SECONDARY OUTCOME MEASURES: The following health indicators, infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, were included to explore their association with the rule of law. We used a novel Rule of Law Index, gathered from survey sources, in a cross-sectional and ecological design. The Index is based on eight subindices: (1) Constraints on Government Powers; (2) Absence of Corruption; (3) Order and Security; (4) Fundamental Rights; (5) Open Government; (6) Regulatory Enforcement, (7) Civil Justice; and (8) Criminal Justice. RESULTS: The rule of law showed an independent association with infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, after adjusting for the countries' level of per capita income, their expenditures in health, their level of political and civil freedom, their Gini measure of inequality and women's status (p<0.05). Rule of law remained significant in all the multivariate models, and the following adjustment for potential confounders remained robust for at least one or more of the health outcomes across all eight subindices of the rule of law. Findings show that the higher the country's level of adherence to the rule of law, the better the health of the population. CONCLUSIONS: It is necessary to start considering the country's adherence to the rule of law as a foundational determinant of health. Health advocates should consider the improvement of rule of law as a tool to improve population health. Conversely, lack of progress in rule of law may constitute a structural barrier to health improvement. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Best Practice and Research. Clinical Obstetrics & Gynaecology. 2014 Aug; 28(6):917-30.Many women in the reproductive years have chronic medical conditions that are affected by pregnancy or in which the fetus is placed at increased risk. In most of these women, ongoing medical management of their conditions is greatly improved, even compared with a decade or two ago. However, their condition may still be seriously exacerbated by the physiological changes of pregnancy, and close monitoring of a carefully planned pregnancy is optimal. This requires effective and safe contraceptive use until pregnancy is desired and the medical condition is stabilised. Many contraceptives will also have adverse effects on some medical conditions, and there is now a considerable awareness of the complexities of some of these interactions. For this reason the World Health Organization has developed an excellent, simple and pragmatic programme of guidelines on a four point scale (the WHO "Medical Eligibility Criteria": WHO-MEC), summarising risk of specific contraceptive methods in women with specified chronic medical conditions. The general approach to contraceptive management of many of these conditions is addressed in this article. Copyright (c) 2014. Published by Elsevier Ltd.
Rehabilitation after cardiovascular diseases, with special emphasis on developing countries. Report of a WHO Expert Committee.
WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES. 1993; 831:i-viii, 1-122.In October 1991, a WHO expert committee met to discuss rehabilitation after cardiovascular diseases, with special emphasis on developing countries. Cardiovascular diseases cause most of the premature mortality in developed countries and have emerged as a major public health problem in developing countries in the mid 1970s. Recommendations for rehabilitative care depend on the risk status of cardiac patients experiencing an early recurrence of cardiovascular events (high, intermediate, and low). Committee members have developed recommendations for functional assessment of patients and for physical activity components of care based on the levels of care facilities are equipped to provide (basic, intermediate, and advanced). Committee recommendations are directed to medical practitioners from a variety of fields (e.g., primary care, pediatric cardiology, and geriatrics) and to other health professionals involved in rehabilitative care. Implementation of cardiac rehabilitation in developing countries follows the introduction of the report, which provides guidelines for determining when patients can return to work and program requirements for basic, intermediate, and advanced facilities. The 3rd chapter is entitled exercise testing and training in rehabilitation of children and young adults with cardiovascular disease, e.g., Kawasaki disease and ventricular septic defect. Chapter 4 covers rehabilitation of severely disabled, medically complex cardiac cases, e.g., heart transplants and hypertrophic cardiomyopathy. The report also discusses existing and upcoming methods for education in the rehabilitation of patients with cardiovascular disease. After overall conclusions and recommendations, the report has 12 annexes, ranging in topics from a light exercise program to contraindications and special considerations for exercise testing.
Oxford, England, Oxford University Press, 1990. xix, 136 p.The Commission on Health Research for Development is an independent international consortium formed in 1987 to improve the health of people in developing countries by the power of research. This book is the result of 2 years of effort: 19 commissioned papers, 8 expert meetings, 8 regional workshops, case studies of health research activities in 10 developing countries and hundreds of individual discussions. A unique global survey examined financing, locations and promotion of health research. The focus of all this work was the influence of health on development. This book has 3 sections: a review of global health inequities and why health research is needed; findings of country surveys, health research financing, selection of topics and promotion; conclusions and recommendations. Some research priorities are contraception and reproductive health, behavioral health in developing countries, applied research on essential drugs, vitamin A deficiency, substance abuse, tuberculosis. The main recommendations are: that all countries begin essential national health research (ENHR), with international partnership; that larger and sustained international funding for research be mobilized; and that larger and sustained international funding for research be mobilized; and that international mechanisms for monitoring progress be established. The book is full of graphs and contains footnotes, a complete bibliography and an index.
Geographical variation in the major risk factors of coronary heart disease in men and women aged 35-64 years.
WORLD HEALTH STATISTICS QUARTERLY/RAPPORT TRIMESTRIEL DE STATISTIQUES SANITAIRES MONDIALES. 1988; 41(3-4):115-40.This is an overview of the WHO MONICA project which was "designed to measure the trends in mortality and morbidity from coronary heart disease (CHD) and stroke, and to assess the extent to which they are related to changes in known risk factors in different populations in 27 countries. Risk-factor data are collected from population samples examined in at least two population surveys (one at the beginning of the study and the other at the end). The results of the baseline population surveys are presented." Risk factors considered include smoking, and blood pressure and cholesterol levels for men and women. (SUMMARY IN FRE) (EXCERPT)
World Health Organization Technical Report Series. 1981; (670):1-120.This report includes the collective views of a World Health Organization (WHO) Scientific Group on Research on the Menopause that met in Geneva during December 1980. It includes information on the following: 1) the endocrinology of the menopause and the postmenopausal period (changes in gonadotropins and estrogens immediately prior to the menopause and changes in gonadotropin and steroid hormone levels after the menopause); 2) the age distribution of the menopause (determining the age at menopause, factors influencing the age at menopause, and the range of ages at menopause and the definition of premature and delayed menopause); 3) sociocultural significance of the menopause in different settings; 4) symptoms associated with the menopause (vasomotor symptoms, psychological symptoms, disturbances of sexuality, and insomnia); 5) disorders resulting from, or possibly accelerated by, the menopause (osteoporosis, atherosclerotic cardiovascular disease, and arthritic disorders); 6) risks, with particular reference to neoplasia, of therapeutic estrogens and progestins given to peri- and postmenopausal women (endometrial cancer, breast cancer, and gallbladder disease); 7) fertility regulating methods for women approaching the menopause (fertility and the need for family planning in women approaching the menopause, problems of family planning in perimenopausal women, and considerations with regard to individual methods of family planning in women approaching the menopause); and 8) estrogen and the health care management of perimenopausal and postmenopausal women. At this time some controversy exists as to whether there is a menopausal syndrome of somatic and psychological symptoms and illness. There are virtually no data on the age distribution of the menopause and no information on its sociocultural significance in the developing countries. The subject of risks and benefits of estrogen therapy in peri- and postmenopausal women is of much importance in view of the large number of prescriptions issued for this medication in developed countries, which indicates their frequrnt use, and the different interpretations and opinions among epidemiologists and clinicians on both past and current studies on this subject. Specific recommendations made by the Scientific Group appear at the end of each section of the report. The following were among the general recommendations made: WHO sponsored research should be undertaken to determine the impact on health service needs of the rapidly increasing numbers of postmenopausal women in developing countries; uniform terminology should be adopted by health care workers with regard to the menopause; uniform endocrine standards should be developed which can be applied to the description of peri- and postmenopausal conditions and diseases; and descriptive epidemiological studies of the age at menopause should be performed in a variety of settings.
WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES.. 1998; (877):v-vii, 1-89.This report presents conclusions and recommendations of the WHO Scientific Group relating to various cardiovascular diseases in women of reproductive age, particularly those using steroid hormone contraception. Chapter 1 presents an introduction on the subject, while chapter 2 describes the epidemiological approaches used to examine the safety of steroid contraceptives and the measurement and interpretation of relative and absolute risks. It also discusses the epidemiological evaluation of the cardiovascular effects of the hormonal contents of combined oral contraceptives (COCs). Chapters 3 to 7 examine data on acute myocardial infarction, ischemic and hemorrhagic stroke, and venous thromboembolism obtained from case-control and cohort studies. Chapter 8 reviews possible biological mechanisms for cardiovascular effects of COCs, including the interplay between glucose and insulin metabolism, lipid and lipoprotein metabolism, the hemostatic system, and blood pressure. Chapter 9 studies the factors which may increase the risk of cardiovascular diseases from COC use and presents a model for assessing the risk of cardiovascular disease among users of COC in different parts of the world. Moreover, this chapter looks at the other considerations concerning the safety of COCs, including the role of screening in reducing the risk of cardiovascular disease, as well the importance of disseminating research findings. This report ends with recommendations for further research.
Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA Project populations.
Lancet. 1999 May 8; 353(9164):1,547-57.The WHO MONICA (monitoring trends and determinants in cardiovascular disease) Project monitored, from the early 1980s, trends over 10 years in coronary heart disease (CHD) across 37 populations in 21 countries. We aimed to validate trends in mortality, partitioning responsibility between changing coronary-event rates and changing survival.... During 371 population-years, 166,000 events were registered. Official CHD mortality rates, based on death certification, fell.... By MONICA criteria, CHD mortality rates were higher, but fell less.... Changes in non-fatal rates were smaller.... MONICA coronary-event rates (fatal and non-fatal combined) fell more...than case fatality.... Contribution to changing CHD mortality varied, but in populations in which mortality decreased, coronary-event rates contributed two thirds and case fatality one third. (EXCERPT)
Family Planning Perspectives. 1999 Jan-Feb; 31(1):49-50.The World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormonal Contraception found no evidence of increased cardiovascular risk in women who used oral or injectable progestogen-only contraceptive methods. The analyses were based on 3697 women with cardiovascular disease from 21 centers in 17 countries in Africa, Asia, Europe, and Latin America. Women with a history of hypertension were at increased risk of stroke, regardless of their use of a hormonal contraceptive, but this pattern did not apply to venous thromboembolism or heart attack. Use of progestogen-only methods was associated with small but nonsignificant increases in cardiovascular risk among smokers. Many of the risk estimates in this study had wide confidence intervals because of the small numbers of users of progestogen-only methods enrolled at the various study centers. The interaction between progestogen-only contraceptives and hypertension merits further assessment, especially because women with a history of high blood pressure use progestogen-only pills more frequently than combined oral contraceptives.
Lancet. 1998 Feb 14; 351(9101):521.The author offers clarification of points made by Spitzer in his commentary on the 1997 World Health Organization (WHO) Scientific Group Meeting on cardiovascular disease and steroid hormone contraception. The scientists and clinical researchers who attended the 5-day meeting had not taken a public stance in the controversy regarding the safety of oral contraceptives (OCs) containing different progestagens. Commissioned background papers and the draft technical report were provided to all participants for review prior to the meeting. Meeting participants addressed the interpretation difficulties associated with observational studies, the complexities and interplay of hemostasis and lipid and carbohydrate metabolism, and the relative contribution of the various cardiovascular diseases to morbidity and mortality at different ages and in relation to other risk factors. It was the opinion of the scientific group that the available low-dose combined OCs are safe contraceptives for healthy women. However, women with cardiovascular risk factors such as hypertension may need to consider alternative contraceptive methods.
CONTRACEPTION. 1998 Mar; 57(3):135-6.The eight articles in this issue of "Contraception" should help restore consumer and provider confidence in the safety of combined oral contraceptives (COCs). The papers were commissioned for a 1997 World Health Organization (WHO) Scientific Group Meeting on Cardiovascular Disease and Steroid Hormone Contraception. The complete report will be published in mid-1998 in the WHO Technical Report Series. Overall, these articles suggest that use of low-estrogen COCs by healthy, nonsmoking women is associated with very small increased absolute risks of venous thromboembolism or ischemic stroke. The risk of myocardial infarction or hemorrhagic stroke, if any, is even lower. Regardless of age, the risk of arterial cardiovascular disease attributable to smoking exceeds that associated with COC use. OC providers must ensure that users are informed about conditions that may increase their risk, however. This can be achieved by taking a family and personal history and checking blood pressure. In developing country settings where blood pressure cannot be monitored, women should not necessarily be denied OCs since the risks associated with COC use are negligible compared with those associated with unwanted pregnancy.
Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives. Results of an international, multicenter, case-control study. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.
CONTRACEPTION. 1998 May; 57(5):315-24.As part of a World Health Organization Collaborative Study conducted at 21 centers in Africa, Asia, Europe, and Latin America in 1989-93, the risks of cardiovascular disease associated with use of oral and injectable progestogen-only and combined injectable contraceptives were investigated. 3697 cases of cardiovascular disease (59% stroke, 31% venous thromboembolism, and 10% acute myocardial infarction) were available for analysis and age-matched with up to three controls. 53 cases were current users of oral progestogen-only contraception, 37 were using an injectable progestogen-only method, and 13 were using combined injectable contraception. The adjusted odds ratios for all cardiovascular diseases compared with nonusers of any type of steroid hormone contraceptive were 1.4 (95% confidence interval (CI), 0.79-1.63) for current users of oral progestogen-only methods, 1.02 (95% CI, 0.68-1.54) for users of injectable progestogen-only contraceptives, and 0.95 (95% CI, 0.49-1.86) for use of combined injectable contraceptives. No significant changes in risk for stroke, venous thromboembolism, or acute myocardial infarction or these three conditions combined was apparent in association with any of the contraceptive methods. However, a nonsignificant increase in risk of venous thromboembolism was apparent for both types of progestogen-only contraceptives. Among women with a history of hypertension, the odds ratio for stroke rose from 7.2 (95% CI, 6.1-8.5) among nonusers of any type of steroid hormonal contraceptive method to 12.4 (95% CI, 4.1-37.6) among current users of all oral progestogens.
WHO Scientific Group Meeting on Cardiovascular Disease and Steroid Hormone Contraceptives. Reunion du Groupe scientifique OMS sur les maladies cardio-vasculaires et les contraceptifs hormonaux steroidiens.
WEEKLY EPIDEMIOLOGICAL RECORD. 1997 Nov 28; 72(48):361-3.More than 100 million women worldwide are thought to use steroid hormone contraceptive methods, with an estimated 93 million women using combined oral contraceptives (COCs). The composition and use of these contraceptive preparations, especially those of COCs, have changed dramatically over the years. The World Health Organization (WHO) convened a Scientific Group Meeting on Cardiovascular Disease and Steroid Hormone Contraception during November 3-7, 1997, to review current scientific data on the use of steroid hormone contraception as they relate to the risk of myocardial infarction, ischemic and hemorrhagic stroke, and venous thromboembolic disease. The group also reviewed the incidence of cardiovascular disease among women of reproductive age in general, how the effect of risk factors for cardiovascular disease may be changed using hormonal contraceptives, and whether different compositions of COCs have different cardiovascular risk profiles. The group was comprised of the authors of background papers prepared for the meeting and experts from around the world. The scientific group's conclusions are presented. The incidence and mortality rates of all cardiovascular diseases are very low among reproductive-age women. For women who do not smoke, who have their blood pressure checked, and who do not have hypertension or diabetes, the risk of myocardial infarction in COC users is not increased regardless of age. While current users of COCs have a low absolute risk of venous thromboembolism, their risk is still 3-6 times greater than that of nonusers, with the risk probably being highest during the first year of use.
NURSING JOURNAL OF INDIA. 1992 Apr; 83(4):82-90.Heart attacks and stroke kill about 12 million people each year or 25% of all deaths. No other single disease takes so many lives or disables so many people each year. Besides many of these dead are <65 years old resulting in considerable premature deaths. Heart attacks and stroke caused by life style choices even affect people living in developing countries as these countries reduce the prevalence of infectious diseases and develop socioeconomically with their concomitant increase in life expectancies. People in these countries still develop heart diseases that almost do not even exist in developed countries including rheumatic heart disease and heart disease caused by Chagas' disease. Crowded living conditions caused by poverty and limited medical services cause strep throat which left untreated can turn into rheumatic fever and then to heart disease. Yet treatment with penicillin protects against all 3 conditions. About 300,000 new rheumatic heart disease cases arise each year. Yearly deaths from rheumatic heart disease equals about 60,000. Poverty is also responsible for Chagas' disease of which about 17 million suffer in Latin America. In developing countries, the middle class is at highest risk of hypertension. Health promotion activities have resulted in a decline in cardiovascular diseases in developed countries in Western Europe, North America, Australia, and New Zealand. These activities include health education, diet changes, exercise, and no tobacco use. These activities also reduce the prevalence of other diseases thus keeping populations healthier longer. It is important that the healthy life styles begin when children are young. WHO dedicated World Health Day 1992 to heart health to promote heart healthy activities which can save 6 million lives yearly.
[The health-for-all strategy: are we reaching our targets to reduce mortality?] Helse for alle-strategien--nar vi malene for redusert dodelighet?
Tidsskrift for den Norske Laegeforening. 1992; 112(1):57-63.The author examines Norway's efforts toward attaining the WHO goal of health for all by the year 2000. "This article presents and discusses the sub-goals for expectation of life and mortality, and analyzes the possibilities of reaching them." Consideration is given to reductions in mortality from accidents, cardiovascular effects, and cancer; age-specific mortality rates; and deaths from suicide and homicide. (SUMMARY IN ENG) (EXCERPT)
London, England, International Planned Parenthood Federation, 1990. 122 p. (IPPF Medical Publications)This booklet intended for family planning doctors primarily in developing countries updates the previous IPPF edition, with new information on oral contraceptives, chapters on the subdermal implant Norplant, post-coital contraception, injectables, and appendices on statistical methods and post-partum contraception. Each chapter contains text with a statement by the IMAP (International Medical Advisory Panel) of the IPPF. After brief introductions on historical background and reproductive physiology, the main part of the book concerns the use of combined oral contraceptives, their actions, beneficial and adverse effects, indications and contraindications, and several aspects of use such as community-based distribution. There are chapters on progestogen-only pills and on orals in chronic disease. Post-coital contraception is discussed, considering combined pills, progestagens, IUDs, Danazol, RU-486, which all have different time limits of effectiveness. Both DMPA and NET-EN injectables, by 3-month and monthly protocols are described, with a section on the controversy regarding their distribution. The chapter on Norplant comprises mostly the IMAP statement: more information would be needed for training in this method. The book ends with remarks on the use of hormonal contraceptives to enhance safe motherhood, taking into account the fact that the pill offers no protection against STDs.
WORLD HEALTH STATISTICS QUARTERLY. RAPPORT TRIMESTRIEL DE STATISTIQUES SANITAIRES MONDIALES. 1988; 41(3-4):267-73.Because declining mortality from infectious diseases is accompanied by increasing mortality from noncommunicable diseases in both developed and developing countries, the World Health Organization (WHO) has initiated the Integrated Program for Community Health in Noncommunicable Diseases (Interhealth). Interhealth is based on the concepts that 1) noncommunicable diseases are related to a set of risk factors some of which can be controlled; 2) the entire community must be involved; 3) health promotion intervention strategies, such as population control, risk identification, screening and prevention strategies, must be integrated; 4) different categories of intervention (e.g., lifestyle changes, health care reorganization) must be coordinated; 5) social and environmental changes will be necessary; and 6) noncommunicable disease prevention and control strategies will be implemented through existing primary health care systems. The core program of Interhealth addresses heart diseases, stroke, diabetes, cancer, and respiratory diseases from the point of view of their common risk factors: diet, tobacco, physical activity, environment, oral hygiene, blood pressure, lipids, and glucose. The Interhealth program is being developed as a dynamic system, consisting of 4 main activities: experimental testing by means of demonstration projects (of which there are currently 18 in 15 countries); mathematical modeling of disease/risk factor interrelations; training; and research activities. These activities will be supported by organizational, financial and information activities at WHO headquarters and in the WHO Regional Offices.
ACTA CARDIOLOGICA. 1988; 43(2):133-9.Age-adjusted mortality trends among men aged 35 to 74 in developed countries are analyzed for the last 35 years using WHO data for seven selected countries. "Mortality from all causes has shown the greatest decrease in Japan and the greatest increase in Hungary. From 1970 on cardiovascular mortality demonstrates a downward trend in all countries, except in Sweden where it remains virtually unchanged and Hungary where it rises markedly. Cancer mortality shows an upward trend which levels off during the last 15 years with the exception of Hungary. Changes in dietary and smoking habits and mass treatment of hypertension offer the most plausible explanation for the observed changes." (EXCERPT)
Sequelae of vasectomy. Report of a Meeting on Vasectomy, organized by the Special Programme of Research, Development and Research Training in Human Reproduction held at WHO, Geneva, 3-6 August 1981.
Contraception. 1982 Feb; 25(2):119-23.In response to enquiries received by the World Health Organization (WHO) from several countries, the WHO Special Program of Research, Development and Research Training in Human Reproduction convened a meeting of experts in Geneva during August 1981 to review the available animal, clinical, and epidemiological data on vasectomy, with particular emphasis on clinical implications of longterm sequelae of vasectomy in cardiovascular disease. The occurrence of circulating antibodies to sperm antigens has been demonstrated after vasectomy in all animal species studied thus far by various techniques. Prospective clinical studies of vasectomized and nonvasectomized men have been conducted at 4 centers in the U.S. involving clinical and laboratory evaluation of subjects before surgery and at intervals thereafter. A total of 412 vasectomized men were enrolled in these studies; most were followed for 2, 3, or 4 years. The only significant finding was the development of antibody to sperm antigens. Alexander and Clarkson first reported that vasectomy increases the extent and severity of diet-induced atherosclerosis in cynomolgus monkeys. In a 2nd study, Clarkson and Alexander extended their previous findings to evaluate the effects of vasectomy on naturally occurring atherosclerosis in rhesus monkeys. The mechanism by which vasectomy exacerbates atherosclerosis in monkeys has not been defined. At present epidemiological data which have been published come from observations in the U.S. and United Kingdom and in particular from 2 studies involving 4830 and 1764 vasectomized men studied at about 5-6 years after surgery. No health risks of vasectomy were detected in these early years. Other epidemiological projects are in progress in the U.S. Various options were discussed for further epidemiological studies which might be conducted in developing countries where large numbers of men have been vasectomized. The cohort approach and the case control method, the 2 main study options, are briefly reviewed.
IPPF Medical Bulletin. 1977 Oct; 11(5):1-2.Lancet recently published 2 papers which reported research fundings indicating that oral contraceptive users, over 35 years of age, are at greater risk of death from cardiovascular disease than nonusers. The findings also suggested that oral contraceptive users who have taken the pill for more than 5 years, who smoke, or who have diabetes, hypertension, or obesity are also at increased risk of death than nonusers. In view of these findings the Presidents of the Royal College of General Practitioners and of the Royal College of Obstetricians and Gynaecologists revised oral contraceptive prescribing recommendations. According to the new recommendations 1) women, who are under 30 years of age, can continue to use the pill but if they smoke they should be advised to quit smoking; 2) women, between 30-35 years of age, can continue to use the pill but if they have taken the pill for 5 or more years and if they smoke they should be advised to switch to other contraceptive methods; and 3) women, over 35 years of age, should be advised to use other contraceptive methods. The British Committee on Safety of Medicines did not issue new prescribing instructions. The International Planned Parenthood Federation, noting the findings of both U.S. and British studies, said that physicians should be aware that the risk of death from cardiovascular disease may be enhanced for oral contraceptive users over the age of 40. The Federation also recommended that couples with completed families should consider sterilization or other alternative forms of contraception.
In: Diczfalusy, E., ed. Regulation of human fertility. (Proceedings of the WHO Symposium on Advances in Fertility Regulation, Moscow, USSR, November 16-19, 1976) Copenhagen, Denmark, Scriptor, 1977. p. 253-282This review of combined oral contraceptive (OC) preparations presents formulations, pregnancy rates, biochemical parameter changes, morbidity, and OC indications in 15 tables. The OC preparations are based on 2 different estrogens and 14 progestagens. Though steroid content differs among products, all act primarily to inhibit ovulation by suppression of midcycle release of pituitary gonadotropins. Variable-dose products are associated with higher pregnancy rates than fixed-dose preparations. Side effects of OCs, while difficult to identify, fall into 2 categories: 1) common adverse associations similar to responses to inert placeboes; and 2) serious biochemical and physiological alterations. There is no evidence of any increase in morbidity due to OC use, whereas avoidance of risks associated with pregnancy is beneficial. No convincing evidence of carcinogenic hazard is presented. Some evidence of reduced systemic side effects by lower-dose products is presented, though gynecological side effects, such as irregular bleeding, may increase. Drug interaction with OCs is described; rifampicin causes the most serious of these. OCs induce wide-ranging metabolic changes in many organ systems. These may relate to undesirable side effects (psychological or neurological signs, skin disorders, and blood pressure changes).
Geneva, Switzerland, WHO, 1975. 100 p. (WHO Technical Report Series No. 568)The objectives of a WHO Expert Committee on Smoking and its Effects on Health, which met in Geneva from December 9-14, 1974, were: 1) to summarize and restate in general terms the evidence on the harmful effects to health of smoking; and 2) to propose actions directed towards discouraging smoking. The Committee was asked to summarize the present evidence of the ill effects of smoking on health, and to suggest action that the WHO might recommend to member states and interested health organizations. The purpose of the present report is to formulate information obtained in general terms, and to recommend certain lines of action. Summaries of additional evidence on the effects of smoking on health since the 1970 report of the Director-General include: 1) smoking habits and total mortality; 2) cigarettes as a cause of excess mortality; 3) lung cancer; 4) other respiratory diseases; 5) ischaemic heart disease; 6) cerebrovascular diseases; 7) peptic ulcer; 8) smoking in pregnancy; 9) dependence on nicotine; and 10) involuntary exposure to smoke. Additional information is presented on worldwide smoking trends; smoking control measures; educational approaches; and legislation for antismoking campaigns. It is concluded that the evidence reviewed by the Committee leaves no doubt that many millions of lives are adversely affected by cigarette smoking each year, resulting in several recommendations for implementation by governments and health authorities, and by WHO. 3 annexes include: 1) smoking and health; 2) the limitation of smoking; and 3) legislation to combat smoking hazards: a code of practice.
Contraception. 1970 Jun; 1(6):409-445.This article reviews the validity of previously published material linking oral contraceptive usage to health hazards. The statistical methods involved in such studies are thoroughly examined, particularly those studies relating oral contraceptive usage to thromboembolic disease incidence. Problems inherent to the basic designs of such studies are discussed. Some relationship between thromembolic disease and oral contraceptive usage has been established. Studies on animals relating oral contraceptive usage with carcinogenesis are inconclusive due to the different metabolic rates obtained for different animals and different strains and the high dosage used to produce tumors. Review of the data relating oral contraceptives with alterations in carbohydrate metabolism, serum lipids, etc., show pure speculation of conclusion. Endrocrine effects persisting after discontinuation of oral contraceptives were rare; apparently both types of steroids play some part. It was suggested that most data on this subject is faulty and filled with fixed opinions which should be avoided.
Contraception. 1982 Mar; 25(3):231-41.A randomized, controlled, clinical trial comparing 6 combined oral contraceptives (OCs) with 50 mcg or less of ethinyl estradiol was undertaken in 10 WHO Collaborating Centers for Clinical Research in Human Reproduction. A total of 2430 women entered the trial and were observed for 28,077 woman-cycles. All low-dose combined OCs demonstrated equivalent efficacy with 1-year pregnancy rates of 1-6%. However, discontinuation rates for medical reasons differed significantly between the treatment groups with the preparation containing 20 mcg ethinyl estradiol and that containing 400 mcg norethisterone acetate being associated with higher discontinuation rates due to bleeding disturbances. Even among the preparations which did not differ in discontinuation rates, the reasons for discontinuation did differ. Women receiving norethisterone preparations tended to discontinue because of bleeding disturbances while those receiving the levonorgestrel-containing preparations tended to discontinue because of complaints of nausea and vomiting. (author's)