Pregnant adolescents in chemical dependency treatment. Description and outcomes.

This study examines the treatment, maternal and infant outcomes of pregnant adolescents (16-19 years) enrolled in an adult perinatal chemical dependency treatment program. Twenty-one adolescent subjects were compared to 323 adult women (mean age, 27.4 years) after enrollment into a randomized treatment trial consisting of intensive outpatient or short-term residential conditions. The results show a similar treatment retention rate. Adolescents differed from adult women on marital status, drugs of choice (alcohol, marijuana vs. opiates and cocaine) and method of administration, with no injection drug users in the adolescent cohort. Tobacco use was high (> 85%) in both groups. Obstetric, maternal, and infant outcomes to 1 year were comparable. Older adolescents who are chemically dependent and pregnant have treatment needs similar to adult women and can benefit from programs designed to treat older women. Recruitment difficulties for adolescents in need of treatment is discussed.

PIP: This study describes a sample of 21 pregnant women aged 16-19 years in treatment for substance abuse through the MOMS Project in Seattle, Washington, during 1991-94 who were followed for at least 90 days after the beginning of treatment with regard to a number of variables. The treatment, maternal, and infant outcomes of these pregnant adolescents enrolled in an adult perinatal chemical dependency treatment program are compared with like outcomes for 323 randomized adults of mean age 27.4 years in the program. The randomized treatment trial involved either intensive outpatient or short-term residential conditions. 27% of adolescents and 32% of adults remained in treatment for longer than 90 days, a statistically nonsignificant difference. The adolescents did, however, differ from adult women on marital status, preferred drugs, and the method of drug administration, with no IV drug users among the adolescents. A larger proportion of the adolescents drank alcohol compared to the adults. More than 85% of the women in both groups smoked cigarettes. Obstetric, maternal, and infant outcomes to 1 year were comparable. These findings demonstrate that older adolescents who are chemically dependent and pregnant have treatment needs similar to adult women and can benefit from programs designed to treat older women.

Female circumcision: persistence amid conflict.

PIP: The continuing practice of female circumcision (removal of varying degrees of external genitalia) was perhaps the most emotional issue discussed at the Ninth International Congress on Women's Health Issues, held in June in Alexandria, Egypt. The results of two studies presented at the Congress have resulted to an argument. Others view female circumcision as a traditional folk practice, similar to scarring of the skin or elongation of the lips among certain African tribes and should not be subjected to "cultural imperialism" from abroad. Instead, the procedure could best be eradicated through focused education--telling patients that it is not required by Islam and that it can be detrimental to health. However, this suggestion was hotly debated by members of the audience who insisted that female circumcision should be considered as a form of child abuse and thus properly addressed as a political issue.^ieng

Oral contraceptives did not affect biochemical folate indexes and homocysteine concentrations in adolescent females.

OBJECTIVE: The study was designed to determine the impact of currently available oral contraceptive agents (OCAs), smoking, and alcohol on biochemical indexes of folate and vitamin B-12 in adolescent females. DESIGN: Subjects completed a 3-day weighed food record along with a detailed lifestyle questionnaire that included questions on OCA, cigarette, and alcohol use. After subjects had fasted overnight, blood samples were collected and analyzed for levels of serum and red blood cell (RBC) folate and serum B-12 and homocysteine. SUBJECTS/SETTINGS: Two hundred twenty-nine adolescent females (aged 14 to 20 years) were recruited from southern Ontario, Canada, by advertisements in newspapers, high schools, universities, shopping malls, adolescent drop-in centers, and community groups. STATISTICAL ANALYSES PERFORMED: Multiple regression models were used to determine the effect of lifestyle factors and covariates (e.g., dietary folate intake, supplemental folate intake, and age) on biochemical indexes. RESULTS: OCA use, alcohol use, and smoking were not significantly associated with lower serum or RBC folate levels, after controlling for folate intake. Serum homocysteine levels were not associated with smoking or OCA use; however, we estimated a 13% higher concentration among alcohol users than nonusers. Smoking and alcohol use were not associated with serum B-12 levels, but OCA use was associated with an estimated 33% lower serum B-12 level than nonuse. APPLICATIONS: Our findings provide no evidence to suggest that currently available OCAs have a negative impact on the folate status of adolescent females; thus, dietary advice designed to specifically encourage an increase in folate intake among adolescents who use OCAs is not supported. In contrast, serum B-12 levels were lower among OCA users than nonusers, which suggests that an interaction between OCA and some vitamins may persist. The suboptimal biochemical folate indexes of smokers may have more to do with the dietary quality of smokers than previously appreciated. Thus, efforts to improve dietary folate intakes of adolescents who smoke may be an important strategy for improving the folate status of young women.

PIP: The impact of oral contraceptive (OC) use, smoking, and alcohol drinking on biochemical indexes of folate and vitamin B-12 was investigated in 229 adolescents 14-20 years old recruited from advertisements in Ontario, Canada. Subjects completed a life-style questionnaire and a 3-day, weighed food record, followed by overnight fasting and the collection of blood samples. Of the 48 participants (21%) who were OC users, 30 had used the pill for more than 12 months. Only 37 adolescents (16%) smoked, but 94 (60%) had consumed alcohol in the month preceding the study. Median daily intake of folate and vitamin B-12 (including intake from supplements) was 215 mcg and 1.9 mcg, respectively. OC use, smoking, and alcohol consumption were not significantly associated with lower serum or red blood cell folate levels, after controlling for folate intake. Serum homocysteine levels were not correlated with smoking or OC use, but were 13% higher among alcohol drinkers than nondrinkers. Finally, although smoking and alcohol use were not associated with serum B-12 levels, OC use was linked with an estimated 33% lower serum B-12 level than was nonuse. These findings fail to validate concerns that OC use has a negative impact on the folate status of adolescent females, but suggest a need to improve the dietary folate intake of young women who smoke.

Depo-Provera and bone density: what should you tell teen users?

PIP: This article discusses the impact of use of Depo-Provera (DMPA) among long-term users on bone density in the US. Depo-Provera suppresses ovarian estradiol production, which maintains bone density by slowing bone resorption. Young women reach peak density of spinal bone about 16 years of age, and the greatest increase in bone density occurs during the first 2 years after menstruation begins. Depro-Provera is particularly attractive to teenagers. The manufacturer, Pharmacia and Upjohn of Kalamazoo, Michigan, conducted a multicenter longitudinal study among long-term users, but did not include adolescents. A retrospective study from New Zealand found a 7% bone density difference between DMPA users 25 and 51 years old and other premenopausal users. Similar findings were found in a Thailand study comparing DMPA users and users of IUDs and Norplant implants. The findings on bone density differences at one point in time are considered unreliable so far, because bone density is known to shift in response to various situations. For example, bone density declines during breast feeding, but returns to normal after weaning. Lactation is not considered a risk for postmenopausal osteoporosis. It is recommended that clinicians recommend calcium supplements for adolescent DMPA users, because adolescents in general are not inclined to be big milk drinkers.^ieng

Prevalence of anaemia and hookworm infestation among adolescent girls in one rural block of TamilNadu.

PIP: Adolescent girls are at particular risk of developing iron deficiency anemia as a result of the growth spurt that accompanies puberty. This risk is further increased in developing countries by hookworm infestation and the attendant intestinal blood loss. This study investigated the prevalence of both anemia and hookworm infestation among 197 female adolescents, 13-17 years of age, attending 10 schools in a rural block of India's Tamil Nadu State. 19% of subjects belonged to a scheduled caste, 72% to a backward caste, and 9% to a forward caste. The prevalence of anemia was 76.6%. Of the 130 girls who provided stool samples, 63% had hookworm. When questioned about personal hygiene practices, 48.5% of girls reported they did not wear slippers when they went outside. Only 65% were bathing daily. Since anemia during adolescence can have an adverse impact on future pregnancies, measures such as iron and folic acid supplementation, as well as improved hygienic practices, are recommended.^ieng

Lactational performance of adolescent mothers shows preliminary differences from that of adult women.

PURPOSE: The purposes of this study were to characterize milk production, milk composition, and the lactational behavior of adolescent mothers, and to compare their lactational performance with that of adult females. METHODS: Twenty-two lactating mothers, 11 adolescents and 11 adults, were studied at 6-week intervals between 6 and 24 weeks postpartum. Milk production was determined by the test-weighing procedure. Milk nutrient composition was determined by standard chemical analyses. Frequency and duration of nursing and the use of supplemental formula and complementary foods were recorded. RESULTS: The amount of milk adolescents produced at 6, 12, 18, and 24 weeks postpartum ranged from 37-54% less (P < .05) than that of the adults and resulted in a 45% weaning rate at 18 weeks postpartum in the younger group. Milk nutrient concentrations were not significantly different between groups, with the exception of significantly higher sodium concentrations during early lactation in the adolescents' milk. Lactational behavior differed significantly between the adolescent and adult groups; however, with the exception of the lower frequency of daytime nursing and the tendency toward the early introduction of supplemental formula in the adolescent group, these behavioral differences were the result of the racial and ethnic differences between the two groups. The differences in lactational behavior did not contribute to the differences in milk production between the adolescents and adult mothers. CONCLUSIONS: This preliminary study suggests that milk production was reduced in adolescent mothers compared with adult females. Although behavioral strategies that increase the frequency of daytime nursing and reduce the frequency of supplemental feedings may enhance the milk production of adolescent mothers, other biological factors may account for their poorer lactational performance.

PIP: In a comparative study of the lactational performance of 11 adolescent and 11 adult breast-feeding mothers from the US, adolescents were found to produce significantly less milk and lactate for a significantly shorter period of time than their adult counterparts. All subjects were assessed at 6-24 weeks postpartum. The adolescents produced 37% and 54% less milk at 6 and 24 weeks postpartum, respectively, than adult women. These differences in milk production were significant even when adjusted for differences in the frequency and duration of breast feeding episodes and use of supplementary feeds. The amount of dietary energy the infants of adolescents received from human milk alone was clearly inadequate, at every time point, to support normal growth rates. In both groups, the average frequency of nursing episodes during the first 12 weeks postpartum was 7 or more per 24 hours (consistent with current recommendations for adequate lactation); adolescents, however, spent significantly less time nursing and provided greater quantities of supplementary feeds. While all adult women breast-fed throughout the study period, 20% of adolescents had stopped breast feeding by 12 weeks, 50% weaned by 18 weeks, and 64% had discontinued breast feeding by 24 weeks. Unexpectedly, the energy, lactose, fat, total nitrogen, protein nitrogen, nonprotein nitrogen, sodium, potassium, calcium, and phosphorous concentrations showed little difference between the two age groups. The absence of data from the first 6 weeks of life makes it impossible to rule out a role for early formula supplementation in the decreased milk production of adolescents. It is believed,however, that adolescents may be biologically incapable of producing a full complement of milk because of their developmental immaturity.

Teenage fertility in the European Union.

PIP: A large proportion of pregnancies which occur among women during their teenage years are unwanted. As such, the abortion rate is high among teenage pregnant women. Teenage women who choose to carry their fetuses to term run an excess risk of delivering premature and low birthweight babies. Teenage mothers often have not finished their studies and will find it difficult to remain in the educational system. There is a high rate of school dropout among teenage mothers. Moreover, they have limited job opportunities, especially in countries like the UK where child care facilities are scarce. Teenage fertility varies widely among the countries of the European Union (EU). In the UK, there are 32 live births per 1000 women aged 15-19, the highest rate in the EU. In the Netherlands, the rate of teenage fertility is only 4 live births per 1000 women aged 15-19 years. In the context of general delayed childbearing throughout the EU, the rate of teenage fertility in the UK has increased in recent years. A more holistic approach to family planning services, improved communication with teenagers, and more appropriate sex education programs are needed if the British government is to succeed in reducing by 50% the conception rate among women younger than age 16 years by the year 2000. An active policy to fight socioeconomic deprivation at the local level should also positively affect teenage fertility.^ieng

Anaemia among women of reproductive age in Burkina Faso.

The control of anaemia among women of reproductive age (15-49 years) is one of the priorities of the Safe Motherhood initiative. This article presents the results of a study that was carried out to provide some of the information needed for an effective and sustainable programme to control anaemia in women of this age group in Burkina Faso.

PIP: The control of anemia in women of childbearing age is essential to prevent low birth weight and perinatal and maternal mortality. To help identify appropriate intervention strategies for the control of iron deficiency anemia in Burkina Faso, cluster sampling of women 15-49 years of age was conducted in Bobo-Dioulasso. Of the 251 women selected, 56 were pregnant and 123 were breast feeding. Chronic nutritional deficiency (defined as a body mass index under 19 kg/m2) was present in 18% of women. The overall prevalence of anemia was 58.6% (71.4% among pregnant women, 64.2% among breast-feeding women, and 38.9% among non-pregnant/non-lactating women). Although health service utilization was high (91% for prenatal care and 72% for delivery) in this sample, only 11% had taken iron tablets. Ignorance about the benefits of iron supplements, the black color of feces associated with use of the tablets, and the tablets' unpleasant odor were the main reasons for non-compliance. When health workers addressed these concerns, women were compliant. Examination of conjunctival pallor had low sensitivity (16%) as a screening mechanism for anemia, while the portable hemoglobinometer was both acceptable and accurate. Recommended are programs to prevent malaria and malnutrition--the two main causes of anemia in Burkina Faso.

Postcoital contraception: present and future options.

PURPOSE: This article reviews information on currently available postcoital contraceptives, and discusses recent advances in postcoital contraception, mostly notably RU 486. METHODS: Postcoital contraceptives, or "morning after pills," are currently available in the form of high dose estrogens, oral contraceptives, danazol and intrauterine devices. These methods are plagued by high incidences of side effects and less than optimal success rates. RESULTS: Currently, their primary use in the adolescent age group is for victims of sexual assault, but they may also be used as back-up for consensual unprotected intercourse. RU 486, best known as a first trimester abortifacient, has a number of potential uses, including that of a postcoital contraceptive. Two recently published studies from the UK showed RU 486 to have a very low pregnancy rate and fewer side effects when compared with current methods. RU 486 may someday replace high doses of oral contraceptives as the method of choice for postcoital contraception.

PIP: Postcoital contraceptives are available for adolescent use in the US. They include combination oral contraceptives (OCs), high dose estrogens, danazol, and IUDs. Mifepristone (RU-486) is currently not available in the US but is used in France, the UK, and Sweden. Postcoital contraception is especially important for adolescents who have a very high pregnancy rate due to poor contraceptive use. Administration of 2-5 mg ethinyl estradiol (EE) for 5 days beginning within 72 hours of unprotected intercourse yields pregnancy rates ranging from 0-0.92%. EE-related side effects include nausea, vomiting, sore breasts, and irregular menstrual bleeding. DES should not be used, since it is associated with reproductive tract anomalies and vaginal cancers in exposed offspring. Conjugated estrogens have not been used in adolescents for postcoital contraception. The Yuzpe regimen consists of 2 tablets of a combined OC with 200 mg EE and 2 mg dl-norgestrel administered within 72 hours of unprotected intercourse followed by the same dose 12 hours later. Common side effects are nausea and vomiting. Its pregnancy rate is 1.8%. Levonorgestrel-containing OCs can also be used. Administration of 800-1200 mg danazol up to 120 hours after unprotected intercourse protects against pregnancy in about 98% of cases. Copper IUDs have a high efficacy rate when used as postcoital contraception (99.9%), but public opinion, medicolegal considerations, financial costs, and potential for infection impede IUD as a postcoital contraceptive in the US. RU-486 is best known as an abortifacient. It is also a potential postcoital contraceptive. Two UK studies find that RU-486 used as a postcoital contraceptive has a very low pregnancy rate and fewer side effects than the Yuzpe regimen and danazol. It is much more costly than currently used postcoital contraceptives (600 mg of RU-486 cost US$ 68, while Ovral costs US$ 0.48-2.24). Nevertheless, RU-486 may replace the higher doses of OCs as a postcoital contraceptive method.

A future at risk: children having children.

PIP: Every day in the US, over 3000 teenagers become pregnant. The US adolescent pregnancy rate is higher than that in most other developed countries and is increasing. About half of the teenage pregnancies result in a live birth, and most of these mothers are unmarried and will not finish high school. The root cause of this problem is that the young women have a sense of worthlessness and hopelessness about their future that makes them establish the relationships that leave them with babies they are ill-equipped to rear. This is creating an ever-growing underclass condemned to poverty, to a dependency on welfare, and to continue the cycle. All of this results in an ever increasing burden on taxpayers. In Missouri, a bill was enacted in 1990 to address a number of school-related issues that are impacted by premature parenthood. Based on research, the bill makes schools responsible for the continued enrollment of pregnant teens. Alternative programs for pregnant and teen parents receive state aid through guidelines established by the Missouri Department of Elementary and Secondary Education which allow local school districts to design their own programs. Nationwide research indicated that the greatest need of the teenage parents is obtaining appropriate child care. Parenting education is also of vital importance as is appropriate prenatal care. These strategies, in addition to intervening in the lives of middle grade students to help them avoid premature parenthood, form the basis of a 5-step program developed by the Committee for Economic Development to address the problem of teen parenthood. In Missouri, emphasis has also been placed on involving teen mothers in the education of their children so that the children are ready for kindergarten. Despite the proven cost-effective nature of these programs for teen parents (which help avoid additional pregnancies), very few states have encouraged such programs, apparently because of the up-front costs. Until Americans decide to devote sufficient resources to this problem, it will continue to place the future of all of society at risk.^ieng

Combatting anemia in adolescent girls: a report from India.

PIP: In a study on anemia in adolescent girls living in slum areas, 105 girls, aged 10 to 18, participated in qualitative (focus group discussions; open ended, in depth interviews) and quantitative (structured survey and hemoglobin estimation) research activities before and after intervention. Perceptions of mothers were also surveyed. The qualitative methods were used on selected subsamples in order to represent all age and ethnic groups and geographic areas of the slum. Quantitative methods were used on all 105 girls. The prevalence of anemia was 98%. The patterns of responses were similar for the focus groups, interviews, and surveys. Mothers and their daughters believed the girls were healthy (" one who ate well, worked without tiring easily and did not fall sick often"). There was no major connection made between menstruation and health, or between present and future health. Most of the girls were unaware of the Gujarati term for anemia, pandurog, which is used in awareness campaigns. The girls described symptoms (weakness = kamshakti) associated with anemia and knew these could be remedied with green leafy vegetables, fruit, milk, meat, tonics from the doctor, and iron tablets (shakti ni goli). Based on these results, a puppet show, using local terms and events, was developed that covered the causes, symptoms, treatment, and prevention of anemia. The term, pandurog, was introduced and reinforced. The girls were encouraged to have their blood tested and to take iron tablets. The hemoglobin levels of the girls were taken after the show and after an iron supplement program lasting three months. Compliance with the supplementation program was monitored biweekly. Group discussions with flash cards reinforced the information in the puppet show. Results from the last hemoglobin level showed a significant increase; however, the prevalence of anemia was 87%. About half of the girls consumed at least 60% of the tablets; one-fifth consumed 80%. Forgetfulness and fasting during Ramzaan were cited as reasons for noncompliance. There was a significant increase in awareness of the term, pandurog; the symptoms of anemia; the importance of diet in preventing pandurog; and the role of menstruation in increasing iron needs and contributing to pandurog.^ieng

Adapting MCH strategies for the nineties.

PIP: Brief overview was given for strategies in maternal and child health (MCH) in India that were used in the 1980s and adapted for the 1990s in the following areas: perinatal outcomes, empowerment of women, immunization, oral rehydration, adolescent girls, anthropometric measurement, health education, management, and coordination with nongovernmental organizations (NGOs). In order to assure a healthy baby weighing 2.5 kg, monitoring of maternal health is occurring. Iron and folic acid and tetanus toxoid vaccine are provided to pregnant mothers, and fetal growth is monitored. Training of traditional birth attendants and multipurpose health workers will contribute to clean deliveries and referral of complicated pregnancies. During the 1990s, women's health in addition to maternal health has received attention. The empowerment of women to care for themselves, to learn how to mix oral rehydration packets (ORS) at home, and to receive the knowledge and skills were deemed more important than the 1980s focus on the delivery system and inputs of MCH. An excellent cold chain for delivery of vaccines has been put in place, which provides the vehicle for the 1990s to maintain high vaccine coverage. The emphasis on oral rehydration in the 1990s will be on teaching mothers about the importance of ORS treatment of diarrhea. During the 1990s, educating the adolescent girl before she becomes married and pregnant will be the focus. Greater emphasis will be placed on stunting or height for age measurements, as a measure of long term nutritional change; age weight for height for measurement of wasting; and maternal nutritional monitoring of arm circumference. Sustained health education, more media exposure to disease conditions and treatment, and social marketing in health will be better coordinated and more cost effective. Accountability for manpower, materials, and money will be in place within management. Management will focus on motivation and training, and other, newer management concepts. Government will begin to work with NGOs, including cost sharing and a favorable attitude toward NGO contributions. In general, all programs will have greater community participation and improvement in method and strategies.^ieng

Health profile of pregnant adolescents among selected tribal populations in Rajasthan, India.

Among primitive tribal communities in India, girls are traditionally married immediately after attaining menarche. In the present study all adolescent girls in the second and third trimesters of pregnancy from 15 randomly selected villages of 4 tribal development blocks of Udaipur district (South Rajasthan State, India) were studied. The data were analyzed with reference to parity, anthropometry, anemia, and other dietary deficiencies. A total of 54 adolescent girls (13-19 years of age) were included in the present study. Of these, 59% (n = 32) were found to be primigravidas, 30% (n = 20) were pregnant for the second time, and 2 girls were pregnant for the third time. A majority were illiterate (n = 46), and almost all of them were found to be suffering from moderate-to-severe anaemia (n = 51). Similarly, a large majority (n = 46) had a body mass index (BMI) less than normal and body weight less than 42 kg. Two of the pregnant girls were also found to be suffering from pellagra, while approximately one-third of the girls had vitamin A deficiency. Only 2 had ever practiced family planning, consisting of some herbal preparations given to them by the folk doctor. Of the study participants, 19 girls (35.0%) were in the third trimester of pregnancy; of these, 7 had evidence of malpresentation or cephalopelvic disproportion. This study highlights the health profile and needs of pregnant adolescents among tribal populations in a drought-affected area in India.

PIP: Among primitive tribal communities in India, girls are traditionally married immediately after attaining menarche. In the present study, all adolescent girls in the 2nd and 3rd trimesters of pregnancy from 15 randomly selected villages of 4 tribal development blocks of Udaipur district (South Rajasthan State, India) were studied. The data were analyzed with reference to parity, anthropometry, anemia, and other dietary deficiencies. A total of 54 adolescent girls (ages 13-19) were included in the present study. Of these, 59% (n = 32) were found to be primigravidas, 30% (n = 20) were pregnant for the 2nd time, and 2 girls were pregnant for the 3rd time. A majority were illiterate (n = 46), and almost all of them were found to be suffering from moderate-to-severe anemia (n = 51). Similarly, a large majority (n = 46) had a body mass index (BMI) less than normal and body weight less than 42 kg. 2 of the pregnant girls were also found to be suffering from pellagra, while approximately 1/3 of the girls had vitamin A deficiency. Only 2 had ever practiced family planning, consisting of some herbal preparations given to them by the folk doctor. Of the study participants, 19 girls (35.0%) were in the 3rd trimester of pregnancy; of these, 7 had evidence of malpresentation or cephalopelvic disproportion. This study highlights the health profile and needs of pregnant adolescents among tribal populations in a drought-affected area in India.

Exercise and "the pill": putting a rumor to rest.

PIP: Every once in a while, female athletes hear the rumor that oral contraceptives (OCs) keep them from performing their best. Yet, studies that have tried to evaluate the effects of OCs on physically active women have not been conclusive. This rumor probably started with the initial, higher-dose formulations instead of with the current biphasic or triphasic OCs. Side effects of the higher-dose OCs included weight gain, nausea, fatigue, headaches, and increased risks of hypertension, thromboembolism, and changes in glucose and lipid metabolism. Current OCs minimize these side effects and the risk of complications. In fact, the aerobic exercise female athletes undergo most likely neutralizes the negative effects of OCs on coagulation and lipid metabolism. Further, OCs may even improve athletic performance because they can decrease bleeding, the risk of iron deficiency, and frequency of cramps. Moreover, athletes can use OCs to orchestrate their menstrual cycles around competitive meets. Some studies with small sample sizes show that athletes on OCs experience a slight reduction in functional aerobic capacity and endurance capability. A Swedish study of female soccer players reported that OC users suffer fewer traumatic injuries than nonusers. It is difficult to attribute this to OCs, because there is considerable psychological control over sports performance. A sports physician in Hawaii is aware of rumors that OCs induce sluggishness or fatigue during certain days of the month, but he does not know a female athlete who believes this. The head trainer of the US Olympic Committee says that many female Olympic athletes use OCs. Strenuous exercise, considerable weight loss, and possibly other stress factors induce athletic amenorrhea, especially in adolescent females. In many cases, OCs can treat it. They are especially needed to minimize the risk of reduced bone density and musculoskeletal injury.^ieng

The changing sexual attitudes of boys in Poland.

PIP: Until relatively recently, boys in Poland, especially in rural areas, were encouraged to have sex before marriage, while girls were expected to remain virgin until their wedding day or at least until they were engaged to be married. Many boys therefore had sex with girls they did not intend to marry, and abstained from sex with the women they hoped to have as wives. That arrangement was accepted by both boys' parents and boys' prospective wives. Women's emancipation, migration, and changing gender roles during the 1970s, however, affected sexual attitudes and behaviors. Girls grew more sexually active and the importance of virginity decreased. Tensions between the sexes subsequently increased as folk and romantic models were replaced by the partnership model and greater adherence to Catholic sexual ethics. The increased tension is readily seen via the growing number of boys with sexual problems. Approximately 90% of boys masturbate, generally without guilt. Almost 50% of 17 year old boys in Poland have had intimate sexual contact. It is common for boys' first act of sexual intercourse to occur after consuming alcohol and generally without the use of contraception. During first sexual contacts and throughout their premarital period, 40% of boys practice coitus interruptus and 38% use no method of contraception at all. An inability among the majority of boys to find willing sex partners after their first sexual intercourse causes them by necessity to not continue having sex immediately after initiation and also to engage in sex with other boys and men. The author notes that alcohol consumption among boys prior to having sex may be their way of overcoming the fear of women, and that some boys expect their female partners to be maternal. Contraception is not widely used because methods are not well known or rejected often for religious reasons. Many young people get married as a result of unplanned premarital pregnancy. Perceiving no common threat from HIV/AIDS due to the low number of AIDS cases and poor information about the problem, boys do not concern themselves with safer sex behavior. Finally, recent political and economic change in Poland has prompted boys to delay their sexual initiation and avoid permanent relationships and early marriages in the attempt to not ruin any plans for their future which they may have.^ieng

Principles and strategies of programming for adolescent girls.

PIP: In consort with the focus on women's enrichment and status improvement in developing countries, the following principles and strategies are discussed: decentralized planning, maximizing schooling, experiential learning, avoidance of exploitation. Planning must involve adolescents and women and be consistent with cultural influences and patterns. Girls also need to be encouraged by parents to stay in schools as long as possible, with minimizing the attractions of staying out of school, and provision for dropouts to return. Experiential learning through interaction, observation, and enjoyment is the best method and will work best with the disadvantaged and neglected, and enable women to, for instance, understand the importance of breastfeeding, immunization, or hygiene. The program which may involved service is not to be exploitative, be a convenience, and benefit her. The content needs to be flexible and suitable to the age such that nutrition must be taught before menarche and at the first sign of breast development, and when bone growth is at its peak. School feeding programs are of proven benefit. Goals can be satisfied without being rigid and allowing for dream time also. The shape of a better tomorrow will depend upon these women. Adequate funding is always necessary, and something for nothing doesn't work without adequate food, useful learning materials, and attractive incentives such as a culturally appropriate items of clothing, confidence and prestige building are a must. The challenges are to provide formal schooling and the concomitant self-esteem building and public recognition of women's competence. Seclusion of pubescent girls in purdah needs to be eliminated and replaced with programs of responsible, mature and positive interaction with older women, who provide leadership skills and linkages to larger society. Interactions between girls is also important with village based continuing education, and practical self-guided curricula. Vocational training in marketable skills contributes to the economy and independence. Awareness of legal rights and utilization of resources available in primary health care needs to be encouraged. Changes need to be made in family perceptions that allow women educational growth without neglect of family chores and responsibilities. Health programs need to assess adequate intake of iron and folic acid, and nutrition starting at menarche, and proper hygiene. Reproductive information must be provided.^ieng

The low birth-weight infants of Saudi adolescents: maternal implications.

Maternal factors and perinatal outcome of low birth-weight (less than or equal to 2,500 g) infants of 46 adolescent mothers was studied and compared with 160 adolescents who delivered infants weighing greater than 2,500 g. The significant factors found in the low birth-weight group were anaemia, small maternal physique and preterm delivery. Expectedly, the perinatal mortality rate was significantly increased in low birth-weight infants.

PIP: From 1981-1985, researchers studies pregnancy outcomes of 206 female adolescents (= or 17 years old at the time of 1st hospital visit) at King Fahd Hospital in Al-Khobar, Saudi Arabia. 23% of all infants born to adolescents were classified as low birth weight (= or 2500g). 17.4% of these mothers were 15 years old or younger, 39.1% were 16, and 43.5% were 17. For mothers who delivered an infant 2500g, 17.5% were 15, 26.9% were 16, and 55.6% were 17. Mothers who had low birth weight infants (mean weight 53.48k) tended to weigh less at time of delivery than those who had infants 2500g (61.89kg; p.005). Further, the stature of 31.1% of those in the low birth weight group was 150cm whereas only 13.5% of the remaining mothers were 150cm. 64% of mothers who had low birth weight infants delivered before 37 weeks gestation (p.005). Anemia (Hb10.6g/dl) was the most significant complication contributing to low birth weight (38.6%; p.005). This suggests that many adolescent mothers did not take iron and vitamin supplements and that they did not take iron and vitamin supplements and that they did not eat adequately during pregnancy. Even though toxemia also contributed significantly to low birth weight (9%; p.05), its overall prevalence was markedly low (1.9% in 2500g group). The mode of delivery did not affect birth weight. Perinatal mortality for low birth weight infants stood at 14.6%. None of the .2500g infants died. All adolescent mothers should receive early prenatal care. In addition, more health education of health professionals and adolescents is needed to stress the importance of regular prenatal care, liberal hospitalization, intensive antepartum and intrapartum fetal monitoring.

Inter-African Committee proceeding with tactful sensitization in fight against female circumcision.

PIP: Despite tremendous health risks, female circumcision is a prevalent practice throughout Africa today, affecting 75,000,000 women and children in 26 different African countries. There are three types of female circumcision: infibulation, excision, and circumcision. The first procedure involves cutting off the whole clitoris, the labia minora and parts of the labia majora and stitching the vulva closed, leaving only a small opening for urination and menstruation. In excision, the prepuce, clitoris, and all or part of the labia minora are removed. Circumcision refers to the removal of the foreskin of the clitoris. Severe medical complications may arise from female circumcision. Immediate risks include hemorrhage, tetanus and septicemia infection from unsterile and crude cutting instruments, sexual mutilation, bleeding of adjacent organs, and shock. Long term complications include scars which shrink the genital passage resulting in blockage of menstruations, painful intercourse, and tearing of tissue and hemorrhaging during childbirth. Adverse psychological effects may also be experienced. The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children employs gentle persuasion and gradual education (instead of government edit and external protest) in their fight against female circumcision. Since 1984, much progress has been made: Active national committees have been established in 11 African nations and have sponsored educational workshops, media talks, and training for nurses and traditional birth attendants. Those seeking to justify continuing female circumcision use moral and religious arguments, but powerful social pressures truly reinforce the practice. Uncircumcised women are still considered second-class citizens. In response, the Inter-African Committee has developed several educational materials and stands behind efforts to have female circumcision addressed in overall national policies of primary health care. They also urge the linkage of this issue with the Alma Ata Declaration of "Health For All By The Year 2000."^ieng

Pregnancy outcomes among adolescent and older women receiving comprehensive prenatal care.

This study compares three birth outcomes, gestational age, birthweight, and type of delivery, among adolescent and older mothers. Data were collected from 911 women who attended a comprehensive prenatal-care program in a large urban teaching hospital. Women aged 13-19 years were at increased risk for low-birth-weight babies (less than 2500 g) and for preterm infants of fewer than 38 weeks gestation, even with antenatal care, ethnicity, and other factors controlled. Results of bivariate analyses suggested that women aged 20-36 years are more likely than adolescent mothers to have a cesarean section; however, multivariate analyses suggested that maternal age was not an important factor in relation to type of delivery. Thus, even with similar comprehensive care, pregnant adolescents were at an increased risk of some adverse outcomes. However, the amount of antenatal care is a more important predictor of pregnancy outcome than is maternal age.

PIP: This study compares 3 birth outcomes, gestational age, birthweight, and type of delivery, among adolescent and older mothers. Data were collected from 911 women who were enrolled in a comprehensive prenatal care program at a large urban teaching hospital in New York City. For purposes of the analysis, the sample was divided into 2 groups: those aged 13-19 (N=529) and those over 20 (N=382). About 53% of the women were of Hispanic background, 2/5 were black and the remainder were white or other ethnic background. The 2 groups did not differ significantly by ethnicity. The younger and older women did differ by parity: 3/4 of the teenage patients were nulliparous, compared to 55% of the older women. Similar and relatively low proportions of both groups had 2 or fewer antenatal visits. Teenage patients were more than twice as likely to experience toxemia than were the older women. Results of bivariate analyses suggest that women aged 20-36 years are more likely than adolescent mothers to face a cesarean section; however, multivariate analyses suggest that maternal age is not an important factor in relation to type of delivery. The bivariate relationship between maternal age and both gestational age and birthweight reveal that younger mothers were more likely than older ones to have babies 38 weeks gestation and weighing 2500 g. In multivariate analyses, with control for antenatal care, ethnicity, parity, sex of baby, and presence of toxemia, maternal age remains a significant predictor of gestational age and birthweight. The number of antenatal visits, is however, an even stronger predictor of these outcomes than maternal age. In conclusion, even with similar comprehensive care, adolescent mothers in this study were at greater risk of adverse outcomes than older mothers. However, because these findings also suggest that prenatal care is even more important in relation to birth outcomes than is maternal age, the need for early and continuous prenatal care should be stressed for both adolescent and older pregnant women.

Merolicos and health education.

PIP: Research on merolicos provides valuable information about receptiveness to public health communication. Merolicos are Mexican medicine showmen who by entertaining means such as ventriloquism, mental telepathy, and snakehandling captivate audiences while imparting medicinal information. It was observed that trust in the merolicos extends to people seeking out advice, consultation and explanations. The effective folk traditional health orientation, accessibility and communicative style of the showmen were appealing aspects of the merolicos to the townspeople. In a pilot project the medicine show method of communication was explored in a specific area of infant nutrition in order to evaluate whether the showmen were able to bring about changes in the knowledge, attitudes and behavior patterns of their audience. This involves community selection, message content control, preparation and surveys. Impressive results were seen in adolescents who showed curiosity and attentiveness during the shows. Many young girls valued information about infant care and nutrition. Mexican medicine showmen combine an ability to dramatically work information into community health programs at low potential cost while discreetly disseminating vital health oriented information.^ieng