HIV/AIDS programmes should focus on improved access.

PIP: This paper discusses the need for HIV/AIDS programs in sub-Saharan countries to focus more on improved access to information to empower poor people living in remote areas. It is noted that despite Glaxo Wellcome's move to reduce the cost of antiretroviral therapy, it is unlikely to have an impact on most of those infected with or affected by HIV/AIDS, since concerns regarding lack of sustainability, bureaucratic administration, and communication difficulties predominate in the country. In this regard, it is therefore recommended that national HIV/AIDS programs be balanced with the needs of both the community and the individual and in prevention and care. Health workers should be explicit in confronting traditional beliefs, such as those about gender roles and traditional medicine, in prevention campaigns. Moreover, there is also an urgent need to improve access to condoms; strengthen health programs such as directly observed treatment short-term (DOTS) courses for tuberculosis and the syndromic approach to sexually transmitted disease treatment; and improve practical support to communities caring for those who are sick and the orphans. Lastly, all partners working with prevention programs should use the more positive community attitudes towards HIV/AIDS issues seen in many sub-Saharan countries to develop evidence-based programs that focus more on improved access and less on sustainability.^ieng

Give choice a chance: new report on Guatemala.

PIP: This paper provides an overview on the research report entitled "An Unfulfilled Human Right: Family Planning in Guatemala," by Bonnie Scott Jones, Staff Attorney of Center for Reproductive Law and Policy. The research examines Guatemala's reproductive health care networks. It also presents the factors influencing the high rates of maternal mortality, unwanted pregnancy and extreme poverty. The information gathered from indigenous women, traditional birth attendants, nongovernmental organizations and government officials revealed an appalling lack of support from the Guatemalan government for promoting and protecting its citizens' right to family planning information and services. In addition, the research indicated the role of the Catholic Church in the country's family planning programs.^ieng

Impact of health centre availability on utilisation of maternity care and pregnancy outcome in a rural area of Haryana.

Six hundred married women of 15-45 years age group were interviewed in 4 villages of the district Ambala in Haryana. Impact of health centre (HC) availability on the knowledge, opinion and practices related to maternity care and pregnancy outcome was assessed after adjusting the effect of socio-economic status. Except 17 women (2.8%), everyone knew at least one correct purpose of antenatal care (ANC) and 98.2% women had contacted health staff for ANC. However, knowledge of the respondents about the components of ANC was found to be poor in study villages. Traditional birth attendants (TBAs) conducted delivery in 76.1% cases in sub-centre (SC), 75.6% in villages without a HC compared to 49.8% in primary health centre (PHC) village. However, preference for TBAs in PHC village was 14.9%, in SC village 33.5%, and in villages without HC 36.3% (p < 0.001). Among respondents having better awareness about ANC components, preference and utilisation of modern delivery attendants was found to be higher. For maternity illnesses, consultation rate of government functionaries was 67.9% in PHC village, 52.2% in SC village and 55.8% in villages without a HC. Perinatal mortality rate of 76.0/1000 births in villages without HC was not significantly different from the rate of 87.4/1000 in SC village but rate of 38.9/1000 in the PHC village was significantly lower (p < 0.01). Awareness and availability of modern maternity services were found to have significant influence on the health seeking behaviour and pregnancy outcome.

PIP: A survey conducted in four villages in Ambala district, Haryana state, India, assessed the impact of health care center (HCC) availability on the utilization of maternity care services and pregnancy outcomes. Interviewed were 600 married women with a delivery in the 2 years prior to the survey. One village had a primary HCC, one had a subcenter, and two did not have an HCC, but were within 5 km of such a facility. Overall, 98.2% of respondents had contacted health staff for antenatal care. High awareness of modern maternity care, defined as knowledge of more than 3 components of antenatal care, was present in 9.6% of respondents in the HCC village, 22.1% in the subcenter village, and 15.3% in villages without an HCC. 49.8% of deliveries in the primary HCC village, 76.1% in the subcenter village, and 75.6% in those without an HCC, were performed by a traditional birth attendant (TBA). Preference for a TBA-assisted delivery was expressed by 14.9%, 33.5%, and 36.3% of respondents, respectively (p 0.001). Both preference for and use of TBAs were lower among women with high awareness of the components of antenatal care. The consultation rate of government functionaries for maternal illnesses was 67.9% in the HCC village, 52.2% in the subcenter village, and 55.8% in villages without an HCC. The perinatal mortality rate in villages without an HCC (76/1000 births) was not significantly different from that in the village with a subcenter (87.4/1000), but was significantly higher than that in the village with an HCC (38.9/1000) (p 0.01). These findings indicate that awareness of and access to an HCC equipped with modern maternity facilities has a significant positive impact on the health-seeking behavior and pregnancy outcome of rural women.

Who uses reproductive health services in the Philippines (and who doesn't)?

PIP: Data from the 1993 National Demographic Survey and the Safe Motherhood Survey have filled gaps in knowledge about the accessibility and use of reproductive health services in the Philippines. Analysis of the data by the East-West Center's Program on Population has revealed that the number of women using family planning (FP) and maternal health services has risen to 40% in 1993 from 17% in 1973. Modest gains were also seen in the past five years despite disruption to program efforts. Prenatal care showed the greatest maternal care coverage rate increase, but 70% of births occurred at home, with only 51% attended by a trained person, and only 32% of postpartum women received care. Adolescents and women who are over age 40, uneducated, Muslim, and/or live in a rural setting have the most unmet need. In addition, less than half of the women reporting symptoms of a sexually transmitted disease sought treatment from a trained practitioner. Most women use public sector services, including 71% of those using modern contraceptives. While trained midwives provided 58% of prenatal care, traditional birth attendants delivered 52% of all births, and a high incidence of maternal mortality persists (209/100,000). Recommendations arising from this analysis include 1) improving prenatal and delivery care, 2) strengthening postpartum FP services, 3) expanding the program to reach more women, 4) extending the range of reproductive health services offered, 5) integrating traditional practitioners into the reproductive health system, and 6) balancing cost and service variations between the public and private sectors.^ieng

Country focus -- Nepal. Making motherhood safer in Nepal.

PIP: The government of Nepal has endorsed the Safe Motherhood policy. It has developed a five-year national plan of action. Maternal mortality in Nepal may be as high as 850-1000/100,000 births. 90% of Nepal's population live in rural areas where roads and telephones are rare. About 80% of the population have worm infestations and are therefore anemic. Malaria, insufficient diet, carrying wood and water for long distances, and heavy agricultural work are other burdens on women's health. Only 25% of women of childbearing age use modern contraception. Breast feeding is the chief means of spacing births. A doctor, nurse, or medically trained midwife attends only 7.4% of births; a traditional midwife attends about 20%; and a relative or neighbor attends 58.2%; leaving almost 10% of women delivering completely unattended. Despite Nepal's strong commitment to primary health care, many Nepalese live as far as a day's journey to the nearest health post. 80% of posts for physicians in rural areas are vacant. Many health post physicians are men, yet village women tend not to go to a man for obstetric problems. The government is setting up sub-health posts in all village development committee areas. A woman heads the new Safe Motherhood Programme, the goal of which is to improve maternal health and family planning services at all levels. The new program should ensure that health facilities receive adequate supplies and equipment, enough staff trained in maternal health service delivery, and staff motivated to become more accessible to women with the most obstetric needs. In-service training is designed to improve the skills of current health care workers and midwives in the diagnosis and management of maternal health problems as well as in referral of women to health facilities prepared to help them. 22,000 village women will be trained as traditional birth attendants. Program challenges include providing equipment, maintaining it, delivering supplies, training staff adequately, and persuading them to work in remote locations. The greatest test is changing society's attitudes to women.^ieng

Use of health care services in two rural communities in Tanzania.

This study was undertaken to investigate the pattern of utilization of medical and dental health care services in rural Tanzania. Two hundred adults, 91 men and 109 women aged 20 or over, were interviewed. Nearly all subjects reported using modern dental and medical health care services. Home remedy was the only indigenous method of treatment used for dental problems while for medical problems a traditional healer was the most commonly used indigenous alternative. The use of both indigenous and modern health care services was significantly lower for dental than for medical problems (P < 0.05). It seems that the pattern of utilization of health care services differs for medical and dental problems. This should be taken into account when planning comprehensive health care services for rural African societies.

PIP: In September 1988 a dentist interviewed 91 men and 109 women aged 20 years and older living in 2 villages in Ilala, Tanzania, to study their pattern of utilization of dental and medical care services. Most adults had used modern dental and medical care services. Most adults had used modern dental and medical care services (96% and 98%, respectively). 84% of adults who used modern dental care services used a dentist, 23% a medical practitioner, and 1% a pharmacy. The only traditional method of treating dental problems was home remedy, which was used by men more often than women (30% vs. 18%; p .05). Use of analgesics likely was included among the home remedies. Adults probably did not use traditional healers for dental problems because they cannot alleviate the acute episodic dental pain. Dentists at hospitals using local anesthesia tend to do tooth extraction, the most common dental treatment in Tanzania. Adults were more likely to use both modern and traditional medical care services for medical problems than dental problems (p .05). They tended to use a traditional healer more often for medical problems than home remedies (61% vs. 34%; p .05). The farther people lived from the nearest modern medical health care unit, the greater the likelihood that they used traditional medical care services (92% for those living = or 5 km away vs. 61% for 5 km; p .05). Older adults were more likely to use both traditional dental and medical services (odds ratio [OR] = 3.85 and 2.65, respectively). Men tended to use traditional dental services more often than did women (OR = 3.93). These findings show that village-level modern dental health care has not been accorded a high priority. Existing medical staff at village-level health dispensaries should take on the responsibility for dental health.

A study of satisfaction among primary health care patients in Saudi Arabia.

Primary Health Care is essential health care based on delivering integrated health services (curative and preventive). The Kingdom of Saudi Arabia adopted this approach in 1980, and by the year 1987 the Ministry of Health had established 1477 Primary Health Care centers. The expansion in Primary Health Care created a need for various types of evaluation. Theorists recommended the study of patients' satisfaction as a way of evaluating care. The aim of this study was to assess the satisfaction of patients with different aspects of Primary Health Care services in Riyadh. The sample consisted of 300 patients chosen systematically from three Primary Health Care centers in Riyadh. The data were collected by personal interviews. The tool consisted of demographic data, a 4-point rating scale of 40 statements measuring satisfaction with different aspects of Primary Health Care services, and an open question eliciting the patients' suggestions for improvements. The analysis of variance (ANOVA) was used to determine the difference in level of patient satisfaction between the three centers. The results show that the patients were moderately satisfied with the services. They were most satisfied with the effectiveness and humane aspects of care, and least satisfied with the thoroughness and continuity aspects of care. It is recommended that the Ministry of Health develop programs for its personnel to sensitize them to the different aspects of Primary Health Care.

Factors related to the utilization of prenatal care in Vietnam.

Data from the 1988 Vietnam Demographic and Health Survey and 1990 Vietnam Accessibility of Contraceptives Survey were used in this analysis of the influence of selected individual and community characteristics on the utilization of prenatal care in Vietnam. Specific analysis of the impact of availability of health services and other development characteristics of the community on utilization of prenatal care was done in a rural subsample. The woman's educational level and total number of living children were the most significant predictors of prenatal care utilization. Age independent of parity did not significantly affect the use of prenatal care. Rural women and women living in provinces with the highest infant mortality rates were significantly less likely to use prenatal services than their counterparts in the urban areas and provinces with low infant mortality rates. Non-physician health care providers were the main sources of prenatal care for women in both rural and urban areas.

PIP: Researchers analyzed data from the 1988 Vietnam Demographic and Health Survey and the 1990 Vietnam Accessibility of Contraceptives Survey to determine the influence of individual and community characteristics on use of prenatal care. Most pregnant women received prenatal care services from midwives or assistant physicians (34.8-51.2%). Less than 5% received prenatal care from a physician. Level of education and utilization of prenatal care were positively associated (p = .0001). Higher parity women were less likely to use prenatal care (47.1% vs. 68.8%), perhaps reflecting that they were more confident about pregnancy and felt less need for prenatal care. Maternal age did not affect utilization of prenatal care, regardless of parity. Urban women were more likely to use prenatal care than rural women and those living in the provinces where infant mortality was higher than 40/1000 live births. The lack of transport in rural areas was likely responsible for this difference in prenatal care utilization. Absence of prenatal care services in provinces with high infant mortality rates probably explained the difference in prenatal care use. Among rural women, the factor having the most influence on prenatal care utilization was education. These findings emphasized the need for promotion of prenatal care services among women with limited education and expansion of the accessibility and availability of prenatal services. They also indicted the importance of improving women's education which in turn improves utilization of prenatal care services.

Local facilities save lives.

PIP: A pilot project that was instituted by the Ministry of Health in the Ivory Coast placed an obstetrician/gynecologist in the Divo City maternity hospital in October 1982. Prior to the appointment, 10 midwives handled normal deliveries in the 31-bed facility; obstetric emergencies were sent to the Cocody teaching hospital which was 190 km away. After the appointment, women who required caesareans and blood transfusions did not need to be transferred. Other hospitals also sent cases to Cocody, including one at Agboville where caesareans were not usually performed (although a gynecologist became available in 1984), and another at Yopougon where no obstetric surgery was performed. An investigation, which compared the number of maternal deaths in 1980 with those in 1985 for the 3 hospitals, showed that 8 of 65 women referred from Divo in 1980 died because they arrived too late for emergency treatment at Cocody. In 1985, no emergency transfers were necessary, and only 1 woman died at Divo; Agboville referred substantially fewer cases to Cocody, and there was a corresponding fall in the number of women who died; and at Yopougo, where facilities remained unchanged, the number of transfers and fatalities did not change significantly. Because of these findings and the scarcity of doctors, particularly in rural areas, midwives and nurses may be required to perform some of the essential obstetric functions. Nurses in the Rural Health Zone of Karawa, Zaire were trained to do ceasarean deliveries, laparotomies, and supracervical hysterectomies. Their case fatality rates were comparable to physicians.^ieng

Abortion in Europe, 1920-91: a public health perspective.

This article grew out of a keynote address prepared for the conference, "From Abortion to Contraception: Public Health Approaches to Reducing Unwanted Pregnancy and Abortion Through Improved Family Planning Services," held in Tbilisi, Georgia, USSR in October 1990. The article reviews the legal, religious, and medical situation of induced abortion in Europe in historical perspective, and considers access to abortion services, attitudes of health professionals, abortion incidence, morbidity and mortality, the new antiprogestins, the characteristics of abortion seekers, late abortions, postabortion psychological reactions, effects of denied abortion, and repeat abortion. Special attention is focused on the changes occurring in Romania, Albania, and the former Soviet Union, plus the effects of the new conservatism elsewhere in the formerly socialist countries of central and eastern Europe, particularly Poland. Abortion is a social reality that can no more be legislated out of existence than the controversy surrounding it can be stilled. No matter how effective family planning services and practices become, there will always be a need for access to safe abortion services.

PIP: A review of induced abortion in Europe encompasses historical perspective of legal, religious, medical, and legislative activity; access to abortion services; abortion incidence and trends including characteristics of abortion seekers, mortality and morbidity, late abortions, and postabortion psychological responses; emerging trends in central and eastern Europe by country; prevention from abortion to contraception; barriers to be overcome in public health oriented efforts; and conclusions. Also included is the Tbilisi Declaration. The article is a byproduct of a conference on Abortion and Public Health Approaches to Reducing Unwanted Pregnancy through Improved Family Planning (FP) Services, held in Tbilisi, Georgia, USSR, in October 1990. One thought was that the 1990s are a time of "desperate women, troubled health professionals, and scared politicians." During the reproductive years in developed countries, a woman is trying to become or actually is pregnant 10% of the time, and 90% of the time she is avoiding more births or trying to postpone births. Abortion rates show a decline in the countries where legal abortion is part of a comprehensive family planning program. The lowest rates are in the Netherlands. Historically Plato recommended abortion for women 40 years, while Hippocrates spoke against it. During the Dark and Middle Ages, women managed their own fertility regulation including clandestine abortions. In England in 1803, severe restrictions were put on abortion and other European and North American countries followed the example. The focus was on preventing life-threatening infection. The early Hebrews fined for abortion, and the Christians followed, with neither group considering the act as murder. The techniques had been around for 2.5 millennia, and the last refinement of technique occurred in 1972. The Catholic Church in 1869 punished with excommunication the aborting woman and the provider and in 1895, condemned explicitly and publicly any therapeutic abortion. Medical restraints were common in Europe in the 20th Century. Abortion law has fluctuated in restrictiveness since the turn of the century. Restrictions have been eased due to recognition of the public health threat, support for women's rights. access to modern contraceptives, and liberalization of legislation on fertility regulation. There is a growing awareness that abortion cannot be obliterated by legal codes. It is expected that increases use and access to modern contraceptives will lead to a decline in abortion. The Tbilisi Declaration affirms the right of reproductive freedom.

Incidence and causes of maternal mortality in five Kampala hospitals, 1980-1986.

This report presents results of a descriptive study to estimate the mortality rate, identify the type and the causes of maternal deaths. The study was conducted in 1987 in Kampala hospitals for a period covering seven years from 1st January 1980 to 31st December, 1986. The non abortion maternal mortality rate (NAMMR) was 2.65 per 1000 deliveries while the abortion related maternal mortality rate (ARMMR) was 3.58 per 1000 abortions. There was a statistically significant increase in NAMMR while the increase in ARMMR was almost significant over the seven year period. Of all maternal deaths, 80 per cent were non abortion while 20 per cent were abortion related. The commonest immediate causes of death, in order of importance, were sepsis, haemorrhage, ruptured uterus, anaesthesia and anaemia. The commonest patient management factors which contributed to death, in order of importance, were lack of blood for transfusion, lack of drugs and intravenous fluids, theatre problems and doctor related factors. We feel that a lot happens to the pregnant mother before she finally reaches a health unit for delivery and that there is a great need to improve on the community's gynaecological and obstetrical services as well as ambulance and emergency services. We also feel that maternal mortality in developing countries could be reduced if the health workers were imaginative in respect to each patient, tried not to operate as though they were working in a developed country, and created relevant solutions for the local problems.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Maternal mortality is examined from June 1980 to December 1986 at Mulago, Nsambyo, Old Kampala, Rubaga, and Mengo Hospitals in Kampala, Uganda. Clinical or immediate causes, direct and indirect, were recorded from case summary forms based on ICD9 definitions of obstetric complications. The nonabortion maternal mortality rate (NAMMR) was 2.65/1000 deliveries (580 deaths); the abortion-related maternal mortality rate (ARMMR) was 3.58/1000 abortions. The hospital maternal mortality rate was 2.0/1000 deliveries. 75% of maternal deaths of women of 28 weeks' gestation or more had delivered outside the hospital. NAMMR doubled between 1980-86, a statistically significant increase. ARMMR increases were almost significant. 75% were direct obstetric and 21% were indirect obstetric causes. 38% had clinical anemia, 29% had some sepsis, 18% had substantial bleeding, and 14% had obstructed labor. Other contributing conditions were pneumonia, ruptured uterus, laparotomy, evacuations and curettage, malaria, preeclampsia, sickle cell anemia, pulmonary embolism, malnutrition, tetanus, meningitis, prolonged labor, and hepatitis. At admission, 48% were in poor condition, 30% in good condition, and 22% in fair condition. 27% had sickle cell anemia, high blood pressure, multiple pregnancy, or malaria at admission. 64% were admitted within 24 hours after delivery, 67% 1-7 days after delivery, and 92% 7-42 days after delivery. Those in good condition were all admitted 7 days postdelivery. 41% of deaths were due to lack of drugs, 7% lack of fluids, 20% with theater problems, 14% with doctor-related factors, and 3% with midwife-related factors. Better information is needed on mortality before delivery, mortality in hospitals vs. outside, and mortality from abortion, and ectopic and hydatidiform molar pregnancies. An explanation given for the increase in maternal mortality is the decline in economic conditions. Abortion complications may be due to the concealment practiced. Causes are consistent with trends from the 1950s, 1960s, and 1970s in Uganda and developing countries in general. Availability and accessibility of gynecological and obstetric services needs great improvement. Training traditional birth attendants and obtaining rural ambulance services are also needed. Health workers lack creativity and imagination for developing country conditions; scarce resources are not the only problem.

Maternal health care utilization in Jordan: a study of patterns and determinants.

This article analyzes the patterns and determinants of maternal health care utilization in Jordan, using data from the Jordan Fertility and Family Health Survey of 1983. The study focuses on the 2,949 women who had a child in the five years preceding the survey. Through multivariate analyses of differentials in the utilization of prenatal care and health care at delivery, the study assesses the effect of sociodemographic factors, including residence, education, parity, and standard of living. The coverage of maternal health care in Jordan is discussed in relation to the overall organization of health services, the various providers of care, and the role of cultural factors.

PIP: Researchers used data from the 1983 Jordan Fertility and Family Health Survey to measure differentials of utilization of maternal and child health (MCH) services. 58.4% of the women had some prenatal care, 57.2% of these went to the private sector, mainly physicians (42.4%). The next leading provider of prenatal care was public MCH centers (25.2%). 48% began prenatal care in the 1st trimester and went 5 or more times (adequate care). 55% using the private sector for prenatal care had adequate care compared to 38% for the public sector. Even though most sought prenatal care in the private sector, 40.5% of the births took place in public health facilities vs. 18.3% for private hospitals. Professional midwives delivered most babies (42.5%) followed by physicians (32.1%) then traditional birth attendants (TBAs; 22.1%). TBAs attended 53% of home births then midwives (38%). 43% who delivered at a public hospital had prenatal care in the private sector, yet only about 20% who delivered in a private hospital received prenatal care in the public sector. 54% of those who had prenatal care in the private sector delivered at home. 54.3% who went to a private hospital had adequate care compared to 28.8% in a public hospital and 14.6% who had their child at home. Living in an urban area, high standard of living, and high education significantly and positively affected the intensity of utilization of prenatal care and the timeliness of this care (p.001). On the other hand, women who had at most limited prenatal care were more likely to have many children and live in a rural area (p.001). Most significant predictors of prenatal care and using a private hospital were a high standard of living, if the woman lived in an urban or rural area outside Amman, and more space/individual, if the household had a high standard of living. Public health facilities in Jordan were underutilized.

Reaching help on time in an emergency delivery.

PIP: Many maternal deaths in developing countries occur because mothers with complicated pregnancies or deliveries cannot be transported at all or fast enough to a health facility. A pregnant woman hemorrhaging greatly had to wait for a taxi because an unauthorized person had the health center's vehicle in Tanzania. Since most physicians practice in cities, most maternal deaths involve rural women. Further the less educated, lower the socioeconomic status, and lower the family's income the more likely she is to die. 3 phases contributed to transport delays of pregnant women. The 1st phase includes the time it take for a woman and her family to decide if her condition is serious enough to require medical attention, and if so, can they afford to pay for transport. Sometimes the services scare her or she considers the services to be of poor quality. The next phase involves the availability of transport and the distance between the mother and the services. Indeed in Nigeria, 96% of mothers who do not use medical delivery services report that they do not do so because of distance. Once at the health facility, the waiting period between arrival and meeting the woman's medical needs make up the 3rd phase. Often health facilities have inadequate number of medical personnel. Moreover the family must buy needed medical supplies before treatment can even begin. Alarm and transport systems are needed. In 1 area of India, pigeons carry messages to a physician that a woman is experiencing labor difficulties. Prior to the civil war in Somalia, a distinct flag informed passing motorists that emergency transport was needed for a pregnant woman who was carried to the roadside on a stretcher or in a cart. High technology transport is not cost effective and should not be part of a primary health care system.^ieng

On health and healing: community health care in India.

PIP: Indian society adhere to certain articles of faith: health is a right of everyone and when the normal healthy state fails illness arises. Therefore health maintenance should prevail over treating illness. Still influential Western trained physicians in India operate under a top down technomanagerial approach where the beneficial health services center around large expensive specialized curative services in urban hospitals. Yet 70% of the rural population do not even have access to basic health services and communicable diseases continue to be the leading health problems, especially among children who compromise 45% of the population. This happens despite adoption of a decentralized health services model where basic health services would be accessible to all, particularly the rural population after Independence from Great Britain. Some in India advocate a model created by 2 research centers that minimizes the importance of medical technology and recognizes the influence of socioeconomic, cultural, and political determinants of health and of health services. This model does not incorporate indigenous and traditional systems, however. For example, Ayurveda is a more holistic approach than Western medicine and more suited to Indian society. Experiences in Kerala state and other small and effective projects reinforces the positive effect of community health services. The new approach needed in India begins with people not the elite and centers on their real problems which include not only medical problems but also socioeconomic and cultural problems. This approach also attempts to know their perception of health and illness. This model begins at the village level with a primary health care center. It is used in projects in Mandwa and Malshiras.^ieng

Indicators of accessibility to primary health care coverage in rural Odukpani, Nigeria.

Indicators of accessibility were investigated in Odukpani Local Government Area using a structured questionnaire administered to mothers or heads of households in the study area. The indicators considered included proportion of births attended by trained health personnel, proportion of children with diarrhea treated with oral rehydration therapy (ORT), distance from home to regular immunization site, and acceptability of primary health care services to the target population. Sociodemographic data revealed a typical developing country population profile and surprisingly high literacy rate (57.8%) relative to the national rate, an observation which may account for the appreciable level of awareness.

PIP: In the Akpabuyo zone in the Odukpani local government area, Cross River State, Nigeria, data collected from a survey of 90 households, from health facilities, the State Ministry of Health, and the Ministries of Local Government and of Lands and Surveys were analyzed to examine accessibility to primary health care (PHC) coverage. Children under 5 years old and reproductive age women comprised 58% of the population. 5 km from home to PHC coverage was considered accessible and all the children lived within this distance. Most respondents (67.8%) considered an immunization site to be not far. The majority (88.9%) used PHC health facilities, suggesting a relatively high rate of acceptability. Health personnel made home visits to 55.5% of respondents. Many adults' work schedules limited their ability to take their children to health sites (52.2% were farmers and 18.9% were traders). Thus, inappropriate scheduling of immunizations and maternal and child health services likely explained low immunization coverage (5.3-12.7%). This coverage was low despite the relatively high literacy rate in Akpabuyo (57.8%). Trained health personnel attended 98.9% of all deliveries, but traditional birth attendants (TBAs) conducted 61.3% of all deliveries, suggesting inaccessibility to health services. Further, 3.7% of deliveries at health facilities resulted in newborn death compared to 9.8% of TBA deliveries. This indicated a need for appropriate supervision and health education of TBAs. Only 39 cases of diarrhea existed. Most (87.2%) received oral rehydration therapy (ORT), reflecting the relatively high literacy rate and awareness levels. Yet, just 2.9% received a home-based sugar/salt solution, suggesting a need to increase ORT education for mothers. Almost all respondents (97%) noted that no village health or development committee existed, indicating a low level of community participation.

Contraception with progestogens and progesterone during lactation.

The growth and development of breastfed infants whose mothers used the contraceptive implants Norplant containing levonorgestrel and the injectable containing norethisterone enanthate were studied. Each group comprised of 120 women who initiated the use during the 5th to 7th week postpartum and were compared with a similar number of IUD using mothers. The breastfeeding performance did not differ between groups. The infants of the three groups performed similarly as regards their physical growth and health as well as the time of acquisition of the various milestones of psychomental development. A vaginal ring releasing 10 mg of the "natural" progesterone per 24 h was tested in breastfeeding mothers. The continuous use of the ring produced a serum level of progesterone around 4 ng/ml. This was effective in augmenting lactational infertility even through the later phases of breastfeeding when such an effect starts to wane off. The use of the ring proved to be acceptable and had no ill-effect on breastfeeding or infant growth or health. Using the natural progesterone as a contraceptive adds a new measure of safety, since the amount of the steroid secreted in the mother's milk will not be effectively absorbed from the infant's gut. These studies suggest the possibility of using two new methods for breastfeeding mothers; Norplant and the progesterone vaginal contraceptive ring. These can be initiated early postpartum, whenever this is considered needed.

PIP: Weight gain and psychomotor development of breastfed infants of Egyptian mothers using Norplant, Cu T-380A IUDs, norethisterone enanthate injectables (NET-EN), Depo Provera and a levonorgestrel minipill were compared in 2 trials. First, groups of 120 women using Norplant and NET-EN were compared to a control group using IUDs, beginning 5-7 weeks postpartum. There were no differences in infant weight gain, mid-arm circumference, triceps-skin-fold thickness, or timing of motor milestones. The mean growth curve of all 3 groups were close to that of the 50th percentile for Egyptian infants. While timing of initiation of supplements was similar in the 3 groups, complete weaning occurred first in the IUD group, second in the Norplant group, and last in the NET-EN users. A second trail compared progesterone implants injected with a trocar that resulted in a blood level of 3 ng/ml for 5 months, with Population Council vaginal rings releasing 10 progesterone/24 hours, and CuT-380A IUDs. Serum progesterone in the ring users averaged 5.2 ng/ml for the 1st 2 weeks, then leveled off at about 4 ng/ml for about 2 months, falling to about 3 ng/ml for the last 3 weeks of use. Each women used 4 rings per year. Evidence of ovulation by ultrasonic vaginal probe and assay of estradiol and progesterone was apparent in 25% of vaginal ring users, compared to 55.9% of controls in the 2nd 6 months postpartum. There was 1 pregnancy in a ring users. The continuation rates were 66.6% for rings and 85.5% for IUDs. The reasons for discontinuation in vaginal ring continuation were logistical problems and unfamiliarity.

Sex role effects on female response to illness.

PIP: This study of sex differentials in health behavior and health service choice among the Korean rural population is based on 1421 individuals aged 14 and over who received medical care at hospitals or clinics, pharmacies, a government health center, or through Chinese medical practices. Logistic regression is used to explore the relationship between the dichotomous variable, the log of the odds of the probability of using formal health care services, and the independent variables (sex, age, education, marital status, perceived health status, perceived medical care need, illness days in bed, limited activity days, total sick days, date of illness). A profile of rural Korea shows for all ages fewer adult females than males, but more females 65 years who have been previously married, which suggests higher male mortality rates in the middle ages. Health service usage is higher among the elderly. Higher level of education is associated with greater use of formal medical service. The results of binomial and multinomial analysis indicate that women receive less medical care from the formal system in spite of complaints and restricted activity, and least of all from health centers. It is suggested that personnel at health centers may reduce the desire for care because of incompatible social backgrounds (young single males who are inexperienced, city bred, and completing required service). A woman must carefully choose from the formal system and may more easily use the informal system of pharmacies and Chinese medicine practice. The responses to self rated health showed many differences; males report better health than females and older people consider themselves more unhealthy than young or adult groups. Those with lower educational attainment also consider themselves unhealthy, and indicate greater need for health services. Females and older age groups also stated their need for professional medical care for an illness within 15 days prior to the survey. The mean number of bed days followed a similar pattern as the perceived need and self rated health. However, women had a lower volume of bed days than men in contrast to typical Western trends. Females reported more restricted days of activity. The old age group had the same restricted days but more bed days than the adult group. Reported chronic diseases were greater for lower socioeconomic groups.^ieng

[Prenatal care in Latin America]. / La atención prenatal en América Latina.

Available data on the coverage of prenatal care in Latin America were reviewed. In recent years, only Bolivia had a coverage of prenatal care of less than 50 per cent. More than 90 per cent of pregnant women received prenatal care in Chile, Cuba, the Dominican Republic, and Puerto Rico. Prenatal care increased between the 1970 and 1980 in the Dominican Republic, Ecuador, Guatemala, Honduras, Mexico, and Peru. The coverage of prenatal care decreased in Bolivia and Colombia. The mean number of visits increased in Cuba and Puerto Rico. The increase of prenatal care in Guatemala and Honduras is due to increased care by traditional birth attendants, compared to the role of health care institutions. We compared the more recent data on tetanus immunization of pregnant women to the more recent data on prenatal care. The rates of tetanus immunization are always lower than the rates of prenatal care attendance, except in Costa Rica. The rates of tetanus immunization was less than half as compared to the rates of prenatal care in Bolivia, Guatemala, and Peru. To improve the content of prenatal care should be an objective complementary to the increase of the number of attending women.

PIP: This article describes the evolution of prenatal care in Latin America during the past 2 decades based on a literature review which utilized the Medline, Popline, and Lilacs (Pan American Health Organization) data bases. The results were compared to the findings of E. Royston and J. Ferguson from their article "The coverage of maternity care: a critical review of available information", published in the World Health Statistics Quarterly in 1985. Rates of antitetanus vaccination during pregnancy were included as an indicator of the content of prenatal care. A large quantity of data on prenatal care in Latin America was found, much of it from surveys with representative samples at the national level. Comparison of information was often difficult because not all countries nor all surveys used the same methodology. From 1985 on, only Bolivia had a coverage of prenatal care of less than 50%. In Chile, Cuba, the Dominican Republic, and Puerto Rico, over 90% of pregnant women had at least 1 prenatal consultation. Coverage in Cuba and Puerto Rico was higher than that in the US, but coverage in Bolivia was lower than in some African countries. Prenatal care increased during the 1970s and 80s in the Dominican Republic, Ecuador, Guatemala, Honduras, Mexico, and Peru, but declined in Bolivia and Colombia. 38.2% of deliveries in Guatemala, 21.3% in Honduras, and 12% in Mexico were attended by traditional midwives. In Honduras, 33.1% of deliveries were attended by midwives and public or private health institutions. Prenatal care was more common in urban than rural areas in all countries except Honduras. In Peru and Bolivia the coverage in rural areas was less than half that of urban areas. The educational differential in prenatal care was even more pronounced. The greatest difference was in Bolivia, where 85% of women with intermediate or higher educations had prenatal care, compared to only 13.9% of illiterates. Rates of tetanus immunization were always lower than for prenatal care except in Costa Rica. In Bolivia, Guatemala, and Peru, rates of tetanus immunization were less than half those of prenatal care. Rates of tetanus vaccination increased in almost all countries in recent years. Prenatal care is worthwhile only when it is effective, but numerous potential biases make effectiveness very difficult to evaluate. Even taking such biases into consideration, most studies have shown a positive effect of prenatal care. It is especially important to assess the effects and quality of prenatal care in countries like honduras and Guatemala that have relied on traditional midwives to increase their coverage. Improving the quality of prenatal care should be an objective complementary to increasing coverage.

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

Child survival in Indonesia.

The 1980 infant mortality rate of 107/1000 live births in Indonesia was 2 to 3 times the average rate in surrounding Asian countries. Provincial rates vary from 187 in West Nusa Tenggara to 62 in Yogyakarta. This variation is explained in part by female education levels, access to health facilities, and the impress of health aid and system programs, especially family planning. In addition, mortality rates and the usage of modern health care continue to reflect historical and cultural imprints. A program strategy for improvements in infant and child mortality focus on 4 basic elements: 1) growth monitoring, 2) oral rehydration therapy, 3) breast feeding, and 4) immunization. These efforts are delivered largely through the Expanded Immunisation Programme and the Family Nutrition Programme. A potential major breakthrough in primary health care has been realized with the development of a network of integrated health posts (posyandu) which deliver multiple services more efficiently in rural areas.