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An estimated 15 million children under 5 die each year, most of them in developing countries. Some 1/2 million women die of causes related to pregnancy, leaving at least 1 million children orphaned. The World Fertility Surveys of the 1970s demonstrated the direct relationship between family planning and maternal-child health. Between 1985-2000, some 2 billion children are expected to be born, 87% of them in developing countries. Some 240 million will die before 5 years. The main causes of death in small children are acute diarrheal disease, respiratory infections, transmissible diseases preventable with vaccination, malaria, malnutrition, and high fertility. 3 aspects of reproduction have significant effects on child survival: spacing, parity, and maternal age. In 1986, approximately 2 million children under 5 died because of risks associated with rapid procreation, and it is estimated that 1/5 of all child deaths could have been prevented with longer birth intervals. Maternal exhaustion and the inability to give adequate care to several small children at once are believed to be the main causes. The problem of abortion or fetal death increases significantly beginning at the 3rd birth, and the proportion of low birth weight babies increases at the 4th birth. The risk of malnutrition increases in large families with limited resources. The safest ages for childbearing are 20-34 years; the worldwide infant mortality rate for mothers under 20 is about 126/1000. Adolescent mothers are at increased risk of problems in the pregnancy and delivery. Family planning can reduce risks related to spacing, family size, and maternal age, and also risk of congenital defects that increase for older mothers. According to the World Health Organization, each year there are some 500,000 maternal deaths, only 6000 of which occur in developed countries. Immediate causes of maternal death in developing countries include hemorrhage, sepsis, eclampsia, dystocic delivery, and induced abortion, but the underlying causes are related to the poor situation of the woman: poverty, illiteracy, lack of adequate prenatal health care, and childbearing at extreme ages. Estimates based on the World Fertility Survey suggest that if all women stating they wanted no more children used contraception, 30% of maternal deaths would be avoided. It is estimated that some 15 million women undergo induced abortions each year, with 100,000-200,000 resulting deaths.
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PMID:[Impact of family planning on maternal-child health]. 1215 88

Nearly 99% of maternal deaths in the world each year occur in developing countries. New efforts have recently been undertaken to combat maternal mortality through research and action. The medical causes of such deaths are coming to be better understood, but the social mechanisms remain poorly grasped. Maternal mortality rates in developing countries are difficult to interpret because they tend to exclude all deaths not occurring in health care facilities. The countries of Europe and North America have an average maternal mortality rate of 30/100,000 live births, representing about 6000 deaths each year. The developing countries of Asia, Africa, and Latin America have rates of 270-640/100,000, representing some 492,000 deaths annually. For a true comparison of the risks of maternal mortality in different countries, the risk itself and the average number of children per woman must both be considered. A Nigerian woman has 375 times greater risk of maternal death than a Swedish woman, but since she has about 4 times more children, her lifetime risk of maternal death is over 1500 times greater than that of the Swedish woman. The principal medical causes of maternal death are known: hemorrhages due to placenta previa or retroplacental hematoma, mechanical dystocias responsible for uterine rupture, toxemia with eclampsia, septicemia, and malaria. The exact weight of abortion in maternal mortality is not known but is probably large. The possible measures for improving such rates are of 3 types: control of fertility to avoid early, late, or closely spaced pregnancies; effective medical surveillance of the pregnancy to reduce the risk of malaria, toxemia, and hemorrhage, and delivery in an obstetrical facility, especially for high-risk pregnancies. Differential access to high quality health care explains much of the difference between mortality rates in urban and rural, wealthy and impoverished areas of the same country. The social determinants of high maternal mortality rates include political, geographic, and economic mechanisms of exclusion which affect the vast majority of the population in developing countries. Political power is concentrated in the hands of relatively small groups whose decisions about such expenditures as health care are usually more favorable to the privileged. A consequence of the very unequal regional development in most Third World countries is that health, educational, and most other resources are concentrated in large cities and perhaps 1 or 2 strategic regions, leaving most of the population underserved. The low social position of women leaves them doubly vulnerable. The social factors adding to risks of maternal mortality should be considered in programs of prevention if the causes and not just the consequences are to be addressed.
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PMID:[Maternal death: unequal risks]. 1228 79

In order to accelerate welfare and nutrition programs for women and children in tribal, hilly, and backward areas of India, the government of India has accepted the National Program of Integrated Services. Delivery of these services is coordinated by the Integrated Child Development Services (ICDS). The package of services for prenatal women include physical and obstetrical exams; serial recording of weight, blood pressure, hemoglobin, and urinalysis; tetanus immunization; iron (60 mg) and folic acid (.5 mg) tablets; food supplements; identification and referral of high-risk mothers; and health education on antenatal care, breast feeding, child rearing, and family planning. Postnatal women received 2 home visits within 10 days of delivery and make 1 visit after 1 month of delivery. These visits cover general health, breast feeding, delivery records, infant health, and birth control measures. Food supplementation continues for nursing mothers. All women 15-44 years of age receive health and nutrition education. Specially organized courses, campaigns, home visits by anganwadi workers, cooking demonstrations, and mass media emphasize simple messages regarding health and nutrition. Areas that are covered include family welfare; antenatal, intranatal, and postnatal care; breast feeding; immunization; prevention of such common communicable diseases as malaria, tuberculosis, and leprosy; weaning and supplementary feeding; improvement of children's nutritional status; balanced diet; food storage, preparation, cooking, and serving; eye and ear care; personal and environmental hygiene; sanitation; management of acute respiratory infections; management of diarrhea; and control and treatment of internal parasites. The mobile food and extension units of the Department of Food are utilized. Pregnant and nursing mothers belonging to families of landless agricultural laborers, of marginal farmers, of the scheduled caste, of the scheduled tribe, and of poorer sections of the community are chosen for this program. Special care is given to pregnant women who: are pregnant for the 1st, 3rd, or 4th time; have gained less than 6 kg; are younger than 18 or older than 35; have had frequent or twin pregnancies; have a history of miscarriage or preterm delivery; are anemic; or have a history of edema, hypertension, or seizure. Personnel, who are monitored, receive training supplemented by reorientation and continuing education.
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PMID:Health and development of mothers through system of ICDS. 1228 36

The Lady Dufferin Fund, founded in 1885 in India, had by 1940 established 400 hospitals to alleviate diseases and mortality related to childbirth. After independence 2328 community health centers and 21254 primary health centers were created in the country. During 1974-94 more than 131,000 subcenters were set up and about 620,000 auxiliary nurse midwives (ANMs) had been trained. The Ministry of Health introduced four health prevention schemes in 1969: 1) immunization of children against diphtheria, pertussis, and tetanus; 2) immunization of pregnant women against tetanus; 3) prophylaxis of mothers and children against nutritional anemia; and 4) prophylaxis of children against blindness caused by vitamin A deficiency. As a result, infant mortality declined from 146/1000 live births to 74/1000 in 1993; but maternal mortality still stayed around 4-5/1000. In 1993 an estimated 117,356 maternal deaths occurred out of a total of 26,057,000 births, equalling 4.5 deaths per 1000 live births. The main causes of maternal deaths are hemorrhage, anemia, abortion, toxemia, and puerperal sepsis. Only about 411 first referral units in community health centers are functioning properly. Prenatal care of mothers includes the administration of tetanus toxoid and iron-folic acid tablets. However, the prenatal coverage reached only about 50% of mothers; and the coverage was only 21.4% in Bihar, 23.8% in Nagaland, 29.3% in Rajasthan, and 29.6% in Uttar Pradesh. In these areas administrative inefficiency is widespread with nonavailability of essential drugs for malaria, infections, sepsis, dysentery, and colds. During 1992-93 the rate of hospital deliveries ranged from 6.1% in Nagaland to 88.4% in Kerala, with a national average of only 25.6%. 71% of deliveries in rural areas and 30% in urban areas were conducted by untrained assistants. Although there are 450 ANM training schools in the country, the level of training has deteriorated. The major causes of infant deaths are respiratory infections and diarrhea, responsible for 13.5% and 6.9% of mortality, respectively. Severe malnutrition and inadequate vaccination are other major causes of child deaths and morbidity.
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PMID:Maternal and child health in India: a critical review. 1229 Sep 61

The main causes of death in rural areas of the Faritany of Toamasina during 1986 are identified and classified by order of importance for the entire population as well as for vulnerable groups such as preschool children and reproductive-aged women. The 10 leading causes of death of infants and children under age 5 years are coughs and fevers, as well as thoracic pains; vomiting and diarrhea; age factors; high, intermittent fevers and chills; protein-calorie malnutrition; convulsions; other high fevers; cough of long duration; sudden death; and measles. Leading causes of death for women aged 15-49 years include coughs and fevers, as well as thoracic pains; high, intermittent fevers and chills; vomiting and diarrhea; other high fevers; delivery complications; cough of long duration; malnutrition; abortion or miscarriage; sudden death; and postpartum illnesses. Over 60% of deaths reported for children aged 0-5 years could have been prevented through a broader vaccination program, oral rehydration therapy, nutrition education and growth monitoring, and the preventive treatment of malaria. Priority focus should be given to respiratory infections.
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PMID:[Causes of mortality in a rural area in the Faritany of Toamasina in 1986]. 1229 43

A new project supported by the Pathfinder Fund to serve migrant farm workers has been developed in Adana Province, a populous region in southern Turkey. The economy their is primarily agricultural, with some heavy industry. As estimated 100,000 migrant workers are needed to planting and harvesting in this region. They make between $55-$60 a month, which is about 1/3 of the minimum age. Most migrant workers travel long distances to Adana where they live in tents. Living conditions are poor, with no running water or toilets. Malaria, gastroenteritis and intestinal parasites are endemic. Unofficial figures show that over 75% of school children have intestinal parasites. UNICEF has helped with vaccinations, maternal and health care, and powdered milk distribution. Most Turkish workers are covered by social security laws that provide health care for them. Almost non of the migrant workers are covered by social security. Surveys show that 80% of migrant workers desire 4 or more children, usually due to economic conditions, (i.e. labor for increased family income). The rates of miscarriage, morbidity and mortality are very high in August and September because pregnant women try to work until the very last day of the term. The pilot program in Adana increased the number of health centers per workers, as well as offering extended evening hours. Health clinic trailers were rotated as needed within the region. The program provided general health care, vaccinations, pre natal and post natal maternity care and a sharp focus on family planning. The year long pilot program was considered wildly successful. This was attributed, in large part, to the extended evening hours of the clinics as well as mobility of the trailers. Also, finances provided by the Fund were also crucial for implementation.
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PMID:Family planning for seasonal migrant workers in Adana Province, Turkey. 1231 53

A new female sterilization method, the insertion of quinacrine hydrochloride pellets into the uterus, has created controversy, because of the potential for coercive use. Supporters of quinacrine believe that its ease of insertion and effectiveness make its use ideal for protecting women from unwanted pregnancy. The UN reports that 23% of reproductive age women worldwide have chosen sterilization. Quinacrine was developed during the 1970s by a Chilean gynecologist. Jaime Zipper first used quinacrine as a sterilizing agent in the 1970s in liquid form. The drug was used originally for malaria treatment. Quinacrine is attractive due to its low cost (a dollar for two insertions), the ease of insertion, and the few side effects (minor cramping and fever). The methods appears to be 95-97% effective. Field trials are being conducted in 11 countries. Current clinical trials, undertaken by the Vietnamese Ministry of Health and published in Lancet, reveal that only 818 pregnancies occurred among 32,000 women using quinacrine. No deaths and only eight serious complications occurred compared to 30 deaths and 1800 serious complications from surgical sterilization. Opponents contend that the research methodology is questionable, because there was insufficient follow-up. Results are based on subsets and extrapolation to the entire study population. Critics desire more research on the potential for coercive use. The president of the Boston Women's Book Collective considers that more retrospective research is needed before confirmation of its safety. Another perspective is that the relative risk of having a baby in a rural developing country is much higher than the quinacrine risk. This position is argued by Marie Stopes International. The president of the Center for Research on Population and Security (Dr. Mumford) agrees that many people are being denied a life-saving method, and the process of review, because of the controversy, does nothing for the many women dying each year in childbirth or due to unsafe abortion.
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PMID:Risks and rewards: family planners weigh quinacrine. 1231 52

Population control among the Yanomamo tribe of the Amazonian tropical rainforest is studied. 25% of male deaths are due to warfare. A male-female balance is achieved by the practice of infantcide, especially among female infants. The male:female ratio among the under-15 age group is 135:100, belying the tribe's contention that neither sex is more likely to be killed than the other. The major population controlffactor, however, is disease with about 54.2% of adult deaths due to malaria, and other communicable disease accounting for 11.7%. Other population controls are abortion and postnatal sex taboos, although the latter is for the most part overruled by the practice of infanticide for any child born while a previous child is still nursing. The intense intervillage warfare is increased by the shortage of women, resulting from female infanticide combined with polygamy and marriage alliances in which even unborn females are promised. Because there is war, male children are preferred and the cycle continues. Other observers, however, feel that the constant warfare is part of the need for new garden sites brought about by reliance on slash and burn agriculture. The author believes the shortage of women is just a side effect of population control occasioned by a protein shortage.
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PMID:Yanomamo ecology, population control, and their relationship to slash and burn agriculture. 1233 55

The government of the National Resistance Movement of Uganda has consistently supported the socioeconomic and political development of women. Thus, women participate in politics right from the village committees to the National Resistance Council. Women are saluted for initiating community efforts through the Safe Motherhood programme. In Uganda, life expectancy is estimated at 53 years, the crude death rate at 20 deaths per 1000 people, the infant mortality rate at 110 deaths per 1000, and the under-five child mortality rate at 180/1000 live births. During the 1960s, malaria had been brought under control, and the majority of the population had access to good quality medical care. The political turmoil and economic decline of the 1970s and early 1980s grossly affected health delivery. Government health expenditure declined from 5.3% of the budget in 1972 to 4.3% in 1983. In the rehabilitation strategy, the share of the health sector rose to 8% of the FY 1992/93 budget. The Ministry of Health facilities can cover only 30% of the population. 50% of the annual deaths are caused by preventable diseases: malaria causes 15% of the deaths and diarrhea another 8.7%. High fertility rates, coupled with inadequate maternal and child health care, are responsible for a large part of female morbidity and mortality. The maternal mortality rate is estimated at 500 per 100,000 live births, mainly resulting from hemorrhage, infections, obstructed labor, and abortion. Only 26% of the women deliver in health institutions, 23% use traditional birth attendants, and 51% give birth at home. 18.4% of children under 5 years are moderately malnourished. Health workers should educate expecting and nursing mothers on child and maternal nutrition. In rural areas about 20% and in urban areas about 50% have access to safe water. To provide clean and safe water needs the co-operation of communities and non-governmental organizations. Women are involved in developmental activities through non-governmental organizations and various women's groups such as the National Association of Women's Organizations of Uganda.
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PMID:International Women's Day address. 1234 1

Malaria is a major cause of maternal and fetal morbidity and mortality, and this risk is highest in the areas of unstable malaria transmission. In 1990 and 1991 the Department of Obstetrics and Gynecology of Sir Sayajirao General Hospital in central Gujarat, India, has cared for a total of 445 urban as well as rural patients with malaria in pregnancy: 232 were labor ward admissions and 213 were antenatal ward admissions. Plasmodium falciparum infection affected 97.27% of patients, both primigravidae and multigravidae. Heavy parasitemia was observed in 27.14% of primigravidae and 48.57% in secundigravidae, however, this was not statistically significant. Out of the 260 (58.42.) cases who had various degrees of anaemia, 59 (22.69) had severe anaemia with haemoglobin of less than 6.0 gm O/dl. Within this group, 71.16% women were primigravidae or secundigravidae, the rest were multigravidae. Out of the 6 patients in first trimester, the miscarriage rate was 100%. In the second trimester, out of 52 patients 74.99 pregnancies were discontinued, whereas in the third trimester, the miscarriage rate was 18.17%. This observation was statistically significant (p 0.05). 178 patients who were admitted antenatally were discharged, their pregnancy outcome was not known, and accordingly they were excluded. There were 11 patients in the first trimester, 139 in the second trimester, and 295 in the third trimester. The known pregnancy losses were 54.54% in the first trimester. 28.05% in the second trimester, and 12.88% in the third trimester. 75.59% of those with minor parasitemia and 47.36% with heavy parasitemia had a normal pregnancy outcome. The overall fetal loss was 31.08%, which was almost twice that of the miscarriage rates among the general population. Maternal deaths attributed to malaria in pregnancy were 15, with cerebral malaria accounting for 5 deaths. 46.66% of the deaths occurred in primigravidae and secundigravidae. The other causes of mortality were postpartum hemorrhage, acute pulmonary edema, and hypoglycemia.
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PMID:Maternal manifestations of malaria in pregnancy: a review. 1234 25


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