Clinical examination of pregnant women by paramedical and medical personnel: an assessment of consistency of findings in a field study.

BACKGROUND: As a part of a project to improve the maternal and child health services in 4 primary health centres (PHCs) in Bellary and Raichur districts of Karnataka, we assessed the consistency in recording symptoms, signs and some clinical observations of pregnant women by three examiners-the junior health assistant, medical officer of the PHC and a private medical practitioner. METHODS: One hundred seventy-four pregnant women were examined independently by the three examiners on the same day for 4 symptoms reported by the women themselves, 4 signs assessed by the examining person and 9 simple clinical observations. Agreement rates in each examiner pair for each parameter were assessed. RESULTS: We found poor rates of agreement in assesment of various parameters by each observer pair. The disagreement rates were lower between the two doctors compared with those between the junior health assistant and each doctor. CONCLUSION: The agreement rates between various healthcare personnel in assessing pregnant women are low. There is a need for measures to correct this situation.

Factors inhibiting the use of reversible contraceptive methods in rural south India.

In two rural districts in South India, the contraceptive prevalence rate for all modern family planning methods was 41 percent, and that for all reversible methods was only about 2 percent in 1990. Interviews with 35 health program professionals, 815 currently married women of reproductive age, 136 of their husbands, and 60 community leaders revealed that neither the demand for reversible methods nor the supply of services was strong in the study areas. Program managers and field-workers were not popularizing reversible methods, and therefore couples were unable to learn about their benefits. According to the authors, a strong commitment from program managers at all levels is needed to increase reversible-method use, and adequate services should be made available at clinics and in villages.

PIP: In 1990 in south India, a study in 45 villages in Belgium and Gulbarga districts of Karnataka state aimed to identify the perceptions and experiences of 35 program personnel about promoting reversible methods of family planning. It also aimed to determine the degree of knowledge about these methods and couples, acceptance of them among 60 community leaders and the knowledge and attitudes of couples (815 married women and 136 of their husbands) towards reversible methods. The contraceptive prevalence rate for all modern family planning methods was 41%, but the rate for all reversible methods was around 2%. The leading modern method was female sterilization. Mean family size was 3.9. Even though district and primary health center program managers approved of promoting reversible methods, they did not do anything to ensure better performance in providing reversible methods in the villages. Their superiors did not provide them any clear direction on how to improve performance of these methods. Health workers and health supervisors were concerned that reversible methods did not receive more emphasis in the program, and that couples were not enthusiastic about using them. Superiors used sterilization methods rather than reversible methods to evaluate subordinates' performance. Most family planning personnel believed that women wanted to achieve their desired family size as soon as possible rather than spacing births. They thought side effects linked to reversible methods and opposition from elders accounted for low use of these methods. The low emphasis on promotion of reversible methods left the couples uninformed about their benefits. These findings showed that demand for reversible methods and the supply of services were low. The researchers recommend a strong commitment to promotion of reversible methods by program managers at all levels, appropriate direction and training for field workers and supervisors to educate and motivate couples to use reversible methods, and adequate services at clinics and in villages.

Determinants of fertility in Athoor block, Tamil Nadu, India.

PIP: Data from at least 10 surveys of thousands of households over the period 1960-86 indicate a decline in crude birth rate (CBR) between 1959-85 from 43.1 to 25.6 in the Athoor community development block. The adjacent community development block of Batlagundu, with a higher literacy rate and level of socioeconomic development, was used as control while identifying the proximate determinants of fertility in the study areas. Socioeconomic, institutional, and programmatic factors influencing these proximate determinants were also considered. Declines in the marital fertility rate, due in large part to high age of marriage and a decline in the incidence of young widows, contributed more than other factors to the decline in overall fertility rate. Greater use of contraceptive methods from 0 to 34.2% by 1986, further stemmed fertility. These effects were tempered, however, by a shortened postpartum amenorrhea from 14 to 10 months. Beyond identifying principal proximate determinants, 2 phenomena were explored. While there was an overall decline in CBR over the period, 25.6 is not the lowers level achieved during 1959-85. CBR reached a low of 23.7 in 1980, then climbed over the next few years to its 1985 level. A strong contributing factor to this reversal in a declining trend is a decrease of family planning activities from the level experienced in the 1960s. The 2nd phenomenon is the higher fertility level, desire for larger families, and greater fertility level variation over socioeconomic groups seen in the higher socioeconomic level control block. The authors concluded that high program efficiency must be maintained in the early stages of demographic transition to stabilize against fluctuations in birth rates and contraception prevalence. Additionally, modernizing influences may also affect proximate determinants in opposing manners. Education on child spacing and motivational campaigns targeted especially to young couples should be developed to afford maximum declines in fertility.^ieng