The articles in this volume address public health interventions and their impact on morbidity and mortality trends in developing countries. The authors attempt to identify "low-cost effective and simple measures both for the identification of groups most in need and for the continuous monitoring of changes in health status particularly where major health interventions have begun." Papers are included on health investment maternal mortality community-based interventions evaluation of health programs and reduction of neonatal mortality. (EXCERPT)
Summary Dynamic models of contraceptive use fill a theoretical gap. They bring behavioural content to the mathematically elegant Markov models of family building. They meet the criterion that Bulatao (1989) advances that method use, discontinuation and switching be considered not in isolation, but with reference to individual reproductive goals. Dynamic models help to link the literature on method choice with the literature on method effectiveness. These theoretical advantages are, at present, counter-balanced by empirical limitations. This article explores the theoretical and empirical underpinnings of dynamic contraceptive choice models.
Recent economic crises have severely affected national and international efforts to reduce the high morbidity and mortality in developing countries. The repercussions of these crises are manifest in declining living standards, increasing poverty, malnutrition, ill health and death. Depressed commodity prices, the oil crisis of the late 1970s, and the ensuing balance of payment problems have weakened most governments' efforts to halt and eventually reverse the economic decline. In sub-Saharan Africa the effects of these crises have combined with an ever-increasing population to render ineffective the limited investments in health care.
Newborn infants are among those which generate the highest health care costs. For instance, the cost of hospital care until discharge was assessed at US $ 14,200 (Boyle et al. , 1983) for babies weighing 1000–1499g at birth. The average hospital stay for a baby weighing less than 1500g at birth in 1981 was 100 days at an average daily cost of US$ 898 (Stahlman, 1984). Achievements in neonatal survival, especially of extremely low birth weight babies, have necessitated frequent revision of the definition of viability. However, modern neonatal intensive care cannot be regarded as appropriate for developing countries as it cannot be made accessible to all at an affordable cost.
When assessing the effects of a programme one must first consider its objectives. When applied to the improvement of health, the word programme implies an intervention which is sustained, complex, dealing with more than a single aspect of one disease and usually going beyond simple provision of fixed curative facilities. How a programme is assessed will vary with the different components and the underlying purpose of the assessment. It is important to ask just what information is needed and whether or not it needs to be collected on a longitudinal basis.
The primary health care programme in Ghana has two objectives: (1) to achieve basic primary health care for 80% of the population of the country by 1990; (2) to attack the disease problems that contribute to 80% of the unnecessary deaths and disability afflicting Ghanaians, also by 1990.
The Gambia provides an unusual opportunity for the application of cost analysis to health due to a relatively long history of immunization and recent empirical research. The results should apply not only to immunization programmes but also to a variety of types of primary health care in developing countries. In particular, well-based estimates of the cost per case averted and the cost per death prevented by alternative health interventions should prove to be of widespread interest and usefulness.
A major Egyptian national programme for the control of diarrhoeal disease was launched in February 1984, with the aim of reducing the dehydration-specific mortality resulting from acute diarrhoea (52% of all infant deaths in 1979) and thus to reduce overall infant and childhood mortality.
Measuring the mortality impact of health interventions is not straightforward; there is now ample evidence of this. So why bother? Clearly, the utility, sensibility and feasibility of measuring the mortality impact of health interventions depend on many factors, which makes it difficult to offer simple prescriptions. The failure of those demanding measurement to appreciate this has led, on the one hand, to the proliferation of largely unsubstantiated claims on the achievements of health interventions and, on the other hand, to disillusionment about the prospects of demonstrating any impact on mortality. It is not difficult to account for the complexity of this area nor the current state of uncertainty. Progress has largely reflected developments in its three components—mortality measurement, health research and programme evaluation. It is thus not surprising to find the almost exclusive emphasis on measuring impact on infant and child mortality; in developing countries, child health is given a high priority in the allocation of resources by governments and donor agencies, and the techniques for estimating child mortality are generally more advanced.
The randomized controlled trial has become the standard basis for the evaluation of new therapeutic agents and procedures (and for measuring the protective efficacy of new vaccines or for assessing the value of screening procedures). Patients, who have met the criteria for eligibility and have agreed to participate in the trial, are allocated on a random basis to the alternative therapies under consideration. In order to avoid possible bias in the handling or assessment of these groups, a double blind procedure is preferred; the therapy given is not known to those who administer it, to those who assess the course of the disease thereafter, nor to the patients themselves. There is an extensive literature on clinical trials covering their logic and history, modern developments and the many complex, often controversial, issues that such trials have provoked. Not all issues have been fully resolved but by and large the principle, the practice and the ethical concerns of clinical trials are worked out and firmly established.
About two-thirds of the world's population live in areas where registration of vital statistics is unsatisfactory (Tietze, 1977), and in many countries such statistics from rural areas are unavailable or grossly underestimated (WHO, 1971). Most of the women who die in pregnancy and childbirth are poor and live in remote areas or city slums. Their deaths are accorded little importance and fail to enter registers.
Shortly after the first reports on the acquired immunodeficiency syndrome (AIDS) in the United States, it became clear that the disease was also particularly frequent in Haitians living in North America (Pitcheniket at., 1983; Curranet al., 1985) and in Africans seen in Europe for medical care (Katlamaet al., 1984; Clumecket al., 1984). Subsequently, surveys in Haiti and in Central Africa confirmed the occurrence of epidemic foci of AIDS in these areas (Papeet al., 1983; Malebrancheet al., 1983; Piotet al., 1984; Van de Perreet al., 1984).
There is nothing new about the belief that the spread of education with its influence on knowledge and outlook is a central force behind the demographic transition. In 1934 Penrose wrote: ‘when a community has gained the knowledge and acquired the habits necessary to reduce the death rate it will sooner or later gain the knowledge and acquire the habits necessary to reduce the birth rate. There may be time lag between the two processes, but both of them in a large share are the outcome of education’ (Penrose, 1934). It is thus surprising that investigation of the specific influence of parental education on the mortality of children in developing countries was neglected until Caldwell's (1979) analysis of survey data from Ibadan, Nigeria, which demonstrated that mother's education was a more decisive determinant of child survival than other family characteristics such as husband's occupation and education. Other studies followed this influential investigation. The greater contribution to mortality decline of educational advance compared to health care provision, it has been argued, is a contribution to the development versus medical technology debate (Mosley, 1985). Inevitably the beginnings of a counter-reaction may be discerned. Caldwell (1986) stressed that the influence of education should not be considered in isolation from the wider context, while Cooksey et al. (1986, unpublished) consider that the effect of maternal education may have been exaggerated.
Summary Contraceptive prevalence rates and estimates of continuation rates are derived from unique longitudinal data on post-partum behaviour collected in the Cebu region of the Philippines. Continuation rates vary by base-line and time-varying socioeconomic characteristics for certain contraceptive methods and for using no contraception. Calendar rhythm users have a much lower relative continuation rate than has been found in cross-sectional samples. For women who use a contraceptive method, breast-feeding does not appear to influence contraceptive continuation, but for those who use no methods, breast-feeding appears to substitute for other forms of contraception. Profiles by socioeconomic characteristics of those who continue to use each type of contraceptive method and who use no method could be used to direct family planning programmes towards population sub-groups. The results suggest that for women wishing to postpone a pregnancy, a family planning programme aimed at the young and less educated could effectively increase contraceptive use and continuation.
SummarySeveral new concepts are used to describe contraceptive use histories for nearly 1200 women in Peninsular Malaysia. These histories are summarized by 81 episode histories. Transition matrices provide useful summaries of the changes women make in their contraceptive practice from one pregnancy interval to the next. Data from the mid-1940s to mid-1970s, during which period there was a dramatic increase in contraceptive use, reveal considerable inertia in individual couples' contraceptive practice. Persistence with a method was greater the less effective the method: while 86% of couples using no method in one interval used no method in the next, only 56% of couples using the pill in one interval also used it in the next. Virtually all transitions are of three types: continuation with the same method, a change from no method to some method, or a change from some method to no method. For only 1% of all pregnancies did couples use one contraceptive method before a pregnancy and a different method after the pregnancy. Differences are examined by calendar year and education.
Summary Contraceptive use and method mix were analysed using Philippines national survey data of 1973, 1978, and 1983. The analyses suggest that the reported decline in contraceptive prevalence between 1978 and 1983 was due to under-reporting of use in 1973 and 1983. The shifts in contraceptive method mix were also partly from under-reporting of rhythm and other methods in 1973 and 1983. Nevertheless, the determinants of method choice were similar in all three sets of data. Filipino couples were making rational choices in terms of their contraceptive goals, access, evaluation, and competence. Modifications in the directions and magnitude of the relationships in determining method choice also occurred, partly reflecting the increased use of sterilization by older, higher parity women.
For nearly three decades men and women have increasingly gained the opportunity to control their childbearing with modern contraceptive technologies. In the early 1960s when oral hormonal contraceptives and intrauterine devices first became publicly available in the United States and Europe, the total fertility rate (TFR) in industrialized countries was about 2·7 implying that two-thirds of childbearing couples, some 87 million, were practising contraception. By comparison, in the developing areas, the TFR was 6·1 and only 18% (60 million couples) were contraceptive users. Thirty years later, estimating for 1990, the number of eligible couples practising contraception in the more developed countries (MDCs) is expected to have increased by half, while in the less developed countries (LDCs) the increase is likely to be six times, suggesting as many as 344 million users. Another way to demonstrate the significance of this trend is with a different statistic—that the level of contraceptive use in LDCs in 1990 will exceed half of all couples of childbearing age and be only ten percentage points below the MDC level of 25–30 years ago.
Summary The determinants of contraceptive method choice in Sri Lanka are examined during a period in which contraceptive prevalence increased by over 60% and involved substantial use of sterilization and traditional methods. Data are from the 1975 World Fertility and 1982 Contraceptive Prevalence Surveys. Polytomous logistic regression is used to model four current contraceptive choices: non-use, use of a traditional method, use of a modern temporary method and use of sterilization. The analysis shows, in 1975 and 1982, strong socioeconomic as well as demographic effects on whether any method is used. However, in both years the type of method chosen is primarily a function of demographic considerations related to the couple's family-building stage rather than social status, implying that in Sri Lanka there are few socioeconomic barriers limiting access to different contraceptive methods. The family planning programme, however, has emphasized sterilization rather than birth spacing methods.
Summary This study examines contraceptive method switching among married women in the US. It enquires first into the effect of method type and women's socioeconomic characteristics on the risk of switching to each of six methods, including no method, and secondly into the previous methods used by women who adopt specific contraceptive means. The results indicate a great deal of circulation among all method types and of movement to unprotected intercourse. The adoption of sterilization is greatest among women not previously using any contraceptive method.
Summary Patterns of contraceptive method change and their association with reproductive motivation and contraceptive failure are examined using data from a 1986 survey of family planning behaviour of rural Sinhalese married women aged 15–44 in seventeen districts of Sri Lanka. A notable degree of rationality in contraceptive method changes occurs with family formation. The attempt to control unwanted fertility leads to more efficacious use of contraception, including traditional methods. Some methodological improvements to the analysis of contraceptive switching are indicated. Implications of the findings for programmatic emphasis on permanent versus non-permanent modern methods are discussed.
