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NOVEMBER/DECEMBER 1992 - VOLUME 23, NUMBER 6

93.18.11 - English - I.O. ORUBULOYE, Department of Sociology, Faculty of Social Sciences, Ondo State University, Ado-Ekiti (Nigeria), John C. CALDWELL and Pat CALDWELL, Health Transition Centre, Australian National University, Canberra (Australia)

Diffusion and Focus in Sexual Networking: Identifying Partners and Partners' Partners (p. 343-351)

This article describes the second stage of a research project on sexual networking that aims to further understanding of the spread of sexually transmitted diseases and HIV/AIDS in Ondo State, Nigeria. A sample of 488 males aged 15-50 were interviewed in depth to ascertain (1) the numbers and characteristics of their sexual partners, (2) the numbers and characteristics of the partners of those partners, and (3) the extent to which these relationships were commercial. In addition, a census was taken of all commercial sex establishments in order to estimate the numbers of their clients. The results show that male (and female) sexual networking is extensive, that in most nonmarital relationships men do not have accurate knowledge of their partners' partners, and that detailed questioning provides a reasonably accurate picture of the number of these relationships that are commercial in nature. The situation revealed was one of sexual diffusion rather than one with a strong focus on commercial sex workers, which fits the model of a slowly increasing HIV/AIDS epidemic rather than an explosive one. (NIGERIA, AIDS, TRANSMITTED DISEASES, EPIDEMIOLOGY, SEXUAL BEHAVIOUR)

93.18.12 - English - Michael A. KOENIG, The Ford Foundation, 55 Lodi Estate, New Delhi 110 003 (India) et al.

Contraceptive Use in Matlab, Bangladesh in 1990: Levels, Trends, and Explanations (p. 352-364)

The results of a 1990 knowledge, attitudes, and practice survey in Matlab, Bangladesh, indicate that contraceptive prevalence has risen to 57% 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%, 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. (BANGLADESH, CONTRACEPTIVE USAGE, CONTRACEPTIVE PREVALENCE, FAMILY PLANNING PROGRAMMES)

93.18.13 - English - Phyllis T. PIOTROW, Center for Communication Programs, Population Communication Services, The Johns Hopkins University, 527 St. Paul Place, Baltimore, MD 21202 (U.S.A.) et al.

Changing Men's Attitudes and Behavior: The Zimbabwe Male Motivation Project (p. 365-375)

A multimedia communication campaign was conducted between 1988 and 1989 to promote family planning among men in Zimbabwe. The campaign consisted of a 52-episode semi weekly radio soap opera, about 60 motivational talks, and two pamphlets about contraceptive methods. Changes over time were measured by comparing a subset of a follow-up survey conducted from October to December 1989 to a baseline survey conducted from April to June 1988. Men exposed to the campaign were also compared to men who were not exposed. The follow-up survey revealed that the campaign reached 52% of men aged 18 to 55. Among married Shona-speaking men, use of modern contraceptive methods increased from about 56% to 59% during the campaign. Condom use increased from about 5% to 10%. Awareness and current use of modern contraceptives was also higher among men exposed to the campaign, primarily because of their greater awareness of condoms. Men exposed to the campaign were significantly more likely than other men to make the decision to use family planning and to say that both spouses should decide how many children to have. (ZIMBABWE, FAMILY PLANNING PROGRAMMES, CONTRACEPTIVE PREVALENCE, MASS COMMUNICATION, PROPAGANDA)

93.18.14 - English - Saumaya Rama RAO, International Institute for Population Sciences, Govandi Station Road, Bombay 400 088 (India)

Evidence from Peninsular Malaysia of Breastfeeding as a Contraceptive Method (p. 376-385)

This report examines Malaysian women's perceptions of the contraceptive effect of breastfeeding, the determinants of their perceptions, and any effect these perceptions might have on nursing duration and contraceptive use. The report also considers whether women are consciously replacing breastfeeding with modern contraceptive methods. Data from the 1976 Malaysian Family Life Survey are analyzed, and the author concludes that Malaysian women do perceive that breastfeeding has a contraceptive effect, but that this perception is not universal. Ethnicity and desire for a particular family size are the most significant determinants of this perception. Finally, Malaysian women's recognition of the contraceptive effect of nursing does not influence either the duration of their breastfeeding or their adoption of contraception. Malaysian women may not be abandoning breastfeeding to adopt contraception. More probably, breastfeeding declines and contraceptive prevalence increases with modernization. (MALAYSIA, BREAST FEEDING, CONTRACEPTIVE PREVALENCE)

93.18.15 - English - Stan BECKER, Department of Population Dynamics, School of Hygiene and Public Health, The Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205 (U.S.A.), and Doris SOSA, Department of Social-Demographic Research, Asociacion Demografica Costarricense, San Jose (Costa Rica)

An Experiment Using a Month-by-month Calendar in a Family Planning Survey in Costa Rica (p. 386-391)

Recent demographic surveys have incorporated a month-by-month calendar for the five-year reference period before the survey for the recording of fertility-related events (sexual unions, contraceptive use, pregnancies, and breastfeeding). In the 1986 survey of Maternal and Child Health and Family Planning in Costa Rica, approximately one-half of the 3,527 women interviewed were administered a questionnaire with traditional fertility and family planning questions; the other half were asked virtually the same questions, but the women's responses were entered in a month-by-month calendar. The assignment of questionnaire type was randomly alternated by cluster. Comparisons of the number of events (live births, pregnancy losses, and contraceptive use) showed that more events were recorded among the women in the calendar group. Significantly less erroneous superposition of events (contraceptive use in the last trimester of pregnancy and hormonal contraceptive use in the first month postpartum) was noted when the calendar was used. (COSTA RICA, FAMILY PLANNING PROGRAMMES, FERTILITY SURVEYS, RECALL ERRORS, CHRONOLOGY)

JANUARY/FEBRUARY 1993 - VOLUME 24, NUMBER 1

93.18.16 - English - Napaporn HAVANON, Graduate School, Srinakharinwirot University, Bangkok (Thailand), Anthony BENNETT, AIDSCAP, Family Health International, Bangkok (Thailand), and John KNODEL, Department of Sociology, Population Studies Center, University of Michigan, 1225 South University Avenue, Ann Arbor, MI 48104 (U.S.A.)

Sexual Networking in Provincial Thailand (p. 1-17)

Thailand is currently experiencing a major HIV epidemic, spread primarily through heterosexual contact. Patronage of prostitutes is relatively common. In-depth, open-ended interviews were conducted in a Central Thai province with a purposive sample of 181 urban men who had had sexual relations with at least two different women during the prior year. Additional qualitative information is provided by interviews with 50 women. The most common network pattern for men was a combination of commercial and non-commercial sexual relationships. Men reported that they commonly used condoms when they engaged in sex with prostitutes, but condom use was lowest for men who were the most frequent patrons. In non-commercial, non-marital relationships, men screen partners for risk rather than practise safe sex and condom use is generally low. Persons involved in non-commercial sexual networks are largely unaware that their partner may link them to a larger network of sexual contacts and associated risks of HIV infection. Men who have both commercial and non-commercial sexual partners can be found throughout the social strata. A programme that focuses only on the closed commercial sex network will address only partially the real risk situations. (THAILAND, AIDS, SEXUAL BEHAVIOUR, PROSTITUTION)

93.18.17 - English - Lynne P. FREEDMAN, Reproductive Rights Project, and Stephen L. ISAACS, Development Law and Policy Programme, Center for Population and Family Health, Columbia University, 60 Haven Avenue, New York N.Y. 10032 (U.S.A.)

Human Rights and Reproductive Choice (p. 18-30)

A central challenge in developing reproductive health strategies is giving real meaning to the right of couples and individuals to determine, freely and responsibly, the number and spacing of their children. This article places the right of reproductive choice in legal and historical contexts, highlights salient issues that arise in trying to formulate international standards for its enforcement and examines two particularly thorny issues: the tension between demographic priorities and reproductive choice and the tension between international standards and local custom/religion. The article calls on health professionals to participate actively in the elaboration of reproductive rights, both through their immediate work in the health-care field and through involvement in the international policy-making process that will take place in three upcoming international conferences. (HUMAN RIGHTS, FERTILITY, MEDICAL PERSONNEL, INTERNATIONAL LAW)

93.18.18 - English - Orieji CHIMERE-DAN, Department of Sociology, University of the Witwatersrand, Jan Smuts Avenue, Johannesburg 2050 (South Africa)

Population Policy in South Africa (p. 31-39)

This report examines the current state and likely future directions of population policy in South Africa with particular reference to family planning activities set against the background of apartheid and its demise. In the apartheid era, population policy was perceived by most blacks as an instrument for the control of their number and movements. Recently, policy has been adjusted by the national Population Development Programme in response to the changing socio-political situations in the country. A national post-apartheid population policy is likely to retain many of the components of this new programme. However, a future non-racist and democratic society would probably invite a review of population activities in the country and raise wider issues concerning rationales, organization and strategies for the delivery of family planning in South Africa. (SOUTH AFRICA, POPULATION POLICY, FAMILY PLANNING POLICY, APARTHEID, SOCIAL CHANGE)

93.18.19 - English - Hernan VERA, Department of Sociology, University of Florida, Gainesville, FL 32611 (U.S.A.)

The Client's View of High-quality Care in Santiago, Chile (p. 40-49)

The meaning of quality of care for the women who receive reproductive health services at a family planning and maternal and infant care clinic in Santiago, Chile, was examined to describe the clinic's service from the women's point of view. A participatory research project with the staff of the clinic was conducted. The central part of that study, reported here, consisted of interviews with 60 of the 330 women who came to the clinic during two weeks in June 1991. The women defined high quality of care as "being treated like a human being". Among specific elements of care they identified were cleanliness, promptness and availability of service, time made available for consultation, learning opportunities for themselves and their partners and cordial treatment. Clients' view of quality of care must be supplemented by professional judgments about how well services meet clients' needs. But the client's view is determinant if improvements are to result in greater acceptance and sustained use of the services offered. The issues identified by the clients involve only minor costs for the clinic. (CHILE, FAMILY PLANNING CENTRES, CLIENTS, EVALUATION, MATERNAL AND CHILD HEALTH)

93.18.20 - English - Thomas T. KANE, Department of Population Dynamics, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, MD 21205 (U.S.A.), and al.

Sexual Activity, Family Life Education and Contraceptive Practice Among Young Adults in Banjul, The Gambia (p. 50-61)

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% of the young women and 7% of the young men had practised 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. (GAMBIA, YOUTH, KNOWLEDGE OF CONTRACEPTIVES, CONTRACEPTIVE PRACTICE, PREMARITAL SEX BEHAVIOUR, FAMILY LIFE EDUCATION)

MARCH/APRIL 1993 - VOLUME 24, NUMBER 2

93.18.21 - English - Rebecca J. COOK, International Human Rights Programme, Faculty of Law, University of Toronto, Toronto, Ontario M5S 2C5 (Canada)

International Human Rights and Women's Reproductive Health (p. 73-86)

Neglect of women's reproductive health, perpetuated by law, is part of a larger, systematic discrimination against women. Laws obstruct women's access to reproductive health services. Laws protective of women's reproductive health are rarely or inadequately implemented. Moreover, few laws or policies facilitate women's reproductive health services. Epidemiological evidence and feminist legal methods provide insight into the law's neglect of women's reproductive health and expose long-held beliefs in the law's neutrality that harm women fundamentally. Empirical evidence can be used to evaluate how effectively laws are implemented and whether alternative legal approaches exist that would provide greater protection of individual rights. International human rights treaties, including those discussed in this article, are being applied increasingly to expose how laws that obstruct women's access to reproductive health services violate their basic rights. (HUMAN RIGHTS, MATERNAL AND CHILD HEALTH, WOMEN'S STATUS, LEGISLATION)

93.18.22 - English - Karin RINGHEIM, Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1211 Geneva 27 (Switzerland)

Factors that Determine Prevalence of Use of Contraceptive Methods for Men (p. 87-99)

Globally, men have not shared equally with women the responsibility for fertility regulation. While family planning efforts have been directed almost exclusively toward women, the lack of male involvement may also reflect the limited options available to men. Current methods for men are either coitus-dependent, such as the condom or withdrawal, or permanent, such as vasectomy. The 20-year history of social science research on male contraceptive methods is examined here in terms of the human and method factors related to the acceptability of hypothetical methods and the prevalence of use of existing methods. New male methods, particularly if reversible, may alter men's willingness to accept or share responsibility for the control of fertility. Research opportunities in the areas of gender, decision-making, communication, health education and service delivery will be enhanced when methods for women and men are comparable. (CONTRACEPTIVE PRACTICE, MALE CONTRACEPTION)

93.18.23 - English - Peter WEIS, Health Population and Nutrition Division, Deutsche Gesellschaft für Technische Zusammenarbeit, P.O. Box 5180, D-6236 Eschborn (Germany)

The Contraceptive Potential of Breastfeeding in Bangladesh (p. 100-108)

A consensus statement issued by the World Health Organization and the United Nations Children's Fund at the Bellagio Conference in 1988 recommended that women begin practising contraception six months after childbirth or when their menstrual cycle resumes, whichever occurs first. The question to be resolved is whether this approach, known as the Bellagio mixed-t strategy, should be adjusted to local patterns of lactational amennorhea. Data from interviews with 4,580 Bangladeshi women with a currently open birth interval were analyzed with respect to the women's current status of breastfeeding, amenorrhea, contraception and pregnancy. Pregnancies among breastfeeding, amenorrheic women occurred only beyond 12 months postpartum, while some menstruating women were observed to be pregnant from three months postpartum onward. The results of this study give evidence that the Bellagio recommendation can be best applied with country-specific adjustments. Bangladesh, for example, could safely adopt a strategy with a 12-months' cut-off point. (BANGLADESH, FEMALE CONTRACEPTION, BREAST FEEDING, POST-PARTUM AMENORRHOEA, FAMILY PLANNING POLICY)

93.18.24 - English - Kathryn KOST, The Alan Guttmacher Institute, 111 Fifth Avenue, New York N.Y. 10003 (U.S.A.)

The Dynamics of Contraceptive Use in Peru (p. 109-119)

In 1986, the Demographic and Health Surveys project administered the first six-year calendar history of events that included women's contraceptive use and their reasons for discontinuation in experimental surveys in Peru and the Dominican Republic. In this report, the experimental survey from Peru is examined to demonstrate how the calendar data can be used to calculate multiple increment-decrement life table rates of contraceptive discontinuation - including contraceptive failure, method switching and abandonment of use - and of resumption of method use following discontinuation. These analyses reveal that nearly half of all Peruvian women who begin to use a method will stop using it within one year; 29 per cent of women discontinue method use for nonpregnancy-related reasons within one year of initiating use. Women who switch methods do so frequently and many will return to a method used previously, or move on to a third method. Women who become pregnant after abandoning contraceptive use have similar contraceptive-use patterns to women who experience a contraceptive failure. (PERU, LONGITUDINAL ANALYSIS, FEMALE CONTRACEPTION, CONTRACEPTION FAILURES, DROPOUTS)

93.18.25 - English - Dale HUNTINGTON, Barbara MENSCH, and Nahid TOUBIA, The Population Council, One Dag Hammarskjold Plaza, New York, NY 10017 (U.S.A.)

A New Approach to Eliciting Information about Induced Abortion (p. 120-124)

Reliable quantitative data on abortion are sorely needed, particularly in developing countries. Past experience in large-scale survey research has demonstrated that direct questioning on this subject results in significant under-reporting. This article presents results of an experiment to collect data on induced abortion in Côte d'Ivoire within the context of a family planning operations research study. First, questions were employed to broach the topic of unwanted pregnancy in a value-free manner, and then, the potential for a variety of actions, including abortion, was acknowledged. The results indicate that approximately 25% of all women attending a family planning clinic on the day of the survey had had an induced abortion. The use of improved abortion-related questions shows promise for providing more complete measurement of a neglected dimension of women's reproductive health. (COTE D'IVOIRE, INDUCED ABORTION, DATA COLLECTION, METHODOLOGY)

MAY/JUNE 1993 - VOLUME 24, NUMBER 3

93.18.26 - English - Thomas K. LEGRAND, Department of Demography, Université de Montréal, C.P. 6128, succursale A, Montréal, Quebec H3C 3J7 (Canada), and Cheikh S. M. MBACKE, Population Sciences, The Rockefeller Foundation (Kenya)

Teenage Pregnancy and Child Health in the Urban Sahel (p. 137-149)

Longitudinal data for more than 20,000 live births in the cities of Bamako (Mali) and Bobo-Dioulasso (Burkina Faso) are used to study the effects of young maternal age (less than 18 years and 18-19) on birth weight, child health care and feeding behaviour, and child mortality, after controlling for other socio-economic and demographic factors. Teenage pregnancies are associated with significantly worse prenatal health care and vaccination behaviour, lower birth weights, earlier weaning and, especially during the second year of life, higher mortality. A proxy for mother's school enrolment at the time of pregnancy is strongly linked to worse prenatal health behaviour and weakly associated with other poor behaviour and health outcomes. Overall, the results highlight the importance of behavioural factors relative to strictly biological factors for explaining child health differentials. (MALI, BURKINA FASO, ADOLESCENT PREGNANCY, MATERNAL AND CHILD HEALTH, BEHAVIOUR, MORTALITY DETERMINANTS)

93.18.27 - English - France DONNAY, World Health Organization, Centre hospitalier Cesar de Paepe, 11 rue des Alexiens, Brussels 1000 (Belgium) et al.

Safe Abortions in an Illegal Context: Perceptions from Service Providers in Belgium (p. 150-162)

Until April 1990, abortion was illegal in Belgium in all circumstances. However, a small group of health professionals had long provided high-quality abortion services in outpatient facilities and in hospitals. This study is a qualitative analysis of perceptions among providers of safe abortion in Belgium before and after it was made legal there. The providers' personal, psychological and andhical reactions to abortion are investigated, as well as their opinions on how their activities should be organized in order to minimize problems. Standardized questionnaires with closed and open questions were used; 143 questionnaires were completed. Emotional reactions were reported as being the most difficult aspects of practising abortion. The experience of Belgian practitioners is of value for health professionals working in a legally restricted setting who are willing to assume some judicial risks to facilitate legal change while demonstrating the public health utility of low-cost, safe abortion. (BELGIUM, ILLEGAL ABORTION, ATTITUDE, FAMILY PLANNING PERSONNEL, PSYCHOLOGICAL FACTORS)

93.18.28 - English - Alex Chika EZEH, Population Studies Center, University of Pennsylvania, 3718 Locust Walk, Philadelphia, PA 19104 (U.S.A.)

The Influence of Spouses over Each Other's Contraceptive Attitudes in Ghana (p. 163-174)

To what extent do spouses influence each other's reproductive goals? This question was investigated in Ghana with particular reference to family planning attitudes. Two mechanisms were identified as plausible explanations for why an individual's characteristics may affect a partner's beliefs and behaviour. Quantitative evidence from the Ghana Demographic and Health Survey and qualitative information from focus-group research in Ghana were used in the analysis. Results from both data sources show that spousal influence, rather than being mutual or reciprocal, is an exclusive right exercised only by the husband. The study attributed the limited impact of family planning programmes in Ghana and most of sub-Saharan Africa to the continued neglect of men as equal targets of such programmes. (GHANA, FAMILY PLANNING PROGRAMMES, INTERSPOUSE RELATIONSHIPS, PSYCHOLOGICAL FACTORS)

93.18.29 - English - Nabil YOUNIS, Al-Azhar University, Cairo (Egypt) et al.

Community Study of Gynaecological and Related Morbidities in Rural Egypt (p. 175-186)

This study assesses the prevalence of gynaecological and related morbidity conditions in a rural Egyptian community. A medical examination was conducted on a sample of 509 ever-married, nonpregnant women. For gynaecological morbidities, genital prolapse was diagnosed in 56%, reproductive tract infections in 52% and abnormal cervical cell changes in 11% of the women. For related morbidities, anaemia was present in 63% of the women, followed by obesity (43%), hypertension (18%) and urinary tract infection (14%). Regression analysis of risk factors demonstrated the contribution of social conditions and medical factors to these diseases. Reproductive tract infections were shown to occur more frequently with uterovaginal prolapse, IUD use, presence of husband (regular sexual activity) and unhygienic behaviour. Genital prolapse increased with age and number of deliveries. Age, recent pregnancy, education, socio-economic class and workload showed significant associations with related morbidity conditions. This evidence challenges national health programmes to go beyond safe motherhood, child survival and family planning in its services to women and to consider the social context of health as well. (EGYPT, MORBIDITY, GYNAECOLOGIC DISEASES, FAMILY PLANNING PROGRAMMES, SOCIAL CONDITIONS)

93.18.30 - English - Dale HUNTINGTON, The Population Council, Dakar (Senegal), and Sidney Ruth SCHULER, Empowerment of Women Programme, JSI Research and Training Institute, Arlington, VA 22209 (U.S.A.)

The Simulated Client Method: Evaluating Client-Provider Interactions in Family Planning Clinics (p. 187-193)

The "simulated client" method was first detailed in the family planning literature in 1985, but it has not been extensively covered since. As used by the authors to study client-provider interactions in family planning programmes, this method essentially consists of sending women to a family planning service provider to request information and interviewing them after the encounter. The women do not reveal to service providers they are participating in the study. This report describes the method; reviews some of the theoretical, ethical and methodological issues related to it; and underlines its usefulness as a tool for examining quality-of-care issues in family planning programmes. (FAMILY PLANNING PROGRAMMES, EVALUATION, METHODOLOGY)

JULY/AUGUST 1993 - VOLUME 24, NUMBER 4

93.18.31 - English - John M. PAXMAN, Boston University of School of Public Health, Lexington, Mass. (U.S.A.) et al.

The Clandestine Epidemic: The Practice of Unsafe Abortion in Latin America (p. 205-226)

In Latin America, induced abortion is the fourth most commonly used method of fertility regulation. Estimates of the number of induced abortions performed each year in Latin America range from 2.7 to 7.4 million, or from 10 to 27% of all abortions performed in the developing world. Because of restrictive laws, nearly all of these abortions, except for those performed in Barbados, Belize and Cuba, are clandestine and unsafe, and their sequelae are the principal cause of death among women of reproductive age. One of every three to five unsafe abortions leads to hospitalization, resulting in inordinate consumption of scarce and costly health-system resources. Increased contraceptive prevalence and restrictive abortion laws have not decreased clandestine practices. This article addresses how the epidemic of unsafe abortion might be challenged. Recommendations include providing safer outpatient treatment and strengthening family planning programmes to improve women's contraceptive use and their access to information and to safe pregnancy termination procedures. In addition, existing laws and policies governing legal abortion can be applied to their fullest extent, indications for legal abortion can be more broadly interpreted and legal constraints on abortion practices can be officially relaxed. (LATIN AMERICA, INDUCES ABORTION, ILLEGAL ABORTION, ABORTION POLICY)

93.18.32 - English - Andrej A. POPOV, Centre of Demography and Human Ecology, Institute for Employment Studies, Russian Academy of Sciences, Moscow (Russia), Adriaan Ph. VISSER, International Health Foundation, 8, avenue Don Bosco, Brussels (Belgium), and Evert KETTING, Netherlands Institute of Social Sexological Research, Utrecht (Netherlands)

Contraceptive Knowledge, Attitudes and Practice in Russia during the 1980s (p. 227-235)

In the former Soviet Union, there was a lack of valid and reliable social research on knowledge, attitudes and practice of contraception. The few available studies have not been published outside the Soviet Union. This article reviews five surveys that were conducted in Moscow and two other cities (Saratov and Tartu) during the period 1976-84. In addition, some data from a large-scale survey conducted in 1990 and covering the entire former Soviet Union are presented. The surveys indicate that the rhythm method, condoms, vaginal douches and withdrawal were the main contraceptive methods used; only 1 to 3% of the women interviewed were using oral contraceptives and about 10% used intrauterine devices. The low prevalence of use of reliable modern methods may explain the high incidence of induced abortions in Russia. The chronic unavailability of reliable contraceptives is one of the main factors of poor family planning. Lack of knowledge and negative opinions about modern contraception also play an important role. Some possibilities for improving the family planning situation in Russia are discussed. (RUSSIA, KNOWLEDGE OF CONTRACEPTIVES, CONTRACEPTIVE PRACTICE, CONTRACEPTIVE PREVALENCE)

93.18.33 - English - Regina Maria BARBOSA, Maternal and Child Health Division, Institute of Health, Sao Paulo (Brazil), and Margareth ARILHA, Studies and Communication on Sexuality and Human Reproduction, Rua Dos Tupinambas, 239, Sao Paulo (Brazil)

The Brazilian Experience with Cytotec (p. 236-240)

Cytotec, the commercial name for misoprostol, which is a synthetic analogue of prostaglandin E1, was approved for use in Brazil in 1986 to treat gastric and duodenal ulcers. The drug can and has also been used to induce abortion, which has created controversy in a country in which induced abortion is illegal. A study of the drug was undertaken in 1992 that included analyses of the drug's sales profile, of information published by the media, and of its use from women's and gynaecologists' points of view, the latter examined using qualitative methodologies. The analysis of Cytotec's sales volume showed quick growth from its introduction until the first half of 1991, when its use was restricted by the Ministry of Health. For women, Cytotec's main advantages have been that it is relatively inexpensive, convenient to use and can be used in private. Data obtained from gynaecologists show that Cytotec's addition to the obstetric therapeutic arsenal was welcome and also confirmed the drug's influence in reducing the complications of illegal abortions shown in other studies. (BRAZIL, DRUGS, ABORTIFACIENT AGENTS, ILLEGAL ABORTION)

93.18.34 - English - Terence H. HULL, Demography Programme, The Australian National University, Canberra (Australia), Sarsanto W. SARWONO and Ninuk WIDYANTORO

Induced Abortion in Indonesia (p. 241-251)

Induced abortion is one of the most difficult sociomedical problems facing the Indonesian government. While well-known in traditional society, the practice was discouraged by all Indonesian religious groups and forbidden by the Dutch colonial authorities. Although abortion was technically illegal under the criminal code, a judicial interpretation in the early 1970s permitted medical professionals to offer the procedure so long as they were discreet and careful. The numbers of medical abortions carried out in Indonesia rose dramatically and there was evidence of matching declines in the incidence of morbidity and mortality caused by dangerous illegal procedures. Medical and community groups campaigned for a more liberal abortion law to protect legal practitioners and stamp out illegal traditional practices. Their efforts appeared to bear fruit in the draft Health Law, but when the law was passed by the legislature in late 1992, the issue was again clouded by contradictions and inconsistencies. (INDONESIA, INDUCED ABORTION, ILLEGAL ABORTION, ABORTION POLICY)

93.18.35 - English - Pamela LYNAM, Leslie McNeil RABINOVITZ and Mofoluke SHOBOWALE

Using Self-assessment to Improve the Quality of Family Planning Clinic Services (p. 252-260)

A follow-up study was conducted to evaluate the effect of a self-assessment technique called COPE (client-oriented, provider-efficient) on the quality of family planning clinic operations in Africa. In 1991, the Association for Voluntary Surgical Contraception revisited 11 clinics where it had introduced COPE from five to 15 months earlier. Changes that had occurred as a result of the COPE intervention were assessed by (1) determining how many of the clinic problems identified by staff at the COPE introduction had been solved; (2) comparing the results of a second client-flow analysis with the initial analysis; (3) interviewing service providers to obtain their opinions of the effects of COPE. Of the problems identified by staff, nearly three-quarters of those that could be solved internally were solved. The study revealed improvements in the quality of care provided as well as increased staff involvement in solving clinic problems. (AFRICA, FAMILY PLANNING CENTRES, EVALUATION, METHODOLOGY)

JULY/AUGUST 1993 - VOLUME 24, NUMBER 5

93.18.36 - English - Ruth DIXON-MUELLER, International Women's Health Coalition, 24 East 21st Street, new York, NY 10010 (U.S.A.)

The Sexuality Connection in Reproductive Health (p. 269-282)

Sexuality and power relations based on gender are relevant to researchers, policymakers, and service providers in the reproductive health field, because they underlie virtually all of the behaviors and conditions that their programs address. Yet, a review of conventional treatments in the demographic and family planning literature reveals that, when they consider these topics at all, researchers typically adopt narrow definitions of sexual behavior and focus almost exclusively on risks of pregnancy and disease. This article proposes an analytic framework as a guide to researchers and family planning providers. It relates four dimensions of sexuality to reproductive health outcomes and concludes that family planning policies and programs should address a broader spectrum of sexual behaviors and meanings, consider questions of sexual enjoyment as well as risk, and confront ideologies of male entitlement that threaten women's sexual and reproductive rights and health. (SEXUALITY, RESEARCH, FAMILY PLANNING PROGRAMMES, MATERNAL AND CHILD HEALTH)

93.18.37 - English - Regina GÖRGEN, Birga MAIER, and Hans Jochen DIESFELD, Institute of Tropical Hygiene and Public Health, University of Heidelberg, Heidelburg, D-69000 (Germany)

Problems Related to Schoolgirl Pregnancies in Burkina Faso (p. 283-294)

A qualitative study of pregnancy among school girls in a small town in Burkina Faso was conducted that described the situation of pregnant students and their motherhood, their social environment, and the situation of their children. The analysis of findings revealed four main factors that influenced students' pregnancies: lack of contraceptive knowledge, ambiguous feelings about pregnancy and contraception, conflicting messages concerning the reproductive role of young women, and the girls' low self-esteem in their interaction with older, experienced male partners. The study revealed that existing family planning programs fail to address the needs of the sexually active school-age population. Recommendations are made concerning sex education and service delivery. (BURKINA FASO, ADOLESCENT PREGNANCY, SCHOOL AGE, SEXUALITY BEHAVIOUR)

93.18.38 - English - Judith A. McDIVITT, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112-2699 (U.S.A.), Susan ZIMICKI, Robert HORNIK, Center for International Health and Development Communication, Annenberg School for Communication, University of Pennsylvania, Philadelphia (U.S.A.), and Ayman ABULABAN, Noor al Hussein Foundation, Amman (Jordanie)

The lmpact of the Healthcom Mass Media Campaign on Timely Initiation of Breastfeeding in Jordan (p. 295-309)

Initiation of breastfeeding within several hours after a child's birth increases the likelihood of exclusive breastfeeding and longer duration of breastfeeding. However, common beliefs among mothers and health-care providers and routine hospital practices can constrain timely breastfeeding initiation. This article examines the impact of a mass media breastfeeding campaign in Jordan within the context of other activities occurring during and after the child's birth. The campaign had a positive impact on all mothers' knowledge, and on timely initiation of breastfeeding for home and public hospital deliveries, but not for those in private hospitals. The findings indicate that a communication campaign can bring about change in breastfeeding initiation behavior, but that providing mothers with information should be but one part of an integrated program to ensure that hospital and midwife policies and practices support timely initiation. (JORDAN, BREAST FEEDING, MASS COMMUNICATION)

93.18.39 - English - Jagdish C. BHATIA, Health Services Management, Research and Publications, Indian Institute of Management, Bannerghatta Road, Bangalore 560 076 (India)

Levels and Causes of Maternal Mortality in Southern India (p. 310-318)

Most studies of maternal mortality are hospital based. However, in developing countries, where many such deaths take place in the home, hospital statistics do not reflect the true extent of maternal mortality. Furthermore, the socioeconomic and demographic factors and health behavior affecting maternal mortality are rarely known. A study conducted in 1986 in South India demonstrates a new approach to investigating maternal mortality that combines the collection of information from hospital and health-facility records, field surveys, and case-control studies. The findings from this study indicate that there were 7.98 maternal deaths per 1,000 live births. Approximately one-half of the deaths occurred in the home or on the way to the hospital. Maternal deaths accounted for 36% of mortality for women of reproductive age. Analysis reveals that many of these deaths were preventable and that significant differentials existed with regard to demographic, social, and behavioral factors between the cases of maternal deaths and the controls. (INDIA, MATERNAL MORTALITY, METHODOLOGY, MORTALITY DETERMINANTS)

93.18.40 - English - Antonio BUGALHO, Cassimo BIQUE, Luisa ALMEIDA, Department of Obstetrics and Gynecology, Maputo Central Hospital, Mapputo (Mozambique), and Anibal FAUNDES, The Population Council (Brazil)

The Effectiveness of Intravaginal Misoprostol (Cytotec) in Inducing Abortion after Eleven Weeks of Pregnancy (p. 319-323)

At Maputo Central Hospital in Mozambique, intravaginal misoprostol was used by 169 women whose request for interruption of pregnancy had been approved. The drug was used by women who had completed between 12 and 23 weeks of gestation. The initial dose was 800 micrograms, repeated 24 hours later if abortion had not occurred or was not in progress. The treatment was considered a failure when abortion was not advanced by 48 hours after the initial dose, and curettage was performed in all but one of such cases. During the course of the study, the dosage was successively reduced to 600, 400, and 200 micrograms. Abortion was successfully induced in 154 women (91.1%); there were 10 failures (5.9%), and 5 women (3.0%) dropped out of the study. The mean time from initial dose to abortion was 14.3 hours. No significant association of success rate and time from dosage to expulsion was found with age, parity, previous abortion, or gestational age. Preventive vacuum aspiration of the uterine cavity was carried out on all subjects. (MOZAMBIQUE, INDUCED ABORTION, ABORTIFACIENT AGENTS, EVALUATION)

NOVEMBER/DECEMBER 1993 - VOLUME 24, NUMBER 6

93.18.41 - English - James F. PHILLIPS, Research Division, The Population Council, One Dag Hammarskjold Plaza, New York, NY 10017 (U.S.A.), Mian Bazle HOSSAIN, Maternal and Child Health-Family Planning Extension Project, The International Centre for Diarrhoeal Disease Research, Dhaka (Bangladesh), Ruth SIMMONS, Department of Population Planning and International Health, University of Michigan, Ann Arbor, Michigan (U.S.A.), and Michael A. KOENIG, Program Officer, The Ford Foundation, New Delhi (India)

Worker-Client Exchanges and Contraceptive Use in Rural Bangladesh (p. 329-342)

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 bil fostering ideational change. (BANGLADESH, CONTRACEPTIVE USAGE, FAMILY PLANNING PERSONNEL, HOME VISITS)

93.18.42 - - Elisha P. RENNE, Department of Demography, The Australian National University, GPO Box 4, Canberra, ACT 2601 (Australia)

Gender Ideology and Fertility Strategies in an Ekiti Yoruba Village (p. 343-353)

This article investigates the influence of gender ideology on number of children wanted, son preference, family-size discussions and decisionmaking, and use of birth control in a rural Ekiti Yoruba village in southwestern Nigeria. Interview and survey data indicate that attitudes about these matters vary more with age than with sex, suggesting that both women and men subscribe to the prevailing gender ideology of male authority in matters of family size and composition. However, women and men differ about who decides family size, largely because the ideal of fathers'financial support of their children is sometimes belied by practice. The article concludes with a discussion of the strategies that husbands and wives employ to obtain their reproductive goals, and their implications forfamily planning programs in Nigeria. (NIGERIA, SEXISM, CONTRACEPTIVE USAGE, DESIRED FAMILY SIZE)

93.18.43 - English - Carla MAKHLOUF OBERMEYER, Department of Population and International Health, Harvard School of Public Health, 655 Huntington Avenue, Boston, MA 02115 (U.S.A.)

Culture, Maternal Health Care, and Women's Status: A Comparison of Morocco and Tunisia (p. 354-365)

This report assesses the role of demographic, socioeconomic, and cultural factors in explaining differentials in maternal health-care use in North Africa. Analyses of the Demographic and Health Surveys for Morocco and Tunisia show substantial differences in the use of prenatal care and in the proportion of home compared with hospital births, both within and between the two countries. The findings raise the question of whether lower use rates are a reflection of the low status of women. The question is addressed first through a statistical analysis of the differences within the two countries in terms of the demographic, socioeconomic, and educational characteristics of individilals, and second, through a comparison of the social context, health-care systems, and population policies of the two countries. The findings are interpreted in light of field research on the cultural context of maternal health care. (MOROCCO, TUNISIA, MATERNAL AND CHILD HEALTH, PRENATAL CARE, WOMEN'S STATUS)

93.18.44 - English - Amna M. SWAR-ELDAHAB, Geography Department, University of Liverpool, P.O. Box 147, Liverpool L69 3BX (U.K.)

Constraints on Effective Family Planning in Urban Sudan (p. 366-374)

This article is an investigation of the constraints on contraceptive use in Sudan, from the perspective of current non users, never-users, and discontinuers, based on data obtained from 305 married women aged 15-49 through a field survey undertaken in Khartoum city. Results indicate that lack of knowledge of contraceptive methods accounts for the low level of contraceptive prevalence, 15 percent overall, found in this study. The overwhelming majority of iiotiusers (85 percent) either perceive contraception as a risk to their health and fertility, regard it as unacceptable, or do not know which method to choose. A comprehensive and rigorous family planning information program is crucial to address existing constraints on the use of contraceptives in urban Sudan. (SUDAN, CONTRACEPTIVE USAGE, OBSTACLES, INFORMATION DISSEMINATION, URBAN POPULATION)

93.18.45 - English - Federico R. LEON, c/o The Population Council, Paseo Padre Constancio Bollar 225, El Olivar, Lima 27 (Peru), and Agustin CUESTA, Department of Evaluation and Research, Asociacion pro-Bienestar de la Familia Ecuatoriana (Ecuador)

The Need for Quasi-Experimental Methodology to Evaluate Pricing Effects (p. 375-381)

Family planning program managers may be easily misled by conclusions about the effects of price increases on the demand for services when the findings are based on pre-experiments such as the single-group pretest-posttest study, generally believed to be practical. This report presents financial and service data from clinics of the Asociacion Pro-Bienestar de la Familia Ecuatoriana (APROFE) in Ecuador, which, analyzed according to the single-group pretest-posttest design, would suggest that the demand for intrauterine device services is inelastic. However, considerable demand elasticity is detected when data are analyzed according to more rigorous quasi-experimental designs. Using the single-group pretest-posttest design for pricing studies is too flawed to be considered practical. Wherever possible, strong designs should be used in operations research, especially in pricing studies. (ECUADOR, PROGRAMME EVALUATION, FAMILY PLANNING PROGRAMMES, METHODOLOGY)

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