Contending with contradictory data in a risk assessment context: the case of methylmercury.

Two large sample, prospective longitudinal studies one in the Seychelles Islands in the Indian Ocean, the other in the Faroes Islands in the North Sea were conducted during the 1990s to examine the effects of prenatal methylmercury exposure on intellectual function in childhood. The Faroes study found evidence linking this exposure to adverse outcome, but the Seychelles study did not. A peer review workshop held in Raleigh, NC, in 1998 concluded that the inconsistencies between the Faroes and Seychelles findings could be explained by differences in study design and sources of exposure. The US Environmental Protection Agency contracted with the National Academy of Sciences (NAS) to convene an expert panel to provide guidance for a new risk assessment for methylmercury. The NAS panel reviewed the Faroes and Seychelles studies in light of data from a smaller New Zealand study and other data not available to the Raleigh reviewers. These additional data provided evidence of adverse effects in studies whose design and source of exposure were similar to that in the Seychelles, leading the NAS panel to conclude that the weight of the evidence supported the Faroes findings. A power analysis, conducted by computing standardized regression coefficients for the three studies, indicated that many of the Faroes findings were so subtle that the power to detect them in the Seychelles study, despite its large sample size, was only about 50%. Because prospective epidemiological studies are often hampered by limited control over confounding and other factors, including unmeasured between cohort differences in genetic vulnerability and nutritional adequacy, inferences about toxicity often depend heavily on a qualitative assessment of the weight of the evidence from multiple studies.

Transforming family planning programmes: towards a framework for advancing the reproductive rights agenda.

Recent international agreements call for the transformation of family planning programmes from a focus on demographic goals to the promotion of health and rights objectives. But the practical implications of this agenda for current and future programmes remain unclear. Public health resources are devoted to preventing illness and reducing the prevalence and incidence of disease across a population. Human rights methodologies focus on protecting the rights of individuals, and on the right to health and health care. Both of these approaches need to be re-thought and reconciled on a practical level to promote rights-based health programmes. Applying a rights framework to reproductive health programmes means, among other things, focusing as much on the process as on the outcome, incorporating efforts to address the gender and power dimensions of reproductive and sexual decision-making into every level of programme, and focusing on building a sense of entitlement among both the seekers and the providers of services. It also means moving beyond a focus only on the technical quality of clinic-based services to incorporate the ethos of a rights perspective at every level. Political, institutional, and technical barriers to the realisation of the reproductive health and rights agenda include national level politics, lack of capacity within civil society, and lack of transparency of institutional actors.

Prospective, longitudinal assessment of developmental neurotoxicity.

Methodological issues in the design of prospective, longitudinal studies of developmental neurotoxicity in humans are reviewed. A comprehensive assessment of potential confounding influences is important in these studies because inadequate assessment of confounders can threaten the validity of causal inferences drawn from the data. Potential confounders typically include demographic background variables, alcohol and smoking during pregnancy, the quality of parental stimulation, the child's age at test, and the examiner. Exposure to other substances is assessed where significant exposure is expected in the target population. In most studies, control variables even weakly related to outcome are included in all multivariate statistical analyses, and a toxic effect is inferred only if the effect of exposure is significant after controlling for the potential confounders. Once a neurotoxic effect has been identified, suspected mediating variables may be added to the analysis to examine underlying processes or mechanisms through which the exposure may impact on developmental outcome. Individual differences in vulnerability may be examined in terms of either an additive compensatory model or a synergistic "risk and resilience" approach. Failure to detect real effects (Type II error) is of particular concern in these studies because public policy considerations make it likely that negative findings will be interpreted to mean that the exposure is safe. Important sources of Type II error include inadequate representation of highly exposed individuals, overcontrol for confounders, and inappropriate correction for multiple comparisons. Given the high cost and complexity of prospective, longitudinal investigations, cross-sectional pilot studies focusing on highly exposed individuals can be valuable for the initial identification of salient domains of impairment.

The other epidemics. Sexually transmitted diseases.

PIP: Around 70% of female infertility in developing countries is caused by sexually transmitted diseases (STDs) that can be traced back to husbands or partners. STDs and reproductive tract infections cause 750,000 deaths and 75 million illnesses among women each year worldwide, and these deaths may more than double by the year 2000. Death rates are rising fastest in Africa, followed by Asia and Latin America. About 450,000 cases of potentially fatal reproductive tract cancers are diagnosed annually: an estimated 354,000 occur in Third World women, virtually all of whom die. Worldwide, roughly 250 million new infections of chlamydia, gonorrhea, and the human papillomavirus are sexually transmitted each year. Chlamydia and the human papillomavirus account for 50 million and 30 million new cases per year, respectively. The human immunodeficiency virus (HIV) infected 1 million people worldwide between April and December 1991, according to the World Health Organization. A study in the Indian state of Maharashtra revealed that 92% of the 650 rural women examined had an average of 3.6 infections of gynecological type or sexually transmitted type per women. Another study in 2 rural Egyptian villages found that half of 509 nonpregnant women aged 20 to 60 years had infections. Only 2 facilities for the diagnosis and treatment of STDs exist in all of Kenya. In Ibadan, Nigeria, with a population of 2 million, there is only 1 recognized STD clinic. The physical consequences of several STDs have been linked to increased risks of AIDS transmission. Early recognition and treatment of STDs in pregnant women would cut infant mortality. Maternal infections with chlamydia, gonorrhea, or herpes are transferred to infants at birth 25% to 50% of the time. In Africa, infant blindness caused by gonorrhea infection is 50 times more common than in industrial countries. The International Women's Health Coalition's March 1992 meeting of more than 50 Third World scientists, health advocates, and policymakers made suggestions to make universally available simple, inexpensive, rapid diagnostic tests for STDs and to develop vaginal microbicides that protect women against STDs.^ieng

Impact of polychlorinated dibenzo-p-dioxins, dibenzofurans, and biphenyls on human and environmental health, with special emphasis on application of the toxic equivalency factor concept.

A scientific evaluation was made of the mechanisms of action of polychlorinated dibenzo-p-dioxins, dibenzofurans and biphenyls. Distinction is made between the aryl-hydrocarbon (Ah) receptor-mediated and non-Ah receptor-mediated toxic responses. Special attention is paid to the applicability of the toxic equivalency factor (TEF) concept.

Out of the woods.

PIP: Throughout Africa, Asia and Latin America women are pushed out of forests and from their maintenance by governments and private interests for cash crop development disregarding the role of women in conserving forests. In developing countries forests are a source of wood for fuel; 60-80% of women gather wood for family needs in America. Fruits, vegetables, and nuts gathered in woods enhance their diet. Indonesian women pick bananas, mangos, guavas, and avocados from trees around their homes; in Senegal shea-nut butter is made from a local tree fruit to be sold for cash. Women provide labor also in logging, wood processing, and tree nurseries. They make charcoal and grow seedlings for sale. In India 40% of forest income and 75% of forest products export earnings are derived from nonwood resources. Poor, rural women make items out of bamboo, rattan, and rope to sell: 48% of women in an Egyptian province make a living through such activities. In India 600,000 women harvest tendu leaves for use as wrappings for cigarettes. The expansion of commercial tree plantations replacing once communal natural forests has forced poor households to spend up to 4-% of their income on fuel that they used to find in forests. Tribal women in India know the medicinal uses of 300 forest species, and women in Sierra Leone could name 31 products they obtained or made from trees and bushes, while men named only 8 items. Only 1 forestry project appraised by the World Bank during 1984-97 named women as beneficiaries, and only 1 out of 33 rural development programs funded by the World Bank did. Women provide food, fuel, and water for their families in subsistence economies, they know sustainable methods of forestry, yet they are not included in development programs whose success or failure could hinge on more attention to women's contribution and on more equity.^ieng

India's misconceived family plan.

PIP: India's goal of reducing the national birth rate by 50% by the year 2000 is destined to failure in the absence of attention to poverty, social inequality, and women's subordination--the factors that serve to perpetuate high fertility. There is a need to shift the emphasis of the population control effort from the obligation of individual women to curtail childbearing to the provision of the resources required for poor women to meet their basic needs. Female children are less likely to be educated or taken for medical care than their male counterparts and receive a lower proportion of the family's food supply. This discrimination stems, in large part, from parents' view that daughters will not be able to remunerate their families in later life for such investments. The myth of female nonproductivity that leads to the biased allocation of family resources overlooks the contribution of adult women's unpaid domestic labor and household production. Although government statistics state that women comprise 46% of India's agricultural labor force (and up to 90% of rural women participate in this sector on some basis), women have been excluded systematically from agricultural development schemes such as irrigation projects, credit, and mechanization. In the field of family planning, the Government's virtually exclusive focus on sterilization has excluded younger women who are not ready to terminate childbearing but would like methods such as condoms, diaphragms, IUDs, and oral contraceptives to space births. More general maternal-child health services are out of reach of the majority of poor rural women due to long distances that must be travelled to clinics India's birth rate could be reduced by 25% by 2000 just by filling the demand for quality voluntary family planning services. Without a sustained political commitment to improve the status of women in India, however, such gains will not be sustainable.^ieng

Incidence and correlates of breast-feeding in socioeconomically disadvantaged women.

Although the incidence of breast-feeding has more than doubled in the United States in recent years, this increase has been less evident among blacks and in lower socioeconomic groups. To understand better this lower incidence, cognitive and personality correlates of breast-feeding were examined in two independent lower-class samples: 137 black inner-city mothers and 50 predominantly white mothers. Ego development, depression, and verbal competence were assessed during the first postpartum year. Only 21.9% of the black sample chose to breast-feed, in contrast with 58.0% of the white sample. Although unrelated to depression and social support, breast-feeding was positively associated with ego level and cognitive ability in both samples. Cognitive ability was assessed using the Peabody Picture Vocabulary Test-Revised, which was found to be valid in relation to maternal and infant characteristics for the black socially disadvantaged sample. When compared using multiple regression analysis, the relation of ego maturity to breast-feeding was generally stronger than that of cognitive ability. Women with more ego maturity may breast-feed because of increased feelings of empathy or nurturance or because they are more attuned to current health advisories and able to deviate from community norms to adopt breast-feeding practices more characteristic of the white middle class.

Maternal mortality and morbidity. Zimbabwe's birth force.

PIP: The training of traditional birth attendants (TBAs) as a national public health strategy was implemented in the late 1970's in Zimbabwe. Since 1982, the Manicaland rural health programs have trained 6000 women in 12-week courses to change their practices of using unsterilized razor blades, shards of glass, or knives to sever the umbilical cord. These practices and others had led to high rates of neonatal tetanus mortality and maternal mortality. TBAs learned from state certified nurses the basics of personal and domestic hygiene, identification of pregnancy and associated risk factors, the importance of good nutrition, rest, and immunization for pregnant women, and safe practices in labor and delivery. Refresher courses and additional training in prenatal care and family planning have been added recently to the program. Completion of the program leads to a public recognition of their graduation in the base village. Maternity care services are provided as back up. This includes village based maternity waiting homes for women in labor, community health workers, and auxiliary midwives with higher level training. A district health center has been set up for more complicated cases. This access to better health care has led to a 50 and 66% reduction in maternal and infant mortality rates, respectively. A 1988 government survey shows increases in the use of contraceptives and the number of women receiving prenatal care. The components of the program which have contributed to program success and provided similarities to other country's TBA programs are as follows: developing a sense of self esteem and pride among TBAs for their work, utilizing creative ways to teach the largely illiterate TBA population through role plays and songs, and providing involvement in the health care system which reaffirms the TBA's importance. In spite of the advancements made however, there are still problems to solve. Unsafe practices are resorted to when TBAs forget their training. Disruptions in medical supplies handicap TBAs in carrying out their work. Some of the solutions are to utilize bicycles for transporting supplies to remote areas, or mobile clinics which provide supplies and training. If more countries followed Zimbabwe's lead, other countries would benefit from reduced birth rates and improved infant and maternal mortality in a cost effective and culturally compatible way.^ieng

Out from behind the contraceptive Iron Curtain.

PIP: In the early 1950s, the Soviet Union and several of its Eastern European satellites completed their transition from high to low fertility before the US and Western Europe. They did this even though there were not enough modern contraceptives available to meet the needs of its citizens. As late as 1990, the Soviet Union had no factories manufacturing modern contraceptives. A gynecologist in Poland described domestically produced oral contraceptives (OCs) as being good for horses, but not for humans. The Romanian government under Ceaucescu banned all contraceptives and safe abortion services. Therefore, women relied on abortion as their principal means of birth control, even in Catholic Poland. The legal abortion rates in the Soviet Union and Romania stood at 100/1000 (1985) and 91/1000 (1987) as compared to 18/1000 in Denmark and 13/1000 in France. All too often these abortion were prohibited and occurred under unsafe conditions giving rise to complications and death. Further, the lack of contraceptives in the region precipitated and increase in AIDS and other sexually transmitted diseases. On the other hand, abortion rates were minimalized in Czechoslovakia, East Germany, and Hungary due to the availability of modern contraceptives and reproductive health services. Hungary and East Germany even manufactured OCs. OC use in these 2 nations rated as among the world's highest. East Germany also treated infertility and sexually transmitted diseases. The region experienced a political opening in latecomer 1989. In 1989, IPPF gave approximately 15 million condoms and 3000 monthly OC packets to the Soviet Union to ease the transition. More international assistance for contraceptive supplies and equipment and training to modernize abortion practices is necessary.^ieng

Baby budget.

PIP: The author evaluates China's one-child family policy and concludes that it has been successful in bringing down the rate of population growth, but that its future effectiveness is threatened by recent economic and political reforms.^ieng

The forgotten resource.

PIP: The impact of economic development aid on women in the third world has generally been adverse, even though they are the core of food production and family economy. In the developing world, women provide 50% of the agricultural labor, and grow 80% of family food in Africa, 60% in Asia, and 46% in the Caribbean. They work 10-16 hours a day, foraging for fuel, fodder and water, raising children, as well as doing the required "woman's work" on husbands' fields, while husbands work 6-8 hours, and keep money they earn from cash crops separate. Some of the trends in economic aid in the last 30 years that adversely affect women include: emphasizing cash export crops, providing credit to men to excluding collateral women can provide, privatizing and turning over to men common farm lands, supporting cash crop timber rather than natural forests, providing farm machinery for men's crops that women are obliged to tend after initial clearing, providing cash-intensive hybrid maize rather than sorghum or millet that women raise for families, and directing aid for livestock to men when women traditionally raise them. Traditional cultural, religious and legal barriers do exist against women, yet colonial, common, and Napoleonic law has codified them. New trends in foreign aid include laws in Canada and Italy requiring more gender equitable programs, and a review requirement for USAID by the Women in Development Act enacted in 1988.^ieng

Anti-abortion policy leads to more abortions.

PIP: In 1984, the Reagan administration announced in Mexico City a reversal in the US international family planning policy. The new policy strictly forbids any international family planning group that receives US funds from providing abortion services or counseling. An immediate impact on family planning programs in developing countries was that it prevented the opening of much needed clinics in the poorest, most rapidly growing countries in the world, such as Bangladesh. The University of Michigan School of Public Health estimates an additional 380,000 unwanted pregnancies, resulting in 311,000 births, 69,000 abortions, and 1200 maternal deaths in the next 3 years. Not only did the US change its policy, but congress decreased funding for international family planning programs 20% between 1985 and 1987. The majority of the funding goes to the US Agency for International Development (USAID), and in 1988 the Reagan administration allowed USAID to funnel about $75 million of this money to other projects, e.g. general African development fund. Fewer contraceptives are available due to the reduced funding, and therefore more women seek an abortion as a last resort against unwanted pregnancy. An additional effect of this 1984 policy reversal is that fewer nongovernmental organizations (NGOs) are eligible for grants, so USAID gives its family planning funds to government agencies who are not the most effective users of funds and are not always trusted by the people served.^ieng

Choice at any cost.

PIP: Women have devised ways of ending unintended pregnancies since the dawn of civilization and will continue to do so. Human behavior, misplaced political priorities, and inadequate technologies all are responsible for the fact of abortion. An estimated 50 million abortions were performed worldwide in 1987, slightly less than 2/3 of which were legal. Spontaneous abortion ends far more conceptions than does induced abortion. Based on rates of use around the globe, abortion ranks 4th among family planning methods, after female sterilization, IUDs, and oral contraceptives (OCs). Unplanned pregnancies are essentially the result of lack of access to and inconsistent use of contraceptives. Mere access to abortion does not assure an end to unplanned pregnancy. Inconsistent birth control use and reliance on contraceptive methods with high failure rates contribute to unintended pregnancies and abortions around the world. The World Health Organization (WHO) estimates that each year 1 million or more women die from pregnancy-related causes. Fully 99% of these deaths occur in the 3rd world, where complications arising from pregnancy and illegal abortions are the leading cause of death in women in their 20s and 30s. Most of the 20 million or so illegal abortions that occur every year are performed by unskilled attendants under unsanitary conditions, leaving women vulnerable to serious infection, internal bleeding, hemorrhaging, and pelvic inflammatory disease. Modern abortion procedures performed under proper medical supervision in countries where they are legal are responsible for fewer maternal deaths than pregnancy itself. Regardless of the country or the law, gaining access to abortion actually is a matter of economics and social attitudes. The past 2 decades have seen a general continuation of the post-World War II trend of liberalizing abortion laws, with more than 30 countries increasing access at least statutorily, but some countries actually have made their regulations more restrictive. So-called abortion migration, from countries with restrictive laws to those with more lenient policies, works to divide women with unintended pregnancies into those who can afford to travel to obtain an abortion and those who cannot and consequently resort to illegal procedures or carry the pregnancy to term. History documents that women determined to exercise control over their reproductive choices will do so, even if this means opting for dangerous illegal abortions. Laws cannot suppress abortion practices. All they can do is make abortion more or less safe and costly.^ieng