Mortality and use of health services surveys in rural Zaire.

The Combatting Childhood Communicable Disease (CCCD) project is a comprehensive public health programme designed to reduce child mortality by 25% through the use of the following strategies: vaccination, oral rehydration therapy, and prompt treatment for malaria. To evaluate this programme, cross-sectional surveys were conducted in neighbouring health zones in Zaire in 1984 to determine the use of selected medical services by the population and to estimate the child mortality rate before the CCCD programme began. A reinterview survey was conducted on a subsample of women previously interviewed to determine the reliability of the mortality estimates. In both health zones 84-85% of women used antenatal services, 45% of children under age 6 who had had fewer were treated with an anti-malarial drug, 19-22% of children age 12-23 months had been vaccinated against measles, and virtually no children who had had diarrhoea were treated with oral rehydration therapy. Women's underreporting of births and deaths resulted in low estimates of mortality in both surveys. The reinterview survey provided more accurate estimates of mortality and led to a better understanding of the factors influencing underreporting. The estimated infant mortality rate was 74 deaths per 1000 livebirths; and the probability of dying before age 5 was 191 per 1000. Because births and deaths reported with incomplete dates were excluded from analysis, the mortality rates from the reinterview survey are underestimates. Given the difficulty in obtaining accurate estimates of mortality, primary importance should be given to developing and improving routine health information systems that measure changes in health status and provide information to evaluate programmes.

Changes in use of health services in a rural health zone in Zaire.

As part of the Combatting Childhood Communicable Diseases (CCCD) project funded by the US Agency for International Development (USAID), the Zairian CCCD programme conducted surveys in the rural health zones of Kingandu and Pai-Kongila, Zaire, in 1984-1985 and 1988-1989 to determine whether a strategy of selective primary health care would affect childhood mortality. This paper describes the changes in the medical care infrastructure and the increasing coverage of selected services. The strategies evaluated were vaccination, oral rehydration therapy, and treatment of febrile episodes with antimalarial drugs for children; and tetanus vaccination and malaria prophylaxis for pregnant women. The health infrastructure in the Kingandu and Pai-Kongila Health Zones expanded considerably from 1984 to 1989, with health centres increasing from 7 to 18. During this period, economic conditions deteriorated moderately, with the nation experiencing nearly 700% inflation. Medical care costs remained stable because of external subsidies. Use of health services was assessed in 1984, 1988, and 1989. Between 1984 and 1989, the proportion of children aged 12-23 months vaccinated against measles increased from 22% to 71%. Coverage with other vaccine antigens increased similarly. Women's knowledge of the correct recipe for the preparation of sugar-salt solution increased from 0% to 61%. Reported treatment at home with sugar-salt or oral rehydration solution increased from 6% to 53%. The proportion of children with febrile episodes who were treated presumptively for malaria with chloroquine remained unchanged (47% in 1984; 44% in 1988). We conclude that, despite a moderate deterioration in economic conditions, Kingandu and Pai-Kongila Health Zones achieved remarkable increases in use of selected health services between 1984 and 1989, especially in vaccination coverage.

Impact of selective primary care on childhood mortality in a rural health zone of Zaire.

Following the introduction of intensified child survival activities, use of health services for children increased markedly: measles vaccination reached 74% of children aged 12-23 months, and the use of oral rehydration therapy for the treatment of diarrhoea had increased. During the same period, childhood mortality declined by 33% for children aged 1-4 years. Data on cases of measles in the local hospital reveals that the pattern of measles epidemics characteristic of the years preceding programme implementation was altered in the years following programme implementation. The mean annual number of inpatient measles cases declined from 108 before the programme to 36 after its start. The high correlation between the number of inpatient measles cases and mortality at ages 6-35 months suggests that the programme reduced mortality largely by reducing the incidence of measles. Primary health care activities, supported in part by the Combatting Childhood Communicable Diseases Project, is estimated to have reduced mortality at ages 6-35 months by at least the 18-23% associated with the change in the incidence of measles and may have been responsible for the full 28% reduction recorded between 1980-1984 and 1985-1989.

Determinants of the sex ratio at birth: review of recent literature.

PIP: The fact that more boys are born than girls (104-107 boys for every 100 girls) has been known since 1662. Factors determining the sex ratio at birth rate are of 2 kinds: factors determining the primary sex ratio, i.e., sex ratio at conception, and factors determining the survival of the embryo in utero. Y-bearing and X-bearing sperm may have different motility or different survival time. The age of the ovum at fertilization and the chemical balance of the female genital tract have an effect on sex ratio at conception. High levels of circulating gonadotropins may imply a lower sex ratio at birth as well as a higher rate of dizygotic twinning. Male conception also appears to be higher early and late in the menstrual cycle. The fact that women exposed to higher coital rates conceive earlier in the menstrual cycle may account for the greater number of boys born during wars. Prenatal male mortality is reportedly highest between gestational months 3-5, lower between months 6-8, and higher again st term. Also, immunological interaction between mother and embryo may account for some sex selective spontaneous abortions. 3 sociodemographic determinants of sex ratio at birth are thought to be maternal age, paternal age, and birth order. Higher prenatal male mortality may be correlated with socioeconomic conditions, since higher socioeconomic status lowers prenatal mortality in general. The effects of parental age, birth order, and parity are less clear. Race is also a factor, since the sex ratio at birth for blacks is lower (102-104) than for whites (106). 14 univariate and 19 multivariate studies of effects of maternal age, paternal age, parity, birth order, race, and socioeconomic status on sex ratio at birth, with sample sizes in the millions from various countries have been analyzed. More boys are born to younger parents, and lower order births have a higher proportion of males than do higher order births. In the multivariate analyses, when the effects of paternal and and birth order are controlled for, the effect of maternal age weakens, and the effect of paternal age appears to be stronger. The effect of birth order remains but is very small, and the effect of race persists independent of any effect of other variables. Maternal age, parity, and birth order are positively correlated with proportion of male stillbirths. The results of the multivariate analyses show all of the effects to be very small, but that maternal age has no effect on sex ratio at birth; paternal age and birth order have a negative effect, and the racial effect persists independent of any other effect. The racial effect is clearly biologically determined at conception because blacks have higher levels of circulating gonadotropin and therefore a higher probability of conceiving girls. Parents in higher socioeconomic classes are more likely to have sons, but the effect is largely due to the excess male mortality during most of the gestational period.^ieng

Marriage and ethnicity in West Malaysia.

"This paper will focus on ethnic differentials in the nuptiality of West Malaysia and on their evolution since the Second World War. The growing similarity of nuptiality patterns in the Malay, Chinese, and Indian communities will be outlined and the influence of age and sex distributions on the observed changes will be examined. The sources of data for this study are the 1947, 1957, and 1970 Population Censuses and the 1974 Malaysian Family and Fertility Survey."