Socioeconomic and health implications of adult deaths in families of rural Bangladesh.

Effects of adult deaths on subsequent health and socioeconomic well-being of rural families of Bangladesh were examined. Data for this study were drawn from the longitudinal Sample Registration System (SRS) operational in two rural areas of the then MCH-FP Extension Project (Rural) of ICDDR,B. In total, deaths of 327 married adults aged 15-59 years, during January 1983-December 1987, were reviewed. The families of the deceased were followed up for five years after death. Factors, such as survival status of children, educational status of children aged 6-12 years, and out-migration status among adolescents aged 12-20 years in those families, was observed and recorded. A control group of 3,350 families experiencing no adult deaths was also followed up for five years. The health and socioeconomic impacts on children in both the groups five years after death of the adult were compared. The findings of the study showed that negative impact was more pronounced among the children of poor families, and the female children were most severely affected. Death of a father or a mother was associated with a higher rate of out-migration (especially marriage) of adolescent daughters. An adult death was associated with a significantly higher mortality risk of children during the five years following death of the adult. These child-mortality risks were significantly higher when an adult female died, and when the index child was a female and/or aged less than five years at the time of death of an adult. The children, aged 6-12 years, in families where a parent had died were significantly more likely to be uneducated and out-of-school after the death of a father or a mother compared to the children in families where neither of the parents had died. This finding remained valid even after controlling for the educational status of the parents who died and of those who did not die. Since the study used a limited number of independent variables and since there is a need to understand the specific reasons why such significant differences occurred, it is recommended to conduct a more in-depth qualitative study to know more clearly the nature and mechanisms of the socioeconomic and health impacts of death of an adult on the family and the society.

User-fees for family-planning methods: an analysis of payment behaviour among urban contraceptors in Bangladesh.

The study was carried out to review the experience with the existing user-fee (pricing) strategies and examine the socioeconomic and demographic factors associated with payment behaviour among contraceptors in urban Bangladesh for selected contraceptive methods, such as injectables, pill, and condom. Data for the study were drawn from a survey of more than 5,000 married women of reproductive age in Zone 3 of Dhaka city, Bangladesh, within the sample frame of the Urban Panel Survey of the ICDDR,B's former Urban MCH-FP Extension Project. The findings of the study showed that most (80%) urban contraceptors have been paying for selected family-planning services. This indicates the existence of a notable demand for contraceptives which suggests that there is scope for improved financial sustainability of the family-planning programme through charging appropriate user-fees for contraceptives with proper analyses of willingness-to-pay among the contraceptors and price elasticities of demand. Higher socioeconomic status of households, marked by higher levels of education and house rent, and location of residence in non-slum areas, is predictive of paying for contraception. Households having 1-3 living child(ren) are also more likely to make payment for the selected contraceptive services.

Who's at risk? Men's STD experience and condom use in southwest Nigeria.

Many STD/HIV-prevention programs worldwide assume that individuals' risk of acquiring sexually transmitted diseases, including HIV infection, is highest in the context of commercial sex. To address this assumption, research conducted in urban Southwest Nigeria combined qualitative and quantitative methods to examine men's sexual behavior, condom use, and STD experience in different types of sexual relationships (marital, casual, and commercial). Logistic regression analysis of survey data indicates that number of sexual partners and sex with sex workers are positively and significantly related to STD experience. Follow-up in-depth interviews with clients of sex workers indicate, however, that these men are actually more likely to report having contracted an STD from a casual sex partner than from a sex worker. Men are most uncertain about their vulnerability to STDs with casual partners. Men's condom use is highest in commercial sex, inconsistent in casual relationships, and lowest in marriage. STD/HIV-prevention programs need to address the range of sexual relationships and the meanings and behaviors associated with them.

The effect of birth interval on malnutrition in Bangladeshi infants and young children.

This study was undertaken to investigate the independent effect of the length of birth interval on malnutrition in infants, and children aged 6-39 months. Data for this study were drawn from a post-flood survey conducted during October-December 1988 at Sirajganj of the Sirajgani district and at Gopalpur of the Tangail district in Bangladesh. The survey recorded the individual weights of 1887 children. Cross-tabulations and logistic regression procedures were applied to analyse the data. The proportion of children whose weight-for-age was below 70% (moderate-to-severely malnourished) and 60% (severely malnourished) of the NCHS median was tabulated against various durations of previous and subsequent birth intervals. The odds of being moderately or severely malnourished were computed for various birth intervals, controlling for: the number of older surviving siblings; maternal education and age; housing area (a proxy for wealth); age and sex of the index child; and the prevalence of diarrhoea in the previous 2 weeks for the index child. About one-third of infants and young children were moderately malnourished and 15% were severely malnourished. The proportion of children who were under 60% weight-for-age decreased with the increase in the length of the subsequent birth interval, maternal education and housing area. The proportion of malnourished children increased with the number of older surviving children. Children were at higher risk of malnutrition if they were female, their mothers were less educated, they had several siblings, and either previous or subsequent siblings were born within 24 months. This study indicates the potential importance of longer birth intervals in reducing malnutrition in children.

A comprehensive assessment of the quality of services provided by family planning field workers in one major area of Dhaka city, Bangladesh.

PIP: Bangladesh has considerable national experience promoting and providing family planning services through home visits to reproductive-age married women by paid female community workers. Since 1978, the government has trained and employed 24,000 such workers, known as Family Welfare Assistants (FWA), while nongovernmental organizations (NGO) have trained and employed an additional 7000 field workers to carry out similar activities. NGO field workers are considered to be part of the national family planning program. Findings are presented from an assessment of the quality of family planning services provided by community-based field workers in zone 3 of Dhaka City, Bangladesh, and are based upon a large household survey of a representative sample of clients, direct field worker observation, and interviews with field workers and clients. Areas in greatest need of improvement include the frequency of contact with clients who are nonusers or who have special needs, client education about family planning methods, and counseling about side effects and warning signs.^ieng

The impact of a family planning multimedia campaign in Bamako, Mali.

An integrated multimedia campaign featuring family planning messages saturated the 900,000-person city of Bamako, Mali, for three months during the spring of 1993. With traditional theater and music, family planning messages were repeatedly broadcast on radio and television that conveyed information about modern contraceptive methods, the need for male sexual responsibility, the health and economic advantages of family planning, the need for communication between spouses, and that Islam, the predominant faith of Mali, does not oppose family planning. A separate sample pretest-post-test quasi-experimental research design was used to evaluate the effects of the campaign and exposure to specific messages on changes in contraceptive knowledge, attitudes, and practice. Results indicate a high level of exposure to and agreement with the messages. A dramatic drop was found in the proportion of men and women who believe that Islam opposes family planning. Logistic regression results indicate that contraceptive knowledge and use and more favorable attitudes toward family planning are positively associated with intensity of exposure to the project interventions, after controlling for relevant variables.

PIP: According to the Demographic and Health Surveys conducted in Mali in 1987 and 1995-96, the current use of any form of contraception among currently married Malian women increased from 5% to 7% during the period between the 2 surveys. Family planning messages were disseminated throughout Bamako through radio and television for 3 months in a spring 1993 information, education, and communication (IEC) campaign. With traditional theater and music, family planning messages were repeatedly broadcast on radio and television to convey information about modern contraceptive methods, the need for male sexual responsibility, the health and economic advantages of family planning, the need for spouses to communicate with each other, and that Islam, the predominant religious faith of Mali, does not oppose family planning. Impact evaluation found a high level of exposure to and agreement with the campaign messages. The campaign also led to a dramatic decline in the proportion of men and women who believe that Islam opposes family planning. Logistic regression results indicate that contraceptive knowledge and use and more favorable attitudes toward family planning are positively associated with the intensity of exposure to the project interventions, after controlling for relevant variables.

Awareness of sexually transmitted disease among women and service providers in rural Bangladesh.

Sexually transmitted disease (STD) in rural Bangladesh is currently a topic of great concern. To date, little information is available in the literature regarding its prevalence. It is now known, however, that the current level of STD awareness among the rural population with regard to modes of transmission and means of prevention is inadequate. In 1994, the MCH-FP Extension Project (Rural) of ICDDR, B surveyed 8674 married women of reproductive age (MWRA) in 4 rural thanas to examine their awareness of STDs. The association between socio-demographic and programmatic factors (variables which affect STD information availability) and awareness of STDs was examined by both bivariate and multivariate analyses. Seven focus group discussions were conducted among groups of government health and family planning workers and paramedics to assess their knowledge of STDs and attitudes about their prevention. Only 12% of the original group had even a basic understanding about STDs and how to protect themselves from them. Twenty-five per cent of the women surveyed had ever heard of either syphilis or gonorrhoea. Of these women, less than half could mention specific mechanisms involved in the transmission of these diseases. Seven per cent reported that syphilis and gonorrhoea are transmitted through sexual intercourse. Thirteen per cent reported that the infections are transmitted from spouses to their partners. Four per cent reported that STDs can be spread by having multiple sexual partners. The results of logistic regression analysis indicate that awareness of STDs was higher among relatively older women than among younger women. Awareness of STDs was most strongly and positively associated with the education of both the women and their husbands. Awareness of STDs was also found to be higher among women who were more socially mobile (e.g. those who frequent cinemas or mothers' clubs). The findings of focus group discussions indicate that family planning and health care service providers have a moderate level of STD awareness. Modes of transmission and means of prevention, however, were areas of weakness. It will, therefore, be necessary, whether to prevent a potential STD epidemic or to combat current STD prevalence, to implement culturally acceptable and affordable means of disseminating knowledge in rural areas of Bangladesh. Training of health care providers will be an essential first step.

PIP: Both a 1994 survey of 8674 married women of reproductive age from four rural thanas (Abhoynagar, Bagherpara, Keshobpur, and Sirajganj) of Bangladesh and focus group discussions conducted among government health and family planning providers in the same thanas revealed inadequate awareness of sexually transmitted diseases (STDs) and their transmission. Only 12% of survey respondents were considered to have a basic understanding of STDs and how to protect themselves from infection. Even after probing, only 25% of married women had ever heard of syphilis or gonorrhea; of these, just half knew the mechanisms of disease transmission. In the logistic regression analysis, awareness of STDs and their transmission was significantly associated with older age, higher educational level, Muslim religion, attendance at a family health and welfare center, current contraceptive use, and women's mobility outside the home. Although service providers had moderate levels of STD knowledge, there were many misconceptions (e.g., that STDs could be transmitted by wearing the clothes of an infected person). Providers agreed couples should be counseled to use condoms and avoid brothels. Awareness of AIDS was even lower than knowledge of syphilis and gonorrhea among both married women and health care workers. Training of health care providers is recommended as a first step in a national campaign aimed at disseminating accurate, culturally acceptable knowledge about STDs throughout rural Bangladesh.

Reduced caliber of the internal carotid artery: a normal finding with ipsilateral absence or hypoplasia of the A1 segment.

PURPOSE: To determine whether a relationship exists between normal variations in anatomy of the circle of Willis and the size of the internal carotid arteries (ICA). METHODS: MR angiograms and axial MR images of the brains of 104 patients were reviewed. Included were 10 patients with unilateral absence of the A1 segment of the anterior cerebral artery, 10 with hypoplasia of one A1 segment, 28 with asymmetric A1 segments, nine with isolated unilateral fetal origin of the posterior cerebral artery, and 47 with balanced circulation. RESULTS: The mean ICA diameter measurement for the total population was 4.62 +/- 0.68 mm. In patients with absent A1, the mean ipsilateral and contralateral ICA diameters were 3.63 +/- 0.41 mm and 5.25 +/- 0.52 mm, respectively. The mean percentages of the difference between the diameters of the right and left ICA (31% in the group with absent A1 and 21% in the group with hypoplastic A1) varied significantly from the differences in the ICA diameters among the rest of the population. The diameter differences produced by other common variations (unilateral small A1 segment or fetal origin of the posterior cerebral artery) did not differ significantly from those of the 47 patients with balanced intracranial circulation. CONCLUSIONS: There is an association of unilaterally absent or hypoplastic A1 segments of the anterior cerebral artery with ipsilateral decrease in ICA caliber, and this can be seen on MR angiograms.

Sexual activity, family life education, and contraceptive practice among young adults in Banjul, The Gambia.

This report presents results from a 1986-87 two-stage probability sample survey of 2,507 young men and women aged 14-24 living in the Greater Banjul region of The Gambia. Although premarital sexual activity was common and began at an early age, lack of knowledge and limited access to modern contraceptives were obstacles to the use of family planning. Of all ever sexually active single persons, only 21 percent of the young women and 7 percent of the young men had practiced contraception at the time of first intercourse. Almost half of the sexually active young adults had ever used contraceptives, with oral contraceptives and condoms being the methods most widely known and used. Results of logistic regression analyses show that attendance at family life education lectures in school had significant positive relationships to both knowledge and use of contraceptives among the young people surveyed. The study presents encouraging evidence that acceptance of modern contraceptive use is beginning to take hold among young people in urban Banjul.

Maternal mortality in Giza, Egypt: magnitude, causes, and prevention.

This article presents results from a population-based study of the magnitude and causes of maternal mortality in the Giza governorate of Egypt in 1985-86. Deaths to women in the reproductive ages were identified through the death registration system. Family members of the deceased were interviewed using the "verbal autopsy" approach. Immediate and underlying causes of death were then assessed by a medical panel. This methodology allows for the classification of multiple causes of death and is appropriate when registration of adult deaths is nearly complete, but reporting on cause of death on death certificates is poor. Of all reproductive-age deaths, 19 percent were maternal deaths. The maternal mortality ratio for Giza is estimated to be, at minimum, 126 maternal deaths per 100,000 live births. The maternal mortality rate is estimated to be, at minimum, 22 maternal deaths per 100,000 women aged 15-49, over 100 times the rate in Sweden. An average of 2.3 causes per maternal death were reported; the most common causes were postpartum hemorrhage (31 percent of cases) and hypertensive diseases of pregnancy, such as toxemia and eclampsia (28 percent of cases). Women experiencing hemorrhage, hypertensive diseases of pregnancy, or other serious complications must have easy access to hospital and maternity centers equipped for handling these conditions. Since most deliveries occur at home, many with the help of traditional birth attendants, TBAs will need training in early diagnosis, treatment, and/or effective referral of problem pregnancies.

PIP: Researchers analyzed death records of 156 women who died from obstetric causes between August 1985-August 1986 collected from 5 health sectors in Giza, Egypt to examine incidence and causes of maternal deaths. Social workers interviewed family members about circumstances of the mother's pregnancy and death (verbal autopsy approach). The maternal mortality ratio stood at 126 deaths/100,000 live births and the rate stood at 22/100,000 15-49 year old women). The cumulative risk of maternal death was at least 1 in 155 women. 50% died at a maternity center or a hospital. Remaining deaths occurred at home, another person's home, en route to the hospital, or the traditional birth attendent's (TBA) home. 35-39 year old women had the highest maternal mortality rate (40.5) while 15-19 year old women had the lowest (6.6). 24% of maternal deaths occurred to women of at least parity 7. Even though family members and the medical panel concluded that medical complications (39.1% vs. 25%) such as heart failure and hemorrhage (19.2% vs. 30.7%) were the major causes of maternal mortality, the most frequently reported causes of death as determined by the medical panel were postpartum hemorrhage (31.4%), hypertensive disease of pregnancy (27.6%), and other maternal complications (25.6%) such as prolonged and obstructed labor. This discrepancy can be explained by the fact that 70% of the mothers died of multiple causes. The researchers emphasized the need to train TBAs to diagnose problem pregnancies and to treat or refer them to hospitals or maternity centers. Health professionals used the medical profiles produced for each deceased women to formulate prevention strategies for specific cause of death strategies. The leading policy implication of this study was that most of the maternal deaths could have been prevented.

[Adolescent fertility in the Gambia. Education and declining age at marriage, two limiting factors]. / Fecondite de l'adolescente en Gambie. L'instruction et le recul de l'age au mariage, deux facteurs limitants.

PIP: In Gambia, more than 50% of the population is less than 20 years old. Adolescent fertility comprises 15% of total fertility. It is linked with certain health problems and socioeconomic problems. Adolescent fertility contributes to population growth and can influence socioeconomic development and the level of mortality risks among reproductive age women and their children. In 1983, the total fertility rate for Gambia was 6.4 births per woman compared to 6.5 in 1973. In the urban areas of Banjul and Kombo St. Mary Districts, it was 5.5 and 5.6, respectively. In Gambia overall, women have on average one child during adolescence. In metropolitan Banjul, 61% of all sexually active women and 37% of all sexually active single women had a child during adolescence. 40% of married girls aged 14-15 have been pregnant at least once. Based on the 1983 census, fertility among 15-19 year olds in metropolitan Banjul was 148 births/1000 women. In 1973, it was 199/1000 nationwide. The 1986-1987 fertility survey found their fertility to be 113/1000 based on registered births. Increase of the mean marriage age, higher educational level, and more contraceptive use in metropolitan Banjul may explain the decline in adolescent fertility here. 23% of women aged 15-19 in metropolitan Banjul were married in 1987 compared to 30% in 1983 and 53% for all Gambia in 1987. During 1986-1987, 83% of unschooled 19 year old females in greater Banjul were married compared to 13% of same-aged females with at least 7 years of education. In all of Gambia in 1983, women aged 15-19 with primary education had a fertility rate more than two times greater than that of same-aged women with superior education (220 vs. 103/1000). Adolescent fertility can limit education possibilities and darken economic perspectives. As societies continue to develop and modernize, it will be important to survey adolescent fertility and its socioeconomic and health impact on all youth as well as on the rest of society.^ieng

[Adolescent pregnancy and contraception in greater Banjul. Young people need precise information]. / Grossesse de l'adolescente et contraception dans l'agglomeration de Banjul. Les jeunes ont besoin d'une information precise.

PIP: During November 1986-February 1987, a knowledge, attitude, and practice study was conducted among 2521 youth 14-24 years old in the Banjul area of the Gambia. Sexual activity was more common among single men than single women (73% vs. 28%). Single men were more likely to be currently sexually active than single women (31% vs. 15%). 51% of single sexually active women had had at least one pregnancy. About 66% of pregnancies were unwanted. 90% of women who were in school when they conceived quit school. Most youth (76% for women and 89% for men) had heard of at least one contraceptive method. More than 33% of the youth thought it impossible to conceive during first intercourse. Most youth thought that oral contraceptives (OCs) were a greater risk than an unplanned pregnancy. Sexually active youth were more likely to have heard of at least one contraceptive method and to approve of its use (regardless of marital status) than non-sexually active youth. Single men knew more about most family planning methods than single women. Family life education at school or at social service programs increased family planning knowledge. Among the sexually active, 38% of married women, 56% of single women, and 43% of single men had used contraception, especially OCs and condoms. Contraceptive use increased with age. Single women were more likely to have used contraception at first intercourse than single men (21% vs. 7%). Lack of information was a major reason for non-use of contraceptives among single youth. Male youth were more likely to know about sexually transmitted diseases (STDs) than female youth (87% vs. 46%). Sexually active single men were 5 times more likely to have had an STD than married women and sexually active single women. Men were more likely to have heard of AIDS than women ( 50% vs. 25%). Family life education at school or in the communities may be an important first step to achieve access to family planning and reproductive health information and services.^ieng

Contraceptive social marketing in Nepal: consumer and retailer knowledge, needs and experience.

In 1986, a survey was conducted to assess knowledge, health concerns and experience with marketing (retailers) and use (consumers) of Gulaf and Nilocon pills and Kamal vaginal tablets distributed by the Nepal Contraceptive Retail Sales Company (CRS). A sample of 763 consumers of Gulaf, Nilocon and Indian pills and Kamal vaginal tablets, and 361 retailers from a stratified sample of urban medical shops were interviewed. The CRS marketing programme is reaching people who have previously never used family planning; most of the users were practising contraception to limit, not space, births; a high proportion of pill users over 35 smoked; only about a third of CRS pill users had prescriptions or consulted a physician prior to use; CRS training of retailers was found to have increased their knowledge. Recommendations are made for improving communication, education and marketing of CRS contraceptives to ensure their safe and effective use and increase the acceptability of this mode of service delivery.

PIP: A 1986 evaluation of the Nepal Contraceptive Retail Sales (CRS) program indicated that, while there is a need for improvements in IEC and marketing of subsidized contraceptives, the program is reaching unprecedented numbers of 1st-time family planning acceptors. The sample included 763 users of Gulaf, Nilocon, and Indian oral contraceptives (OCs) and Kamal vaginal tablets and 361 retailers from urban medical shops. 91% of the acceptors had learned of CRS products through radio advertisements. Only half made the contraceptive purchase themselves. Convenience--proximity to home or work and less waiting time--was the major reason given for buying contraceptives from private medical shops rather than government sources (where contraceptive supplies are free). 75% of Gulaf consumers and 50% of Nilocon and Kamal consumers were 1st-time contraceptives users, indicating that the CRS is reaching a new audience. Gulaf users were of lower socioeconomic status than acceptors of the other CRS products. Both consumers and retailers have a good basic understanding of the contraindications, method of use, and side effects of OCs and the vaginal foaming tablet. On the other hand, there were important gaps in knowledge. For example, retailers were not clear that Kamal can be used by lactating women and unsure of how to counsel consumers who had missed 3 consecutive pills. In addition, 6% of Gulaf and 8% of Nilocon consumers were smokers over 35 years of age--a category of women for whom OC use is contraindicated. Married, higher educated retailers had the highest levels of correct knowledge about CRS products. It appeared that husbands who purchased contraceptives for their wives either were not given adequate information about proper use or failed to transmit this information. Retailers expressed interest in expanding their stock to include Depo-Provera, pregnancy detection kits, and delivery kits.

Family planning communication between spouses in Sri Lanka.

PIP: Drawing on data from a national follow-up survey of 2310 currently married women aged 15-49 conducted in Sri Lanka in 1985, this study examines patterns of family planning communication between spouses, social and economic factors related to those patterns, and the consistency between spouses in their responses to questions about family planning attitudes and practice. The results of the analysis indicate a high degree of family planning communication between spouses in Sri Lanka. The communication, however, varied according to couples' number of living children and to wives' age, education, place of residence, religion, and work status. Multivariate logistic regression generally confirms that older women, those with little or no education, those living on tea estates, and Muslims were less likely to communicate with their husbands on family planning matters than were women in other age, education, residence, and religion categories. These findings suggest the existence of social and cultural obstacles to communication between spouses about family planning matters in Sri Lanka. Among the 577 pairs of spouses whose answers were compared for consistency, a large proportion of wives reported hearing about male contraceptive methods directly from their husbands, and a large proportion of husbands reported hearing about female methods from their wives. These findings are a reminder that both spouses are potentially important sources of information about contraception.^ieng

Side effects and discontinuation of oral contraceptive use in southern Brazil.

PIP: Oral contraceptives have many advantages, but sometimes also have side effects which can cause users to switch appropriately or inappropriately to less effective methods or abandon contraception. In Brazil, 2/3 of married women of childbearing age were using contraception in 1981, and 1/2 of these were using orals. Contraceptive behavior following reported side effects in users of oral contraceptives in Southern Brazil is examined in this study, in relation to diverse factors. Among 2904 currently-married women, aged 15-44, almost 75% reported that they had used the pill at some time, and of these, 45.6% were still doing so. Data on perceived side effects were gathered for all women. There was no independent medical evaluation of the effects, so the data did not necessarily represent actual prevalence of pill related problems. Women who reported problems with the pill were less likely to be current users (25%) than women who did not (65%). However, overall contraceptive prevalence was about the same in both groups (66.2% and 67.0% respectively), indicating that women who stop using oral contraceptives usually switch to another method. However, they are more likely to be using traditional methods than women in the general population, especially if they want more children. Termination of pill use varies little according to the type of problem reported. Women with problems who sought medical attention were more likely to stop using the pill, and 82.4% of women advised to stop by their physician did so, but the major factor affecting discontinuation was the reported experience of a problem. The most frequently reported problems were headaches (38.1%), nausea (34.1%), nervousness (27.9%), and vertigo (18.3%). Physician intervention should help to avoid women's abandoning oral contraceptives unnecessarily.^ieng