A study of the acceptability and effectiveness of Norplant (R) contraceptive implants in Kuala Lumpur, Malaysia.

PIP: A clinical trial was carried out on the levonorgestrel-containing subdermal contraceptive implant to evaluate its efficacy and acceptability among Malaysian women. The study recruited 121 women in and around the Kuala Lumpur Federal Territory over a 13-month period (March 1986-March 19870 and followed regularly for 2 years at intervals of 3, 6, 12, and 24 months. The acceptors consisted of 53.7% Malays, 24.8% Indians, and 21.5% Chinese. 81% of the selected females were between 20-34 years in age (mean=30). The average parity was 3.9 children; 81.8% reported that they did not want to have a child in the he next 3 years. In the last 6 months, 45.5% of the study group had used the oral contraceptive pills, 15.7% had used the intrauterine contraceptive device, and 17.4% had not employed any method. The results showed that the subdermal implant Norplant (R) is effective and safe. The gross cumulative continuation rate was 93.8 at 6 months, 88.2 at 12 months, and 72.2 at 24 months. Within the 24 month period, 26 terminations occurred as a result of pregnancy (n=1), menstrual problems (n=9), medical reasons (n=12), and personal reasons (n=4). the gross cumulative termination rate/100 women for pregnancy was 0 at 12 months and 1.7 at 24 months. Major side effects include menstrual problems, weight gain, dizziness, and headache. After 1 year, 13.3% of the cases (n=2) had the implant removed. The acceptability of the method among our women in 4 clinics around Kuala Lumpur and other Norplant (R) studies in other countries is comparable to the intrauterine devices among Malaysian women; the termination rate for accidental pregnancy is lower than that of IUD. The device is easy to administer in a small clinical set-up though it requires personnel specially trained in the surgical techniques; 86.0% of the acceptors reported complication-free insertion. This may be a method to be introduced to our National Family Planning Program in our efforts to offer a wider range of safe and effective methods of family planning. (author's modified).^ieng

A study on the age at menopause and menopausal symptoms among Malaysian women.

PIP: The authors examine age at menopause and menopausal symptoms among 677 Malaysian women interviewed in 1986. Consideration is given to psychological as well as physical effects. Findings indicate that approximately 7 out 10 women entered menopause between ages 45-54 and that socioeconomic status did not affect onset or symptoms.^ieng

An evaluation of the BIOSELF 110 fertility indicator.

The BIOSELF 110 is a hand-held, non-invasive electronic instrument that measures basal body temperature and cycle length, and automatically identifies the fertile and infertile phases of the menstrual cycle with flashing red light and green light signals, respectively. The device was evaluated in 77 cycles from 33 ovulatory women in Kuala Lumpur, Malaysia. Ultrasound monitoring of maximum follicular diameter (MFD) and urinary LH measurements with Ovustick were used as reference methods to estimate the time of ovulation and the fertile period. Based on the MFD day, the BIOSELF correctly identified the entire fertile period, and at least four fertile days, in 89% and 94% of the cycles studied, respectively. The mean duration of the fertile period as determined by the number of flashing red light days was 11.0 days (SD 2.9). The device correctly identified the onset of the postovulatory infertile phase in 94% of cycles, with a mean duration of about 10 (green light) days. The results were similar using the LH peak day as the reference method. The mean interval from the onset of the fertile period (first flashing red light day) to the MFD day was 6.9 days (SD 2.6), and from the MFD day to the end of the fertile period, 3.1 days (SD 2.2). The BIOSELF 110 showed itself to be a reliable device for identifying the fertile and infertile phases of the menstrual cycle and, thus, should be a useful aid for couples seeking pregnancy. Prospective clinical trials are underway to assess the contraceptive effectiveness of the device.

PIP: The BIOSELF 110 is a handheld, noninvasive electronic instrument that measures basal body temperature and cycle length, and automatically identifies the fertile and infertile phases of the menstrual cycle with flashing red and green light signals. The device was evaluated in 77 cycles from 33 ovulatory women in Kuala Lumpur, Malaysia. Ultrasound monitoring of maximum follicular diameter (MFD) and urinary LH measurements with Ovustick were used as reference guides to estimate the time of ovulation and the fertile period. Based on the MFD day, the BIOSELF correctly identified the entire fertile period, and at least 4 fertile days, in 89% and 94% of the cycles studied, respectively. The mean duration of the fertile period as determined by the number of flashing red light days was 11.0 days (SD 2.9). The device correctly identified the onset of the postovulatory infertile phase in 94% of cycles, with a mean duration of about 10 (green light) days. The results were similar using the LH peak day as the reference method. The mean interval from the onset of the fertile period (1st flashing red light day) to the MFD day was 6.9 days (SD 2.6), and from the MFD day to the end of the fertile period, 3.1 days (SD 2.2). The BIOSELF 110 showed showed itself to be a reliable device for identifying the fertile and infertile phases of the menstrual cycle and, thus, should be a useful aid for couples seeking pregnancy. Prospective clinical trials are underway to assess the contraceptive effectiveness of the device.

Electrolyte profile of Malaysian mothers' milk.

PIP: The influence of socioeconomic status (ethnicity, income and parity) on electrolyte composition (sodium and potassium) in human milk is little known. We have thus quantitatively analyzed approximately 700 samples of milk (1-90 days postpartum) obtained from healthy Malaysian mothers' (Malay, Chinese and Indians) of full term infants. Results show that the mean concentration (mmol/l) of sodium is highest (48.2+or-1.7, Mean+or-SEM) in the Malaysian mothers' colostrum and this value decreased by 30% in their transitional milk and remained constant throughout subsequent days of lactation (mature milk). Ethnically, it is found that the level of sodium in colostrum of Malay and Chinese mothers were similar while the Indian mothers' colostrum showed apparently higher value (52.7+or-3.4 mmol/l) that is statistically insignificant. The transitional milk of all 3 ethnic groups studied exhibited similar levels of sodium. On subsequent days of lactation (mature milk) the Malay mothers exhibited lowest concentration (25.9+or-2.6 mmol/l) of sodium that is significantly (P0.05) different from that of Chinese and Indian mothers. Income and parity do not significantly affect the sodium level in Malaysian mothers' milk during all stages of lactation studied. The level of potassium, however did not change significantly with days of lactation. Like sodium, potassium too was not influenced by income and parity. (Author's).^ieng

Filshie clip sterilization -- single puncture laparoscopic approach (a preliminary report).

PIP: In 1986, single puncture laparoscopic application of the Filshie clip was introduced into Malaysia's National Population and Family Development Board's female sterilization program for an evaluation. A total of 42 female sterilizations were performed by this method between June 1986 and December 1986. Laparoscopy was performed on an outpatient basis under local anesthesia. In 37 cases, the sterilization was interval. Filshie clips were successfully applied to the fallopian tubes of 40 women; in the remaining 2 cases, the latching mechanism jammed and Falope rings were used instead. The average time from application of 1st clip to skin closure was 10 minutes. During clip application, technical problems (faulty applicator, clip fell into the pelvic cavity, failure of latching mechanism) were encountered in 4 cases and surgical difficulties (poor visualization, hydrosalpinx, and tubal adhesions) occurred in 10 cases. In general, complications were minimal: 1 patient developed cynosis after anesyhesia (Pethidine) injection, the omentum was torn during introduction of the trocar in another, and a 3rd patient developed thrombophlebitis at the intravenous site. Only 1 pregnancy was recorded during the follow-up period; this occurred 15 months postoperatively and was intrauterine. Given the facts that this procedure is easy to learn, fast and simple, associated with no more complications than other laparoscopic procedures, and is cosmetically more acceptable to women, its more widespread application is recommended.^ieng

An overview of the population dynamics in Malaysia.

PIP: Between 1900 and 1985 the population of Malaysia has increased from 2 million to 16 million. Before World War II most of the growth was due to immigration from China and India; after World War II it was due to natural increase. The crude birth rate appears to be leveling off at about 31.3 and the crude death rate at 5.3. At the current rate of growth the total population will be about 32 million by 2015. The proportion of urban population increased from 27% in 1979 to 34% in 1980. In 1980 83% of the population lived in Peninsular Malaysia (39% of the land area), and 17% lived in Sabah and Sarawak (61% of the land area). Population density ranges from 12 persons per square kilometer in Sarawak to 4521 in the Federal Republic of Kuala Lumpur. The median age of the population is 17.4 years; 40% are under 14, and 3.6% are over 65. In most age groups there are more women than men. The annual growth rate for Malays is higher than for Chinese and Indians, and Malays constituted 55% of the population in 1980. 34% are Chinese and 10% are Indian. Total fertility rate declined from 68/1000 in 1957 to 39/1000 in 1985. Malay fertility (4.8 children) is higher than either Indian (2.9) or Chinese (2.7) Malay fertility has been increasing while that of Indians and Chinese is decreasing due to contraception. Also, among all 3 groups age at marriage has increased. Data from the 1984/85 Malaysian Population and Family Survey show that the differential fertility of the 3 groups is due largely to rural/urban distribution, education, and work patterns. Ideal family size, according to the survey, is 4.8. The National Population and Family Development Program would like to achieve a growth rate of 2%/year, and family planning knowledge has become virtually universal. KAP surveys show that by 1984 contraceptive prevalence was 51%; however 42% of all eligible women were using unreliable methods. In terms of efficient methods, contraceptive prevalence rate was 16% for Malays, 47% for Chinese, and 40% for Indians. Crude death rate has declined to less than 6/1000, largely due to reductions in infant and child mortality. Internal migration to the cities has done much to achieve the objectives of the New Economic Policy to equalize location and vocations of the 3 ethnic groups. Urbanization has slowed since the launching of various land development schemes in the 1960s. The population policy of the government is to achieve a stabilized population of 70 million by year 2070, which means that the fertility level must decrease from 4 to 2 children per woman. By 2000 when the population is expected to reach 22.4 million, the percentages of Malays, Chinese, and Indians is expected to be 61.5%, 28.7%, and 9.8% respectively.^ieng

Hemorrheology and fibrinolytic response in women taking oral contraceptive pills.

PIP: The effect of low-dose oral contraceptives (OCs) on hemorheology and fibrinolytic response was investigated in 107 women attending the Malaysia Maternity Hospital in Kuala Lumpur. The OC contained 0.03 mg estrogen and 0.15 mg progestagen. Study subjects were divided into 3 groups. The 30 women in Group 1 took the low-dose OC for 3-6 months, while the 27 subjects in Group 2 took the pill for a duration of 1-2 years. Group 3 was comprised of 49 controls. The 3 groups were comparable in terms of age, weight, height, and parity and included Malays, Chinese, and Indians. No significant differences were noted between the 3 groups in any of the parameters analyzed (platelet aggregate ratio, fibrinogen levels, red blood cell deformability index, euglobulin clot lysis time, and full blood count). Since the level of estrogen in the OC analyzed in this study did not cause significant alterations in any of these blood parameters, it is concluded that low-dose OCs do not confer a risk of thrombosis in their users.^ieng

Nonsurgical female sterilization with quinacrine pellets: Malaysian experience.

PIP: The objectives of the study were to evaluate the effectiveness of intrauterine quinacrine pellet application as a method of female sterilization on the basis of 1 year follow-up; and to evaluate the safety, cost, acceptability and ease of administration of this procedure. In this Malaysian study acceptability appeared to be the main problem towards establishing quinacrine insertion as a nonsurgical female sterilization method for contraception. A number of eligible clients declined to be included in the study when informed that the effectiveness is lower than the other (surgical) method currently available. Also another sterilization study being conducted at the same center was drawing away some of the women seeking permanent contraception. Nevertheless the acceptors included those women with lower education, older age and high parity who therefore would benefit most from this method of sterilization. Due to the small sample size of only 25 subjects it is difficult to draw conclusions at the present moment on the effectiveness and safety of this method of sterilization. Only 1 failure was noted in the insertion period. No pregnancies were reported in the 1-year follow-up period. However, continual follow-up is mandatory considering that pregnancies may occur years later. While menstrual complaints were common, most of the complaints were transient and well tolerated. On the whole morbidity is low. A larger study is needed to test the acceptability of this method.^ieng

A five-year review of diagnostic laparoscopy and female sterilizations in 52 centers in Malaysia.

PIP: Doctors participating in the Laparoscopy Program of the National Population and Family Development Board, Malaysia, return data on all cases of diagnostic laparoscopy and female sterilizations carried out in their centers. Data on 2179 cases of diagnostic laparoscopy and 4740 cases of female sterilizations for the period 1981-1985 are analyzed. States with the highest return rates are Kuala Lumpur Federal Territory, Negeri Sembilan, Johor and Perak. The Specialist Center of the Board alone accounted for 1/3 of the cases. Data for female sterilizations are further analyzed. Complication rates for laparoscopy and minilaparotomy techniques are low at between 0.5 to 2.5/100 procedures. All doctors providing such services should be encouraged to participate in this Program and submit data in order to improve and learn from this Program.^ieng

Paramedic insertion of intrauterine device in a Malaysian family planning clinic.

PIP: A study was done by the Malaysian family planning clinic to check the feasibility in using paramedical personnel to insert IUDs. There were 250 insertions by trained senior nurses and 369 insertions by doctors. In the follow-up, no differences were found in terminations due to IUD complications, and also none in terminations for pregnancy, bleeding, pain, expulsion and pelvic infections. Studies in Turkey, Philippines, Korea, Iran, and Thailand showed similar results in that paramedical personnel are just as effective as doctors in the insertion of IUDs. The follow-up was done in this study by nurses at 6 weeks, 3 months, and 6 months and from then, on a yearly basis. There was a large unexplained loss of follow-up in the nurses group, 12.7% and only 6% in the doctors. There was a 8.9% rate for removal for a planned pregnancy, and both groups had a high continuation rate: 63.3% for nurses and 70.5% for doctors. The conclusion of the study indicates that trained paramedical people can perform insertion of IUD's as effectively as doctors when there are no medical or gynecological problems in the patients. It is also noted that in some areas women prefer to have nurses do the insertion because of their conservative nature.^ieng

A prospective study of the acceptability of Today vaginal contraceptive sponge among Malaysian women.

PIP: In a 2 month study to test the viability of vaginal sponges for use among Malaysian women 50 cases were followed. Of the 50 cases 1 developed an allergic reaction, 49 participated in a 1-month checkup after which 13 stopped for various reasons not related to the use of the sponge. The other 36 completed the study in which there were few side effects and many of the women said sexual intercourse was less messy. The 50 subjects were 18-45 years of age, healthy with no vaginal infection, irritation, inflammation and pregnancy, and had to be sexually active. All but 1 of the cases had been pregnant before and the majority of the group had sexual intercourse twice a week. Only 3 cases had problems in the initial insertion and removal of the sponge. 2 cases reported non use at some time, but the majority retained the sponge from 6-24 hours. Of those who discontinued use, 3 migrated to other areas, 6 had husbands who did not like it, 1 had vaginal cramps, 1 unplanned pregnancy, and 1 had a planned pregnancy. Of the remaining 36 there where 4 who lacked confidence in the effectiveness of the sponge. The general conclusion of the study is that the sponge is an acceptable, safe, convenient, inexpensive, and does not cause discomfort to those using it. Its longterm use as a reliable contraceptive device should be verified.^ieng

A need-responsive programme in post-partum female sterilisation.

PIP: In Malaysia, the National Population and Family Development Program has registered approximately 5000 acceptors on sterilizations annually for the past 5 years. Between 1982 and 1985, a total of 1365 cases of laparoscopic tubal ligations were carried out at the Specialist Center of the NPFDB. 70% of these were postpartum cases. The results of 358 of these cases of laparoscopic sterilization carried out in the intermediate and late postpartum period demonstrate that the procedure can be effectively concluded and comparable to the standard procedures done in the interval period. However, more thorough screening is required to reduce the incidence of surgical difficulties of trocar insertion (due to obesity) and visualization (dut to adhesions). The problem of ring application has been minimized; but Filshie clips can be applied in difficult situations. 2 other local studies have shown that Filshie clips are superior to the rings for tubal occlusion at all periods of sterilization. Hence it can be concluded that women can be offered laparoscopic tubal ligation at anytime they want, whether postpartum or later. Since the laparoscopic sterilization can be safely carried out as an outpatient procedure, women in the postpartum period need only come to the clinic or hospital for the surgery and return home to continue their rest.^ieng

Predictors of contraceptive use among women in Kuala Lumpur and Petaling Jaya.

PIP: The purpose of this study is to examine some socioeconomic factors that are associated with family planning practice in a metropolitan area of a developing country, namely Malaysia. Data collected during the 1977 Family and Health Survey in Kuala Lumpur and Petaling Jaya is utilized. The study population comprised currently married women aged 15-49 years residing in Kuala Lumpur and Petaling Jaya, the 2 densely populated, rapidly expanding and adjoining metropolitan areas in Peninsular Malaysia. The study population was selected using a 2-stage systematic sampling technique from specifically defined areas in Kuala Lumpur and Petaling Jaya. These areas were selected accourding to socioeconomic criteria, namely, the squatter or slum areas, the new villages located on the periphery of the metropolitan area, other Kuala Lumpur and other Petaling Jaya. Family planning behavior, specifically, contraceptive use is also associated with socioeconomic variables. It is determined that the best predictors of contraceptive use, in order of importance are ethnicity, age and area. However, the relationship between age and contraceptive use varies across ethnic groups. In particular, among Malay and Chinese women, contraceptive use decreases as age increases, but among Indian women usage is not related to age. For the Malay women, usage decreases rapidly after age 24 years but the decline is more gradual for the Chinese women. In general, Chinese women are more likely to be current users in comparison to Malays, while the Indians occupy an intermediate position. The probability of usage is higher for women residing in Petaling Jaya and squatter areas in comparison to those residing in Kuala Lumpur and new villages.^ieng

Attitudes towards induced abortion in Peninsular Malaysia--a Guttman scale analysis.

PIP: The data for this study are from the 1974 Malaysian Fertility and Family Survey. The analysis focuses on the responses given by about 6000 women to the question whether they would approve or disapprove of induced abortion under each of the following conditions: poor health, contraceptive failure, unwanted pregnancy, lack of finances, rape, and unmarried status. There was substantial endorsement of induced abortion if the pregnancy is due to rape (71%) but a progressively diminishing amount of endorsement of all other conditions: unmarried (54.3%), health (52.2%), lack of finances (34.5%), contraceptive failure (19%), and unwanted pregnancy (12.3%). A Guttman scale analysis is applied to the responses, coded "1" if "yes" or "depends" and as "0" if "no". A set of attitude items is said to form a Guttman scale if the items fall along a contimuum in a cumulative manner such that an endorsement of any 1 item implies endorsement of all items falling below it. The application of Guttman scale analysis reveals tht the 6 items do arrange themselves in this order. This study demonstrates that there was in the mid-1970s a fairly consistent patern of attitudes with respect to induced abortin in Peninsular Malaysia. This study also demonstrates the usefulness of the Guttman scale analysis. A replication of this study with more recent data would be useful in documenting any changes in attitudes towards induced abortion in Malaysia.^ieng

Socio-economic correlates of contraceptive knowledge among women in Kuala Lumpur and Petaling Jaya, Malaysia.

PIP: Knowledge about contraception was examined in relation to selected socioeconomic variables. A total of 2567 currently married women aged 15-49 years residing in Kuala Lumpur and Petaling Jaya were interviewed. The majority of the women knew of at least 1 contraceptive method. An index termed Contraceptive Knowledge Score (CKS) was used to measure the level of knowledge about contraception. The CKS achieved differed significantly by age, area of residence and ethnic group. The other socioeconomic variables significantly associated with CKS are schooling, occupation, income, childhood residence and age at marriage. These relationships persisted even after adjusting for differences in age, ethnicity and area of residence. Overall the CKS attained have a wide range and there is no significant difference of the mean CKS attained, between users and non-users of contraceptives.^ieng

Changes in human milk vitamin E and total lipids during the first twelve days of lactation.

Our previous study showed vitamin E deficiency in newborns (69.7%) and mothers at term (85.9%) when the ratio between serum vitamin E in mg/dl and total lipids in g/dl was used as an indicator of vitamin E status. This study was conducted to determine the human milk content of vitamin E. During the first 12 days of lactation milk vitamin E levels remained almost constant (day 1, 0.68 mg/dl; day 12, 0.65 mg/dl), milk total lipid levels increased daily (day 1, 1.11 g/dl; day 12, 3.60 g/dl), and the ratio between milk vitamin E and total lipids dropped steadily (day 1, 1.3; day 12, 0.2). In spite of this drop in vitamin E status, it is unlikely that vitamin E availability will be affected in neonates, because normal neonates absorb milk fats well and this ability increases with age.

Laparoscopic female sterilization--an evaluation exercise in a Malaysian family planning clinic.

PIP: 185 women received outpatient laparascopic sterilization at the Family Planning Clinic in the Maternal Hospital Kuala Lumpur, in 1983. THe aim was to identify the profile of these patients with regard to their race, age, social beckground, gravidity, parity, abortions, and previous usage of contraceptives. Immediate complications and difficulties encountered during the operation were noted. The pregnancy rate of the area, as of June 1985, was ascertained. Patients were mainly of immediate postpartum cases; however, 2 were interval cases and 1 was post-abortal. Few Malays favoured sterilization, whereas more Indians preferred it. Nearly all patients were between the ages 25-39, with about 44% from the 30-34 years age group. 53% of the patients came from rural areas. Majority of these patients came from the poor income group below US$700 per month. 22.7% of the patients never received formal education, and 59.5% only had primary education. 61.6% of these patients already had more than 4 children, and 31.9% had 4 children. Nearly 40% had not used any contraceptive method despite widespread information on this subject. The overall eomplication rate was 3.7%. Sterilization could not be carried out in 2 cases due to extensive adhesions. Difficulties were encountered in about 13% of the cases. By June, 1985, approximately 2 years from the time of laparoscopic sterilization, 4 pregnancy cases were recorded. Failure was due to either tying the round ligament, or the ring slipping off after some time due to tube shrinkage, or due to poor technique.^ieng

Some aspects of maternal care in rural peninsular Malaysia.

PIP: The effectiveness and impact of the Population and Family Health Project in the rural areas of Malaysia is evaluated. A total of 790 women who delivered during the past 3 years from the time of the survey, were identified from 2,013 women aged 15-49 years, during the 2nd Family and Health Survey (1979) in Peninsular Malaysia. The rural health districts which were selected by random sampling include: Perlis, Kubang Pasu, Sebeang Perai Selatan, Kuala Selangor, Hulu Langat, Melaka Utara, Kota Bharu/Tumpat, and Pasir Mas. The pattern of maternal care during pregnancy, delivery and puerperium are examined with respect to selected variables. These women are further classified into 2 groups by type of birth attendant at delivery and these 2 groups are also examined in relation to selected socioeconomic variables. The major proportion of women had their 1st antenatal visit during the 2nd and 3rd trimester of pregnancy. The highest % (28.3%) of 1st antenatal visits occurred during the 5th month of pregnancy. Use of a trained medical practitioner is preferred (82.5%), while only 17.5% of women preferred the services of traditonal birth attendants. Women in this latter group had less education and were in lower income groups, than the former group of women. Majority of women in all ethnic and age groups had no postnatal check after their last childbirth.^ieng

Pregnancy after contraceptive use.

PIP: The initial results of a study conducted to develop guidelines for the clinical management of family planning acceptors with regard to return of fertility following contraceptive use, are presented. 193 parous women attending an urban family planning clinic were interviewed regarding their last pregnancy conceived after stopping a method of contraception. The average interval to pregnancy was 3.9, 2.8 and 1.8 months for ex-users of oral pills, intrauterine devices and conventional methods of contraception, respectively, with median delays to conception of 1.9, 1 and within the 1st month for the 3 categories. In comparison, 149 women who had not used any method at all took 7.3 months before becoming pregnant. Selected variables including age and parity, duration of use and problems encountered, and outcome of pregnancy are further analysed. Follow-up investigations and treatment are recommended 12 months after stopping oral pills and 6 months after removal of intrauterine device for those who have not yet conceived.^ieng