Ressonância magnética no rastreamento de mulheres com alto risco para câncer de mama / Magnetic ressonance in the screening of women at high risk for cancer breast

A técnica de ressonância magnética (RM) tem alta sensibilidade, mas especificidade limitada, podendo ser utilizada em indicações específicas como adjuvante à mamografia e à ultra-sonografia. As limitações da mamografia no rastreamento de mulheres de alto risco para câncer de mama estimulou o desenvolvimento de ensaios clínicos para avaliar a ressonância magnética como adjuvante à mamografia. Em mulheres de alto risco familiar para câncer de mama e nas portadoras de mutações conhecidas para BRCA1 e BRCA2, o câncer ocorre mais precocemente e o rastreamento deve começar em pacientes mais jovens cujas mamas são mais densas e a mamografia sofre importante queda na sensibilidade. Com base no resultado desses ensaios clínicos, houve um aumento no interesse em oferecer a RM a mulheres de alto risco após discussão dos potenciais riscos e benefícios. Este artigo revê a experiência do rastreamento do câncer de mama por RM em populações de alto risco.

The technique of magnetic resonance (MR) has high sensitivity, but a relatively limited specificity. It may only be used for specific indications for adjunct to mammography and ultrasound. The limitations of mammography in screening women at high risk for breast cancer stimulated clinical trials to evaluate magnetic resonance imaging as an adjunct to mammography. In women with high familial risk for breast cancer and in the carriers of mutations known for BRCA1 and BRCA2, the cancer occurs more precociously and the screening must start in younger patients in whon the breasts are denser and the mammography suffers important fall in sensibility. Based on the results of these trials, there is increased interest in offering screening MR to high-risk women after discussion the potential benefits and risks. This article reviews the experience of screening breast MR high-risk population.

Maternal mortality in England and Wales 1970-1985: an analysis by country of birth.

OBJECTIVE: To determine the risk of maternal mortality in immigrants to England and Wales. DESIGN: Analysis of death registrations, 1970-1985, by country of birth. SETTING: England and Wales. POPULATION: Women dying in England and Wales during pregnancy, childbirth or the puerperium, or dying from malignant tumour of the placenta. MAIN OUTCOME MEASURES: The risk of dying in pregnancy, childbirth or the puerperium, adjusted for age and year of death, and the risk of cause-specific death, adjusted for age, in immigrants compared with women born in England and Wales. RESULTS: Women born in West Africa (relative risk 10.3; 95% CI 8.0-13.2) and the Caribbean (4.6; 3.8-5.7) were at very elevated risk of maternal death and of the main causes of death. Women from Southern Asia (1.6; 1.3-2.0) and "Europe and the USSR' (1.7; 1.2-2.3) were at moderate risk. Adjustment for year of death increased the estimates of risk and women born in the "Rest of the World' and Scotland were at significantly elevated risk. CONCLUSIONS: An increased incidence of obstetric conditions in immigrant groups may account for the elevated risk but it is also possible that differences in care may account for some of the additional risk. The pattern of increased risk does not appear to be explicable by the parity or social class distribution of immigrants as far as data are available on these. Research is required into the aetiology of the differential incidence of obstetric disease. The collection of routine mortality data which include maternal reproductive and social factors would elucidate the significance of such factors to maternal health. Further investigation into possible differences in the process of antenatal care between immigrants and non-immigrants is required, and into whether this affects the risk of maternal mortality.

[Analysis of the demand for family planning]. / Analisis de la demanda de planificacion familiar.

PIP: Fertility intentions and reproductive risk were used to segment Peru's potential market for contraceptives using data from the 1991-92 Demographic and Health Survey. The four programmatic groups of fertile-aged women in union included 41.4% not wanting more children and at high risk, 30.5% not wanting more children and at moderate or low risk, 12.8% wanting to space, and 15.4% wanting a child in the near future. 84.6% of fertile-aged married women thus needed a contraceptive method to avoid unwanted pregnancy or high risk pregnancy. A range of appropriate methods was identified for each of the four programmatic groups based on method efficacy, clinical contraindications, and legal restrictions. Projections of the prevalence, method mix, and sources of service took into account the range of appropriate methods, local preferences for particular methods, local availability of health posts and infrastructure, and the rational use of limited resources. The four programmatic groups were disaggregated by age to take into account recommendations for use of oral contraceptives, surgical sterilization, and IUDs. The segmentation by source of supply was done separately for type of method and rural or urban residence. Marital status, proportion of fertile-aged women, socioeconomic status and other factors were heterogeneously distributed within and between the 13 planning regions. An estimated 7% of women were infertile, 23.9% were at low reproductive risk, 25.6% at medium risk, and 50.5% at high risk because of age, parity, or a history of abortion, neonatal death, prematurity, or cesarean delivery. Among women not wanting more children at high and medium or at low risk, respectively, 66.6% and 65.1% were using a method, but only 30.0% and 32.0% were using an appropriate method. The projected method mix and sources of supply are presented for Lima as an illustration of application of the methodology. The projected method mix for Lima eliminates use of natural methods, withdrawal, and barrier methods for women wanting no more children and use of oral contraceptives for high risk women.^ieng

Wanted: better care for pregnant women.

In three prenatal clinics in Latin America the average attendance time by pregnant women was 129 minutes but the average time spent with a doctor was only 8-10 minutes. In order to improve prenatal care, providers should analyse what happens during visits. Assessments should be made of the usefulness of the services offered and some thought should be given as to who might best provide them.

PIP: An evaluation of 3 prenatal care clinics in Mexico City, Panama City, and Caracas was conducted to examine the effect of long waiting times before appointments on a woman's decision to continue attending clinics. The clinic in Mexico City had more patients per day than did those in Panama City and Caracas (136 vs. 64 and 102). The average daily hours of operation were more or less equal (5 hours, 35 minutes to 6 hours, 31 minutes). There was a wide range in the average waiting time in the clinics (71-190 minutes), but the average time with clinic personnel was about the same (17-21 minutes). The average time patients had with physicians was short (8-10 minutes). Women with high-risk pregnancies were in the clinics for 81-147 minutes, with clinic personnel for 23-25 minutes, and with physicians for 11-15 minutes. The only slightly improved times for high-risk pregnancies suggested inadequate prenatal care. 34% and 47% of the time physicians spent at the clinics in Panama City and Caracas, respectively, consisted of 2-7 minute long interviews. Physical examinations generally lasted on average about 1 minute. They included measurement of uterine height, blood pressure, fetal heart rate, and vaginal and ankle edema examinations. These findings can help clinic staff identify major administrative and management problems and find ways to resolve them. The length of time with clinic personnel and physicians is not conducive to a sympathetic and considerate attitude. Health providers should encourage women to ask questions and express their views. All clinic staff should work to make the clinic atmosphere welcoming. These program managers should use evaluations to analyze what happens during prenatal care visits and to assess the value of the services provided. They can also use evaluations to determine who can best provide prenatal care services.

[Blood pressure complications of pregnancy: through collaborative studies, WHO seeks solutions]. / Les troubles tensionnels de la grossesse: par des etudes collectives, l'OMS cherche des solutions.

PIP: Eclampsia, an obstetrical emergency described in medical texts going back over a century, is characterized by convulsion, loss of consciousness, and high risk of death in the absence of careful medical treatment. Many cases can be prevented if the signs are recognized and treated in time. High blood pressure often giving rise to severe headaches, proteinuria, and edema causing abnormal swelling of the arms, legs, and face are precursors. The possibility of preventing eclampsia led the World Health Organization to undertake a collaborative study of the prevalence, causes, and effects of hypertensive disorders of pregnancy in different parts of the world. The principal investigators of 7 countries who met in Singapore to compare their findings noted strikingly different rates of eclampsia and preeclampsia in the 4 Asian countries represented. Edema was found to be a useful indicator of increased risk where health resources are scarce and the incidence of hypertension and edema are low. A study of maternal mortality in Jamaica around this time found that about 1/3 of deaths from direct obstetrical causes resulted from hypertensive disorders, most often eclampsia. The Jamaican researchers proposed a research project using techniques developed during the collaborative study. Data on more than 10,000 pregnant women allowed detailed study of hypertension, preeclampsia, and eclampsia. Among the women, .72% had had a crisis of eclampsia and 10.4% had hypertension, accompanied by proteinuria in about half the cases. Primigestes, women over 30, and those gaining more than normal amounts of weight during pregnancy were identified as at increased risk. The best indicator of risk was the coexistence of at least 2 out of 3 factors: edema, diastolic pressure of 80 mmHg or over, and proteinuria. The findings caused Jamaica to launch 2 programs, the 1st to screen pregnant women for risk factors for eclampsia and provide special care, and the 2nd to provide small doses of aspirin to half of pregnant women and a placebo to the other half to verify whether small doses of aspirin are an effective means of preventing eclampsia. The World Health Organization is supporting a controlled study of the efficacy of calcium tablets in preventing eclampsia in Peru and is considering a study comparing 2 different regimes for treating eclampsia in Argentina.^ieng

Neonatal tetanus: countdown to 1995.

Progress in the campaign against neonatal tetanus in South and Central America and the Caribbean is reviewed. The main emphasis is on immunizing women of childbearing age who live in high-risk areas, although importance also attaches to routine tetanus toxoid treatment, adequate care during the prenatal period and delivery, and epidemiological surveillance.

PIP: In 1990, the Pan American Health Organization (PAHO) announced its strategy to reduce neonatal tetanus: immunize all 12-44 year old women in high risk areas with the tetanus toxoid. As of mid-1991, health workers in Bolivia, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Peru, and Venezuela systematically reported neonatal tetanus cases. Only Guatemala had not yet began case investigations. Workers in Argentina, Brazil, Haiti, and Paraguay did not report neonatal tetanus cases. In fact, hospital searches were the only means to detect tetanus cases in Haiti. The number of reported cases/year fluctuated between 1300-1500 between 1985-90. PAHO defined a high risk area as an area that has a neonatal tetanus morbidity or mortality rate higher than the national average for the last 3-5 years. PAHO found 50% of all cases occurred in 5% of municipios. El Salvador, however, case occurrence did not differ from 1 region to another, PAHO proposed training traditional midwives how to vaccinate women with the tetanus toxoid and children with other vaccines as has been done in Bolivia's Department of Santa Cruz. They can also report tetanus cases and refer women to health facilities if they cannot vaccinate the women themselves. Before 1990, 78% of recorded neonatal tetanus cases occurred to women with at least 2 other children. This represented at least 2 missed opportunities for vaccination/woman. In 1990, only 17 of the 212 reported tetanus cases in the Americas were born in a hospital. In 1988, the incidence rate for deliveries in hygienic conditions averaged .11/1000 compared with .5 for all deliveries. 90% of mothers who had infants with tetanus in 1990 had not received any tetanus toxoid vaccinations, and only 22% of all mothers had received the 2nd dose. In addition to prenatal and delivery care, PAHO promoted effective epidemiological surveillance systems.

[The drama of maternal, infant and child mortality in Latin America and the Caribbean]. / El drama de la mortalidad materna e infantil en Latinoamerica y el Caribe.

PIP: 99% of the half-million maternal deaths in the world each year occur in developing countries, and many are the result of inopportune or undesired pregnancies. Each month over a million infants an small children also die. In Latin America and the caribbean, women have a risk 50-100 times greater of dying as a result of pregnancy or delivery than women in the US, and their children have a 5 times greater risk of dying before heir 1st birthday. The majority of infant and maternal deaths are preventable. Education and family planning services, which are neither costly nor complicated, could significantly reduce these high mortality rates. A woman's lifetime risk of maternal death is related in great part to her economic and social environment, how many pregnancies she has had, and the availability of maternal health services, It is often difficult for women in developing countries to maintain good health especially if they are poor. They are frequently poorly nourished, and may be required to perform hard physical labor. Pregnancy places greater physical demands on them and may worsen existing health problems. Maternal health risks are substantially increased as well by age under 18 or over 40 years, parity over 4, previous delivery during the last 2 years, and preexisting health problems that could affect pregnancy. Some 75% of maternal deaths are believed to result from obstetrical complications. Hemorrhage, 1 of the most frequent,is more common among older women who have already had 4 or more deliveries. Hemorrhages can be fatal in areas lacking the capability to provide immediate transfusions. Toxemia can lead to convulsions and death if not treated early. Sepsis usually results from complications of an obstructed delivery in very young mothers. Illegal abortion is another major cause of maternal death. In some Latin American ad Caribbean countries, 1/2 of maternal deaths are due to illegal abortions under unhygienic conditions. The same obstetrical risks exist throughout the world but the probability of death is greater in the developing world where access to obstetrical care is deficient. If family planning were easily accessible, women could plan their pregnancies to reduce these risks. Various factors affect the wellbeing of the children. Infants born too soon after another delivery or into families that already have 3 or more children, those born to mothers under 20 or over 40 years old, and those whose mothers die are at significantly increased risk of early death. Compared with other health interventions, family planning is an economical means of improving both maternal and child health, but it is not widely accessible in many developing countries.^ieng

An assessment of contraceptive need in the inner city.

A survey of low-income areas of Los Angeles County indicates that 41 percent of nonsterile women in their childbearing years who had not made a family planning visit in three years were using some means of birth control, 21 percent were not, 25 percent were not sexually active and 13 percent were pregnant or trying to become pregnant. Given that approximately 10 percent of the respondents were using unreliable means of contraception, at least one-third of respondents were in need of effective contraception. This proportion corresponds roughly to the percentage of respondents who expressed a desire to receive family planning care from a doctor or clinic (34 percent). The percentage of women who were at risk of unwanted pregnancy but not using any method of contraception was greatest among those with incomes below poverty level and among black and Hispanic women. A comparison of survey respondents to a parallel sample of low-income women who had made a family planning visit shows that those who utilized formal family planning services were substantially more likely than those who did not to be married (40 percent vs. 32 percent) and to belong to a health maintenance organization (24 percent vs. 14 percent), whereas nonusers of formal family planning services were slightly older, on average (29.6 years vs. 28.0 years), and more likely to have other types of private health insurance (47 percent vs. 25 percent).(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: A survey of low-income areas of Los Angeles County indicates that 41% of nonsterile women in their childbearing years who had not made a family planning (FP) visit in 3 years were using some means of births control, 21% were not, 25% were not sexually active and 13% were pregnant or trying to become pregnant. Given than approximately 10% of the respondents were using unreliable means of contraception, at least 1/3 of respondents were in need of effective contraception. This proportion corresponds to the % of respondents who expressed a desire to receive FP care from a doctor or clinic (34%). The % of women who were at risk of unwanted pregnancy, but not using any method of contraception was greatest among those with incomes below poverty level and among black and hispanic women. A comparison of survey respondents to a parallel sample of low-income women who had made a FP visit shows that those who utilized formal FP services were more likely than those who did not to be married (40% vs. 32%) and to belong to a health maintenance organization (24% bs. 14%), whereas, nonusers of formal FP services were slightly older, on average (29.6 vs. 28 years) and more likely to have other types of private health insurance (47% vs. 25%). In addition, 95% of those who were at risk of unintended pregnancy and who had made a FP visit were practicing contraception compared with 67% of women at risk of unintended pregnancy who had not made a visit. (Author's modified).

Combating AIDS in the Caribbean: a coordinated subregional approach.

PIP: The extent of the HIV epidemic in the Caribbean is described as related to the subregional coordinating project CAREC, or Caribbean epidemiology Center, an agency under Pan American Health Organization, for 19 English speaking countries and Suriname. By July 1990, 1702 AIDS cases had been reported to CAREC, out of 5726 cases in 27 Caribbean countries excluding Puerto Rico. 90% of the cases occurred in the 5 largest, Bahamas, Barbados, Bermuda, Jamaica and Trinidad and Tobago. Initially the transmission pattern was predominantly among male homo- and bisexuals, but not it is mostly heterosexual with a growing mother-to-child transmission. All countries are now screening blood or blood donors. CAREC is coordinating epidemiologic surveillance, helping national laboratories to screen by providing confirmatory tests, providing culture-relevant health education materials and AIDS information, assisting with surveys, holding training workshops for health care workers, and assisting member countries in designing education and counseling programs for high risk women.^ieng

[Contraceptives in high risk reproduction: a health goal still far away. Editorial]. / La anticoncepcion en el alto riesgo reproductivo, una meta de salud todavia lejana.

PIP: High-risk in reproduction is the major health problem in the developing world, responsible for the high incidence of morbidity and mortality rates caused mostly by high fertility rates and the frequency of complications in pregnancy. Therefore, preventing high-risk pregnancies should become the principal objective of all maternal and child health programs worldwide. Unfortunately, both women and physicians continue ignoring symptoms during pregnancy that should be diagnosed as high-risk. A major constraint remains the lack of family planning (FP) services; only 39% (1,500 million) of populations in developing countries as against 65% (800 million) of those in developed countries have access to FP. Added to this problem are people's rejection of FP because of religious, psychological or social pressures, without any information on the dangers of having high-risk pregnancies. The responsibility should be placed on institutions and health practitioners that suspect women who are in high-risk categories and these women should be informed about the risks of future pregnancies.^ieng

[AIDS in the newborn. Case report]. / SIDA en el recien nacido: reporte de un caso.

PIP: This paper presents a case study on the neonatal acquisition of the Acquired Immunodeficiency Syndrome (AIDS) transmitted transplacentally from mother to baby. 3 years before the delivery the mother had received a (contaminated) blood transfusion because of an abortion. The mother of the baby infected her husband. 2 other children in the family, ages 6 and 7, were seronegative confirming that HIV can only be transmitted through sexual contact, blood transfusions and perinatally. HIV can be transmitted perinatally in 3 ways: 1) transplacentally; 2) during delivery and postpartum through breastfeeding. The baby in this study acquired HIV in the uterus and developed symptoms such as those found in AIDS. His clinical symptoms included low birthweight, poor growth, diarrhea, hemorrhages, hyperthermia, hepatosplenomegaly and recurrent infections. There is concern that HIV transmitted perinatally is on the increase in Mexico due to the growing numbers of bisexuals. 68.9% of women in reproductive ages have already been diagnosed with AIDS and have acquired it through bisexual contacts.^ieng

Family planning and development helping women world-wide.

PIP: This article discusses the need for family planning (FP) as part of the development process, applauds its successes and rallies continued momentum of the FP movement. 500,000 women die each year from pregnancy- or labor-related conditions, and 10s of millions of women suffer pregnancy-related illnesses and impairments that undermine their social and economic productivity. Moreover, the 4 major factors that lead to high-risk pregnancies, namely, becoming pregnant before the age of 20, after the age of 35, after 4 or more pregnancies, and 2 years after an earlier pregnancy, all reveal the need for FP. These tragedies could be avoided by assuring better nutrition, primary health care for all, good antenatal attention and proper facilities and help in childbirth, access to good obstetric care in emergency situations, and universally available FP services. FP organizations must empower women with the knowledge of FP and the means to put it into practice. Developing countries, such as China, India, Indonesia, Thailand and Mexico, in addition to affluent industrialized countries have made strides in FP with the help of such organizations as the International Planned Parenthood Federation (IPPF). IPPF has helped to motivate large numbers of men and women to determine their ideal family size. It has provided the means for them to reach such goals and has ensured that acceptance of FP has been on a voluntary basis. IPPF has also advised and cajoled governments into becoming involved in FP. In the future, national strategies must produce the building blocks for better policies to help women become more responsible for their lives. The education of women will be vital to achieving this objective as well as other aspects of development.^ieng

[Causes of perinatal mortality in Pelotas, RS (Brazil). Use of a simplified classification]. / Causas de mortalidade perinatal em Pelotas, RS (Brasil). Utilização de uma classificação simplificada.

PIP: The causes of perinatal mortality among 7392 hospital births which occurred in Pelotas, RS, Brazil during 1982, were analyzed using the simplified classification described by Wigglesworth. The main advantage of this classification is that it can be used even in places where postmortems are seldom performed. The perinatal deaths were classified into 5 groups: a) macerated fetuses without malformations; b) congenital malformations; c) immaturity; d) asphyxia, and e) other causes of death. The perinatal mortality rate was 33.7/1000 births, nearly equally divided between fetal and early neonatal deaths, and 8.8% of the babies were of low birthweight. 36% of the perinatal deaths were antepartum stillbirths, and 60% of these weighed 2000 g or more. The 2nd most important cause was immaturity, which accounted for 31% of the deaths. In this latter group, 21% weighed 2000 g or more at birth. These findings, as well as the high birthweight-specific perinatal mortality rates, strongly suggest that there are deficiencies in the antenatal and delivery care in Pelotas that must be corrected promptly. Policies that should be implemented by health planners include: decentralization of antenatal care clinics; utilization in these clinics of the "at-risk" concept to identify women at high risk of delivering low birthweight babies, efforts to increase community participation and home visits in order to attract those pregnant women who do not attend clinics. In addition, it is mandatory that well-trained doctors (obstetricians and pediatricians) should be available 24 hours/day at the maternity hospitals to assist mothers and babies identified as being at high risk. (author's)^ieng

[Antepartum cardiotocography in high-risk pregnancies and its effect on perinatal morbidity and mortality]. / Cardiotocografía anteparto en embarazos de riesgo elevado y su efecto sobre la morbimortalidad perinatal.

PIP: 2635 prenatal cardiotocographic recordings were correlated with perinatal mortality in 1000 patients. In some cases, there were extenuating circumstances which, when combined with obstetrical intervention, resulted in an increase in mortality. These included congenital malformations, poor maternal conditions for surgery, a hypertensive crisis, and a delay in surgery. The correlated perinatal mortality was 9x1000. (author's modified)^ieng

Prevalence of sexually transmitted diseases in high-risk women in the Republic of Panama.

This study enrolled 1,032 sexually active women attending social hygiene clinics in Panama City; clinic attendance is mandatory for women employed in houses of prostitution, bars, and cabarets. Women were interviewed, and endocervical specimens were obtained for culture of Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus, and cytomegalovirus. Four occupational groups attended the social hygiene clinics: prostitutes, bar girls denying prostitution, cabaret entertainers, and streetwalkers detained by the police. Prevalence of sexually transmitted disease, nationality, race, contraceptive method, and self-medication varied significantly by occupation; 31% of streetwalkers had gonorrhea as did 10% of prostitutes, 5% of bar girls, and 3% of cabaret entertainers. Rates of positive serologic tests for syphilis followed the same trend: 23% in streetwalkers, 7% in prostitutes, and 3% in nonprostitutes. Rates of chlamydial infection were significantly higher in cabaret entertainers (8%) than in any other occupational group (2%). Cytomegalovirus and herpes simplex virus infections were uncommon and were found in 5% and 1% of the women, respectively. Prevalence of N. gonorrhoeae varied with self-medication and years of "professional" experience. Only one of 160 N. gonorrhoeae isolates was resistant to penicillin and also beta-lactamase-positive.

[Family planning needs help to reduce the number of abortions]. / La planificacion familiar necesita ayuda para reducir el numero de abortos.

PIP: M. Peter McPherson, the administrator of the US Agency for International Development, believes that international assistance for family planning programs is necessary to reduce the number of abortions in the world. When couples desire fewer children and family planning services are unavailable, they frequently have recourse to abortion even when the practice is illegal. Data from some countries of Asia and Latin America indicate that 1 of every 3 women have had abortions, many of which would have been avoided if family planning services had been available. An estimated 360,000 abortions have been avoided in Mexico since the governmental family planning program began in 1972. The number of Chilean women seeking treatment for complications of illegal abortion has declined substantially since modern family planning methods became available in 1965. The health and survival of mothers and children is another important reason for supporting family planning. Studies in 26 countries confirm that children born within 2 years of the previous birth have a risk of death twice that of children born 2 or 3 years after the last birth. Mortality among children under 4 would be reduced by 21% if all births were spaced at least 2 years apart. At least 200,000 maternal deaths each year are attributable to too many pregnancies or to pregnancy at too young or old an age. The desire of many Third World families to have fewer children is not merely a product of western speculation, but is confirmed in surveys which demonstrate that couples are unable to limit or space their children because of lack of family planning services. Even though careful study has not yet clarified the exact relationship between population and economic growth, the impact of population growth on the economy is unquestionable. It is rarely argued that rapid population growth contributes to economic development. Family planning would contribute to economic growth by reducing population pressure.^ieng

[Family planning can reduce maternal mortality]. / La planificacion familiar puede reducir la mortalidad materna.

PIP: Although the maternal mortality rate receives no newspaper headlines, the number of mothers dying throughout the world is equivalent to a full jumbo jet crashing every 5 hours. Population surveys carried out between 1981-83 by Family Health International indicated maternal mortality rates of 1.9/1000 live births in Menoufia, Egypt, and 7.2/1000 in Bali, Indonesia. 20-25% of all deaths in women aged 15-49 were directly related to pregnancy and delivery, compared to 1% in western countries where there is better prenatal care, medical assistance in almost all deliveries, and elimination of most high risk pregnancies through voluntary fertility control. Maternal mortality could be controlled by teaching traditional midwives to identify high risk patients at the beginning of their pregnancies and to refer them to appropriate health services. Maternal survival would also be improved if all women were in good health at the beginning of pregnancy. Families should be taught to seek medical care for the mother in cases of prolonged labor; many women arrive at hospitals beyond hope of recovery after hours or days of futile labor. Health policy makers should set new priorities. Sri Lanka, for example, has a lower per capita income than Pakistan, but also a lower maternal mortality rate because of better use of family planning services, more emphasis on prenatal care, and a tradition of care and attention on the part of the public health services.^ieng

[Control of the nutritional status of women in their fertile years as a factor influencing the decline in infant mortality. Province of Havana, 1979-1983]. / Control del estado nutricional de las mujeres en edad fertil como factor influyente en la disminucion de la mortalidad infantil. Provincia La Habana, 1979-1983.

PIP: The impact of the nutritional status of reproductive-age women on infant mortality in Cuba is analyzed for the period 1979-1983. The risk of having low-birth-weight babies is measured using nutritional indexes based on women's height, weight, and age group. Data are from a survey of 69,655 women aged 15-49 in the province of Havana. (SUMMARY IN ENG AND FRE)^ieng

Contraceptive use and fertility in Guatemala.

In 1983, one-quarter of married Guatemalan women aged 15-44 years were using contraception, and female sterilization was the most prevalent method. Fertility rates for the population were at correspondingly high levels, with an overall total fertility rate of about six births per woman. Contraceptive prevalence varied by residence and ethnic group; less than 5 percent of currently married Indian women and about 50 percent of married women in the capital city area were using contraception. From 1978 to 1983, prevalence increased overall by six percentage points, with surgical contraception accounting for most of the increase. Findings of the study suggest that different strategies need to be employed among Ladino and Indian women in order to increase contraceptive prevalence in these subgroups.

PIP: A 1983 survey shows that Guatemala continues to have a relatively low level of contraceptive use by Latin American standards. However, by comparing the results of the 1983 survey with those of a similar survey conducted in 1978, it is clear that contraceptive use has increased slightly. During the 5-year interval between these surveys, the % of married women aged 15-44 years old who were using contraception increased from 19 to 25%. Most of the increase in prevalence was in the use of sterilization, which was found to be the most prevalent method in both surveys. This report describes the results of the 1983 Family Planning and Maternal/Child Health Survey conducted in Guatemala. Also discussed are trends in fertility, breastfeeding, contraceptive use, source of contraception, and women at risk of unplanned pregnancies since the 1978 survey. The 1983 data indicate that mean parity was higher for Indian women than for Ladino women at every age above 20. The mean parity for all women in the 1983 survey is slightly less than that of women in the 1978 survey, but of generally the same magnitude. Overall, the mean duration of breastfeeding estimated from the 1983 survey is 18 months. Postpartum amenorrhea averages about 12 months for all groups. A comparison of duration of breastfeeding for respondents in the 1978 survey with those in the 1983 survey provides no evidence of a trend away from breastfeeding in Guatemala. Overall, 1/4 of married women aged 15-44 were using contraceptive methods at the time of the 1983 survey. The most prevalent method was female sterilization (10%), which, together with male sterilization, accounted for 45% of all contraceptive use. The 2nd most commonly used method, oral contraceptives, had a relatively low prevalence of 5%, followed by rhythm, the IUD, injectables and vaginal methods, and finally, the condom. Contraceptive use also varied by age, reaching a peak among married women 30-39 years old and was lowest for those 15-24. Use of contraception was strongly related to education, being lowest among women with little or formal education. Results in general suggest that contraceptive use is part of a larger predisposition among women to use modern health care. Among Indians, the major reason given for nonuse of contraceptives unrelated to pregnancy was lack of knowledge of contraception or where to obtain family planning services. Among Ladinos, the most frequently mentioned reason was fear of contraception or fear of side effects. The methods of choice for nonusers desiring to use a method were oral contraceptives (27%), sterilization (18%) and injectables (14%). The survey data indicate that the family planning program in Guatemala should be oriented toward high parity, married, nonworking women living in the interior, both Ladino and Indian, who have less than a primary school education. Family planning efforts need to incorporate different approaches for Ladino and Indian women.

Improving obstetric care in northeast Brazil.

PIP: A pilot program was implemented in 1975 in rural areas surrounding the city of Fortaleza in northeastern Brazil to improve maternal and infant health care using previously untrained local personnel and limited resources. The ongoing program has been unusual, in that not only have traditional birth attandants received basic training, but they have overseen deliveries in small maternity centers provided by the local communities involved, instead of overseeing them in the homes of the expectant mothers. The 1st group of attendants received a 3-month practical and theoretical course at the Assis Chateaubriand Teaching Maternity Hospital, 1 of the 2 free maternity hospitals in Fortaleza and part of the medical school of the Federal University of Ceara. Subsequent courses were given at the obstetric unit, because experience with the course at the hospital indicated that a sophisticated medical setting was an inappropriate place for training unskilled personnel. The basic questions addressed by the study reported here are as follows: 1) how do deliveries by traditional birth attendants compare with hospital deliveries in terms of maternal and infant morbidity and mortality, 2) do the attendants recognize high risk patients and make appropriate referrals, 3) what are the factors affecting the decision to refer a patient, and 4) do complication rates suggest additional areas of training for the attendants or additional services that could be provided to improve perinatal and maternal health. Data were obtained on women delivering at 4 obstetric units. The survey found that almost 30% of the women over 39 years of age and 20% of those with 6 or more previous live births were referred. Some 95% of those with prepartum hemorrhage or hypertensive disorders were referred, and all those with reported premature rupture of the membranes were referred. Almost 25% of the women presenting at the obstetric units were designated as being at high risk. 20% of these women were referred to the hospital for delivery. Almost 98% of the women presenting at the obstetric units delivered babies who were alive at discharge. The traditional birth attendant training project achieved its primary goal of making deliveries safer for rural women. It also demonstrated that traditional birth attendants with little or no formal education can be trained to refer high risk women for hospital delivery while conducting safe deliveries in their own communities.^ieng