Early prognostication markers in cardiac arrest patients treated with hypothermia.

BACKGROUND AND PURPOSE: Established prognostication markers, such as clinical findings, electroencephalography (EEG) and biochemical markers, used by clinicians to predict neurological outcome after cardiac arrest (CA) are altered under therapeutic hypothermia (TH) conditions and their validity remains uncertain. METHODS: MEDLINE and Embase were searched for evidence on the current standards for neurological outcome prediction for out-of-hospital CA patients treated with TH and the validity of a wide range of prognostication markers. Relevant studies that suggested one or several established biomarkers and multimodal approaches for prognostication are included and reviewed. RESULTS: Whilst the prognostic accuracy of various tests after TH has been questioned, pupillary light reflexes and somatosensory evoked potentials are still strongly associated with negative outcome for early prognostication. Increasingly, EEG background activity has also been identified as a valid predictor for outcome after 72 h after CA and a preferred prognostic method in clinical settings. Neuroimaging techniques, such as magnetic resonance imaging and computed tomography, can identify functional and structural brain injury but are not readily available at the patient's bedside because of limited availability and high costs. CONCLUSIONS: A multimodal algorithm composed of neurological examination, EEG-based quantitative testing and somatosensory evoked potentials, in conjunction with newer magnetic resonance imaging sequences, if available, holds promise for accurate prognostication in CA patients treated with TH. In order to avoid premature withdrawal of care, prognostication should be performed more than 72 h after CA.

Statin use and neurologic morbidity after coronary artery bypass grafting: A cohort study.

BACKGROUND: Statin use before surgery has been associated with reduced morbidity and mortality after vascular surgery. The effect of preoperative statin use on stroke and encephalopathy after coronary artery bypass grafting (CABG) is unclear. METHODS: A post hoc analysis was undertaken of a prospectively collected cohort of isolated CABG patients over a 10-year period at a single institution. Primary outcomes were stroke and encephalopathy. Univariable analyses identified risk factors for statin use, which were applied to a propensity score model using logistic regression and patients were divided into quintiles of propensity for statin use. Controlling for propensity score quintile, the odds ratio (OR) of combined stroke and encephalopathy (primary endpoint), cardiovascular mortality, myocardial infarction, and length of stay were compared between statin users and nonusers. RESULTS: There were 5,121 CABG patients, of whom 2,788 (54%) were taking statin medications preoperatively. Stroke occurred in 166 (3.2%) and encephalopathy in 438 (8.6%), contributing to 604 patients (11.8%) who met the primary endpoint. The unadjusted OR of stroke/encephalopathy in statin users was 1.053 (95% confidence interval [CI] 0.888-1.248, p = 0.582). Adjustment based on propensity score resulted in balance of stroke risk factors among quintiles. The propensity score-adjusted OR of stroke/encephalopathy in statin users was 0.958 (95% CI 0.784-1.170, p = 0.674). There were no significant differences in cardiovascular mortality, myocardial infarction, or length of stay between statin users and otherwise similar nonusers. CONCLUSIONS: In this large data cohort study, preoperative statin use was not associated with a decreased incidence of stroke and encephalopathy after coronary artery bypass grafting.

Reversal of transtentorial herniation with hypertonic saline.

OBJECTIVE: To evaluate the role of 23.4% saline in the management of transtentorial herniation (TTH) in patients with supratentorial lesions. METHODS: Consecutive patients with clinically defined TTH treated with 23.4% saline (30 to 60 mL) were included in a retrospective cohort. Factors associated with successful reversal of TTH were determined. RESULTS: Seventy-six TTH events occurred in 68 patients admitted with intracerebral hemorrhage (n = 29), subarachnoid hemorrhage (n = 16), stroke (n = 8), brain tumor (n = 8), subdural hematoma (n = 5), epidural hematoma (n = 1), and meningitis (n = 1). In addition to 23.4% saline, TTH management included hyperventilation (70% of events), mannitol (57%), propofol (62%), pentobarbital (15%), ventriculostomy drainage (27%), and decompressive hemicraniectomy (18%). Reversal of TTH occurred in 57/76 events (75%). Intracranial pressure decreased from 23 +/- 16 mm Hg at the time of TTH to 14 +/- 10 mm Hg at 1 hour (p = 0.002), and 11 +/- 12 mm Hg at 24 hours (p = 0.001) among 22 patients with intracranial pressure monitors. Reversal of TTH was predicted by a >/=5 mmol/L rise in serum sodium concentration (p = 0.001) or an absolute serum sodium of >/=145 mmol/L (p = 0.007) 1 hour after 23.4% saline. Adverse effects included transient hypotension in 13 events (17%); no evidence of central pontine myelinolysis was detected on post-herniation MRI (n = 18). Twenty-two patients (32%) survived to discharge, with severe disability in 17 and mild to moderate disability in 5. CONCLUSION: Treatment with 23.4% saline was associated with rapid reversal of transtentorial herniation (TTH) and reduced intracranial pressure, and had few adverse effects. Outcomes of TTH were poor, but medical reversal may extend the window for adjunctive treatments.

The role of animacy in children's understanding of 'move'.

Animals are distinctive in that they are the causal agents of their own actions (e.g. a dog moves itself), whereas artifacts generally are not (e.g. a marble doesn't move itself). We examined whether children make use of this conceptual link between animacy and agency when interpreting the verb 'move' in English. Specifically, we hypothesized that the semantic interpretation of 'move' would differ, depending on whether the subject noun refers to an animal or to an inanimate object. We hypothesized that, for in animates, children would allow 'move' to have a patient subject (e.g. 'the marble moved' could mean 'the marble was moved by someone else') but not so for animates (e.g. 'the dog moved' could not mean 'the dog was moved by someone else'). In two studies, 65 three-year-olds, 57 five-year-olds, and 74 adults viewed video clips of animals or inanimate objects being transported by a person. For each clip, the child was asked whether the animal or object was moving. A 'yes' response would indicate acceptance of a patient subject (e.g. 'the dog/marble moved' means 'the dog/marble was moved by someone else'). Both five-year-old children and adults more often reported that the toys were moving, than that the animals were moving. However, three-year-olds showed no animacy effects. Thus, between the ages of three and five, children begin to link animacy and agency in language. These findings suggest that children's language use is guided by similar conceptual constraints as those of adults, and/or that children are sensitive to distributional information linking form and meaning in the input language.

Quality of care within the Indian family welfare programme: a review of recent evidence.

India's family planning program represents one of the earliest and most ambitious efforts in a developing country to address the issue of high fertility. Despite its more than four decades of existence, little is known concerning how the program is implemented at the field level, especially in relation to the quality of services provided. In this article, empirical evidence on the accessibility and quality of services provided through the Indian family planning program is reviewed and synthesized. The review highlights the serious and systemic shortcomings in quality of care that characterize the Indian program in such areas as restricted method choice, limited information provided to clients, poor technical standards, and low levels of follow-up and continuity of care. The factors constraining higher service quality are subsequently reviewed, and the prospects for improving quality of care within the Indian program are assessed.

Duration of protective immunity conferred by maternal tetanus toxoid immunization: further evidence from Matlab, Bangladesh.

OBJECTIVES: Although maternal tetanus immunization has been shown to be highly effective in the prevention of neonatal tetanus, unresolved questions remain concerning the required minimum number of doses and the resulting duration of effective immunity. This study examined the duration of effective immunity against neonatal tetanus provided by maternal tetanus immunization. METHODS: A randomized, double-blind cholera vaccine trial of 41,571 children and nonpregnant adult women carried out in 1974 in the Matlab comparison area of rural Bangladesh provided a unique opportunity to address dose and immunity issues. RESULTS: Children of women who received either 1 or 2 injections of tetanus toxoid experienced 4- to 14-day mortality levels consistently lower than those of children of unimmunized mothers. Analysis of neonatal-tetanus-related mortality showed that 2 injections of tetanus toxoid provided significant protection for subsequent durations of up to 12 or 13 years. CONCLUSIONS: The data demonstrate that a limited-dose regimen of maternal tetanus toxoid provides significant and extended protection against the risk of neonatal tetanus death.

The influence of quality of care upon contraceptive use in rural Bangladesh.

Efforts to develop quantitative indicators of quality of care for family planning services, and to evaluate its role in contraceptive behavior, remain at an early stage. The present study, based upon an analysis of prospective data from a sample of 7,800 reproductive-aged rural Bangladeshi women, provides empirical evidence on the importance of quality of care for contraceptive practice. The results demonstrate that the perceptions of women regarding the quality of field-worker care were significantly related to the probability of subsequent adoption of a family planning method. Women who were not using a method and who scored high on an index of perceived quality of care were 27 percent more likely to adopt a method subsequently, compared with women with a low score. Effects were even more pronounced for contraceptive continuation; high quality of care was associated with a 72 percent greater likelihood of continued use of any method of contraception.

PIP: This report opens with an overview of the development of the concept of "quality of health care" and attempts to identify appropriate research methodologies to define and measure quality of care indicators. The present study uses longitudinal data collected after May 1989 via interviews with 7829 women in rural Bangladesh to describe the influence of quality of care on contraceptive behavior. After describing the study setting and data, results are presented in terms of 1) evidence gleaned about the standards of care offered by the government field workers from the perspective of the clients served and 2) the relationship between selected quality of care indicators and contraceptive adoption and method continuation. The analysis provided compelling evidence of the important effect of quality of care on contraceptive behavior. Clients were more likely to continue contraceptive usage if they perceived a high quality of care from field workers. Higher standards of care were also associated with a 27% increase in subsequent adoption of contraception by nonusers. It was also found that the absolute number of contraceptive methods offered to a client may not be as important as the degree of trust developed between the field worker and the client. The findings also indicate that significant improvements are needed in the quality of care provided by field workers. Only half of the ever-visited respondents received acceptable standards of care, only 25% welcomed a return visit, and only a minority had positive views of services provided through government clinics. Further research is needed to collaborate these findings in other settings, and efforts should be made to identify the ways that policies and programs realistically can be changed to improve quality of care in order to meet the needs of individuals and broad demographic goals.

Worker-client exchanges and contraceptive use in rural Bangladesh.

In this article, longitudinal data from rural Bangladesh are used to assess the impact of household visits from family planning workers on contraceptive use. A panel of women was interviewed in a demographic survey and reinterviewed every 90 days for six successive rounds. Regression methods are used to estimate the effect of these encounters on the odds that a woman will use contraceptives. Statistical controls adjust for the potentially confounding effects of underlying demand for contraception. Findings suggest that both male and female worker-initiated exchanges have an effect, although the impact of outreach is more pronounced if the worker is female. Estimated effects are consistent with the hypothesis that the predominant impact of outreach is to crystallize existing latent demand for contraception. Results also suggest, however, that female worker outreach generates new demand by fostering ideational change.

Effects of family sex composition on fertility preference and behaviour in rural Bangladesh.

The effects of family sex composition on fertility preferences and behaviour during the period 1977-88 are examined using longitudinal data from Matlab, Bangladesh. The sex composition of living children was found to be systematically related to fertility preferences and behaviour, with a higher number of sons at each family size associated with a higher percentage of women wanting no more children, a higher percentage currently using contraception, and lower subsequent fertility. However, the highest percentage wanting no more children, using contraception and having lowest subsequent fertility was found among women who already had one daughter as well as at least one son. The effects of sex preference on fertility preferences and behaviour were measured using an index developed by Arnold (1985). The results suggest that while sex preference remained largely unchanged during the study period, its effect on contraceptive use declined and its impact on actual fertility remained modest and fairly stable.

PIP: The hypothesis of this study is that the effect of sex preference on fertility is dependent on the level of contraceptive use, and the relative importance given to sex composition and family preference in determining contraceptive use. The effect of sex composition under different contraceptive prevalence conditions is examined by comparing in the Matlab intervention area 2 different periods: 1977-82 and low contraceptive use, and 1984-88 and higher use. The study area comprised 149 villages and a total population of 187,523. This research used data on 2111 women in the 1977 survey and 3140 women in the 1984 survey. Survey data were linked with the Matlab demographic surveillance system. The results showed that between 1977 and 1984 there was an increase in the percentage of women desiring no more children, a decline in family size preference, and an increase in contraceptive use. Contraceptive use was 20% for modern methods in 1977 and 38% in 1984. The general finding was that the higher the number of sons at any family size level, the higher the percentage of women desiring no more children. The effect of sex preference on the percentage of women desiring no more children did not change between 1977 and 1984 (9.5% during 1978-82 and 19.5% during 1984-88); what did change was the percentage of women desiring no more children, from 39.0% to 54.7%. Change would have occurred is there had been no sex preference; expected changes would have decreased the desire for no more children from 14.6% in 1977 to 16.4% in 1984. Without sex preference, contraceptive use would also have declined from an increased prevalence in 1977 of 20.4% and 9.9% in 1984. the sex preference effect measure (SPEM) of Arnold (1985) was used and modified to quantify the effect of sex preference on fertility preferences and behavior. Fertility was consistently and negatively related to the number of living children. Without sex preference, fertility would have decreased 9.5% during 1978-82 and 10.5% during 1984-88. Family size preference had increased in its importance in determining contraceptive use. The effect of sex composition on subsequent fertility remained constant between the 2 periods.

Mortality-discriminating power of some nutritional, sociodemographic, and diarrheal disease indices.

This study compared the predictive power of selected nutritional (anthropometric), socioeconomic, and diarrheal disease morbidity variables for subsequent childhood mortality over a 1-year period. The data consisted of observations of approximately 1,900 children aged 6-36 months obtained from a longitudinal demographic surveillance system located in a rural area of Bangladesh in 1988-1990. The results suggested that weight-for-age (%) was the best predictor of subsequent mortality over a 1-year period, followed by weight velocity (monthly weight gain or loss in grams). Standardization of weight velocity by the US National Center for Health Statistics standard did not improve the mortality-discriminating power of this variable. Reported diarrheal morbidity was also a useful criterion for predicting mortality. Neither maternal education nor sex of the child had significant mortality-discriminating power.

PIP: The predictive power of selected nutritional (anthropometric), socioeconomic, and diarrheal disease morbidity variables for subsequent childhood mortality were compared over a 1-year period. The data were obtained from the Sample Registration System of the International Centre for Diarrhoeal Disease Research, Bangladesh, located in a rural area of Bangladesh in 1988-90. In 1988 the weights of approximately 1900 children aged 6-36 months were measured to the nearest 100 gm on a bar scale to assess the impact of the flood on the nutritional status of children in the area. The weights of the children were measured again after 3 months for examination of any changes in nutritional status. Information on diarrheal disease during the previous 24-hour period and also during the previous week, including the day of the interview/weight measurement, was also collected. Measurements for 1874 children were available from the 1st weight measurement, and measurements for 1900 children were available from the 2nd weight measurement. The 1664 children for whom measurements were available from both time periods were included in this study; 27 of these died during the 12-month period following the last weight measurement. Below a threshold point of 70% mortality increased very sharply for weight-for-age (percent) and around 70 gm month for the weight velocity index. The sensitivity and specificity curves weight-for-age (percent) appeared to be superior to the weight velocity index as a predictor of mortality. Weight velocity was a weaker predictor than was weight-for-age (percent), and the power of the weight velocity index was lower than that of weight velocity. Neither maternal education nor sex of the child had significant mortality-discriminating power. The discriminating powers of the variables of diarrhea on the day of assessment and diarrhea during the previous week were significant (p 0.05).

Levels and trends in post-partum amenorrhoea, breast-feeding and birth intervals in Matlab, Bangladesh: 1978-1989.

PIP: This study examines the trends in and determinants of length of postpartum amenorrhea during 1978-90 in Bangladesh. Data are obtained from the Matlab project. The sample comprises 6000 women per cohort for cohorts born in two year periods during 1978-80 and 1988-89. Reproductive and lactation records are available for up to 36 months following the birth of the index child. Findings indicate that the duration of postpartum amenorrhea is around 13 months for births during 1978-83. The median duration is 13.5 months for the birth cohort for 1982-83 and 9.4 months for the birth cohort for 1988-89. For 1989 alone the median duration is a further decline to 8.6 months. The seven year decline amounts to a 36% reduction. Findings indicate that age and duration of postpartum amenorrhea are positively related. All age groups show a decline in median duration. The shorter median durations occur among women with fewer than two living children and higher levels of education. Duration of breast feeding peaks in 1984-85 at 34.3 months and then declines to 30.7 months in 1986-87. Full breast feeding duration declines from around 6 months for cohorts 1978-79 to cohorts 1982-88 to 5.2 months in 1986-87 and lags behind durations of postpartum amenorrhea. Full breast feeding declines occur after the 1982-83 cohort among mothers with higher education and after the 1984-85 cohort for uneducated and less educated women. Age patterns of breast feeding women are inconsistent. The oldest mothers have the shortest breast feeding durations. The youngest cohorts show a decreasing trend. Breast feeding durations increase with an increase in the number of living children. However another trend shows initial increases in duration and then declines regardless of the number of living children. The suggestion is that full breast feeding may be important in determining the length of postpartum amenorrhea duration. Contraceptive use increases from 24% in 1977 to 39% in 1984. Median birth intervals increase from 38.7 to 48.8 months and increases pertain to all age and parity groups. Malnutrition is considered to be unrelated to postpartum amenorrhea periods. The trend is clearly reflective of declining postpartum amenorrhea duration, but the nature of the impact of breast feeding or contraceptive use is not clear.^ieng

Contraceptive use in Matlab, Bangladesh in 1990: levels, trends, and explanations.

The results of a 1990 knowledge, attitudes, and practice survey in Matlab, Bangladesh, indicate that contraceptive prevalence has risen to 57 percent in the maternal and child health/family planning project area. Between 1984 and 1990 significant increases were registered in the proportions of women using contraceptives for the purposes of spacing and limiting births. By 1990 fertility control in the intervention area had become so widely diffused that educational differentials in contraceptive practice were no longer evident. Although significant gains in contraceptive use were also evident in the neighboring comparison area during this period, at 27 percent, prevalence there still remained substantially below the levels in the intervention area. The disparity in contraceptive use between the two areas is adequately explained neither by differences in socioeconomic conditions nor in the demand for family planning, but rather by differences in the intensity, coverage, and overall quality of their family planning programs.

PIP: The International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) has conducted research and program intervention on maternal and child health and family planning (FP) since October 1977. The rural study area was in Matlab, a cluster of 149 villages with a population of 180,000. This article reports on recent contraceptive use changes from the FP knowledge, attitudes, and practices (KAP) survey in 1990. Prior surveys in 1984, 1977, and 1975 were also used to show time trends. Current contraceptive use for all currently married women 15-49 years was 57% in the intervention area (IA) and 27% in the comparison area. 94% of contraceptive prevalence (CP) was for modern methods in the IA of which 50% were injectables, 21% pills, and 15% female sterilization. CP constituted 35% for female sterilization, 30% pill use, and 26% traditional methods for the comparison area. The greatest difference in method use between areas was in modern contraceptive use; spacing and limitation differences showed 71% used for limitation in the IA versus 37% in the comparison area. 42% used contraception for spacing in the comparison area. In the IA, contraceptive use levels were associated with maternal age, number of living children, and number of sons; educational level no longer had a dominant effect. Increases in contraceptive use for spacing were evident between 1984 and 1990 and between 1977 and 1984. Limiting increased significantly more after 1984. Increases between 1977 and 1984 were due to primarily increases in injectables, female sterilization, and the IUD; increases after 1984 were due to injectables and the pill. Almost all demographic subgroups experienced CP increases after 1984 in either area. Compared with trends throughout Bangladesh, contraceptive use levels in the rural Matlab IA were higher than the rural national average, while the comparison area remained somewhat lower. Matlab is the socioeconomically least developed region in the country and it was expected that there would be a lag. Discussion includes an explanation for the high levels of use and the nature of the study area, differences in socioeconomic conditions and in demand for family planning, and in service delivery programs. The implication is that carefully planned programs can be successful even under unfavorable conditions.

Employment in family planning and women's status in Bangladesh.

This study investigates how employment in family planning affects the status of community workers. The focus is on three critical variables: prestige, professional status, and social influence. The data are derived from a focus-group study conducted in 1987-88 in the Maternal and Child Health and Family Planning Project in Matlab, Bangladesh. Focus-group sessions were held with community workers, their husbands, community leaders, and community women. Results show that although community workers initially faced intense hostility in the community, they succeeded in maintaining the prestige that is traditionally accorded to women in their conservative, rural society. Moreover, they established themselves as valued health and family planning professionals in a social context where professional roles for women have been extremely circumscribed. Finally, they gained social influence by performing a range of functions in the community that exceed formally prescribed job responsibilities. The professional and social leadership roles that community workers now assume imply a degree of status that seemed inconceivable a decade ago. That such change could result from a well-designed and appropriately managed family planning project deserves careful attention.

PIP: Focus group discussion from 1987-88 among 44 of the 65 community workers who had been with the Matlab Maternal and Child Health Family Planning Project (MCH-FP), Bangladesh over a decade, were conducted in order to investigate how FP affects the status of women. The variables under consideration were prestige, professional status, and social influence. Interviews were also conducted with husbands, community leaders, and educated community women. The social system of purdah which restricts extrafamilial activities places workers in conflict with established social and cultural norms. The findings of this investigation were that many changes took place over the decade. Prestige was regained by workers, who originally were thought to have lost their honor by violating the cultural patterns of seclusion and modesty. Recognition was given to these women for their professional expertise, community service, and control over medical resources. The rise in social status placed them in a position worthy of arbitrating family and neighborhood conflicts and sometimes advocating for women. Social and professional influences were possible because these women transformed traditional purdah into inner purdah, which placed them within the domain of the conservative definitions of gender. The strategy reflected accommodation and reform. The distinction is made between women's prestige which is respect for adherence to culturally defined patterns of female behavior and status which is women's control over resources, information, and other sources of power and influence. Project management was supportive in that routing of patients to the health subcenter or the Matlab hospital was accomplished through the community workers, and project staff deliberately showed respect to the worker when visiting a worker's area. In this manner, the worker's image was reinforced. The social conditions were such that there were adequate resources for service delivery also. Although there were socioeconomic changes taking place in the form of modernization, the status of employment may have been affected but responsibility for the changes in prestige, professional status, and social influence must be directed to the worker's and management. A well-designed and appropriately managed FP project can avail women of employment opportunities which provide access into male space, and provide control over resources, influence, and power.

Excess female deaths among rural Bangladeshi children: an examination of cause-specific mortality and morbidity.

Excess female over male mortality during childhood, well known in the northern Indian subcontinent, is particularly marked in rural Bangladesh. While the determinants of this phenomenon and the respective roles of cultural and economic factors are still debated, little data exist on cause-specific mortality, to identify the specific causes of death producing this differential. In 1986-1987 in Matlab, a study area under intensive demographic surveillance in rural Bangladesh, female children aged 1 to 4 years had a risk of dying 1.8 times higher than male children (95% confidence interval: 1.5-2.1). The causes of death which contributed the most to this excess female mortality were severe malnutrition and diarrhoeal diseases. The risks of dying were 2.5 and 2.1 higher for female than for male children for these two causes, respectively. Possible mechanisms are examined using data on incidence of selected diseases and admission rates to curative facilities. There was no gender difference in incidence of severe diarrhoeal diseases, but female children with diarrhoea were taken to the hospital significantly less often than male children. In contrast, there was a higher incidence of severe malnutrition in female than male children, and a lower rate of hospital admission. The data suggest that gender differentials in mortality may not be as much affected by preventive measures against diarrhoea as by efforts to provide equivalent curative services to female and male children.

Measles among under-9-month-olds in rural Bangladesh: its significance for age at immunization.

Any decision to modify measles immunization strategies away from the use of the conventional vaccine given to children at 9 months of age to the adoption of recently proposed vaccine strains that can be given to 4-6-month-olds will depend on the age distribution of severe cases of measles in the community. Reported are the results of an analysis of two community-based measles surveillance systems in rural Bangladesh, which found that 17% of all measles cases reported for under-5-year-olds in a nonvaccinated population involved infants aged less than 9 months. In a vaccinated population from the same area, 31% of all measles cases reported for under-5-year-olds occurred among under-9-month-olds. Using a rather restrictive definition for measles-related deaths (those occurring within 6 weeks of the onset of the rash), the proportion of measles-related deaths that occurred before 9 months of age was 13% of all such deaths that were reported.

The Sample Registration System: an innovative system for monitoring demographic dynamics.

"The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) has been at the forefront of the development of longitudinal systems for demographic surveillance. The Demographic Surveillance System from the Matlab study area is internationally recognized as a unique source of accurate and complete demographic data for a large rural population within a developing setting. In this paper, an overview is presented of a second demographic surveillance system--the Sample Registration System (SRS)--which has been in operation for six years in two other areas of rural Bangladesh." Fertility and mortality rates for the period 1983-1988 are calculated from the SRS data.

Maternal-child health and family planning: user perspectives and service constraints in rural Bangladesh.

This article presents a microanalysis of interactions between female fieldworkers and women in rural Bangladesh, and a discussion of the broader organizational constraints that hamper service delivery. It is argued that the fieldworker, herself a rural woman, is faced with considerable demand for both maternal-child health (MCH) and reproductive health care services, but that operational constraints prevent her from realizing her potential in both of these areas. Qualitative data show that, in the eyes of rural women, contraceptive use and health care are intricately intertwined, and that this association often raises a range of questions that the worker cannot address competently. A number of specific operational barriers--worker densities, staff motivation, supervision, technical competence, supplies--are identified. These barriers reflect a general institutional weakness in the Ministry of Health bureaucracy that prevents it from organizing itself to deliver user-oriented health and family planning services while maintaining adequate and appropriate standards of care.

PIP: A microanalysis of interactions between female field workers and women in rural Bangladesh is presented. Broader organizational constraints that hinder service delivery are discussed. The field worker, a rural woman herself, is faced with much demand for both maternal-child health (MCH) and reproductive health care services, but operational constraints keep her from realizing her potential in both of these areas. Contraceptive use and health care are intertwined in the view of rural women. Qualitative data based on observations of the exchanges between female workers and rural women during the workers' regular household visits were collected. 65 encounters between 22 workers and rural women of reproductive age were observed. Some of the workers had received special training from the Extension Project. The association between contraceptive use and health care poses many questions which the worker cannot answer completely. The female worker (FWA) in Bangladesh has duties in both areas: MCH and family planning (FP). When the interactions between field workers and rural women were observed in the mid 1980s, each FWA covered an average of 7500 people. Since then the size has decreased to about 4000, due to recruitment of more female workers. In the FP area, the FWA is responsible for information, education, distribution of contraceptives, motivation, and referral for clinic methods. Her MCH jobs include distributing oral rehydration salts (ORS), referral for immunization, education, and for prenatal, perinatal, and postnatal care, and vitamin A distribution. The FWA is supervised by local government and staff of the rural health center at the level of the subdistrict. Technical support to the FWA is the responsibility of a female paramedic who works at a rural subcenter. Rural women in Bangladesh are worried about health consequences of contraceptive use. Family planning is a major health issue. MCH and family planning tasks compete with each other. Workers sometimes see MCH care as something apart from their work. Constraints on FWA's delivery of FP and MCH services include: 1) staffing density and work motivation; worker's technical competence and MCH supplies; supervision; availability and quality of care at subcenters. These problems defy simple solutions.

Birth intervals and childhood mortality in rural Bangladesh.

This study investigates the relationship between birth intervals and childhood mortality, using longitudinal data from rural Bangladesh known to be of exceptional accuracy and completeness. Results demonstrate significant but very distinctive effects of the previous and subsequent birth intervals on mortality, with the former concentrated in the neonatal period and the latter during early childhood. The impact of short birth intervals on mortality, however, is substantially less than that found in many previous studies of this issue, particularly for the previous birth interval. The findings are discussed in terms of the potential for family planning programs to contribute to improved child survival in settings such as Bangladesh.