PN-ABJ- 'I51 The Health Technologies TABLE OF CONTENTS THE HEALTH PROBLEM: WHY CHILDREN DIE...........................l .......................................8 IMMUNIZATION...................................................22 NUTRITION RELATED TECHNOLOGIES .................................29 BIRTH SPACING. .................................................44 DIARRHEAL DISEASE CONTROL HEALTHCOM i s designed t o a s s i s t developing c o u n t r i e s use communications more e f f e c t i v e l y i n support o f n a t i o n a l c h i l d s u r v i v a l programs. T h i s document has been prepared f o r HEALTHCOM p l a n n i n g and assistance teams by HEALTHCOM s t a f f and s e n i o r consultants as a guide to each of the major child survival technologies: D i a r r h e a l disease c o n t r o l Imnunization N u t r i t i o n r e l a t e d technologies B i r t h spacing THE HEALTH PROBLEM: WHY CHILDREN D I E * *This M.P.H., paper was reviewed f o r t e c h n i c a l c o n t e n t by Robert E. Black, The John Hopkins U n i v e r s i t y School o f Hygiene and Pub1 i c H e a l t h M.D., Health cpnditions vary greatly from country to country and kithin most countries, but throughout the developing world they are substantially inferior to those in affluent countries. It is estimated that one-tenth of the life of the average person in a developing country is seriously disrupted by i l l health. The major killers of small children are gastrointestinal and respiratory infections, measles, and malnutrition--conditions for which inexpensive, effective prevention or treatment is technically possible. Most countries now have publicly financed systems of health care and programs of investment in sanitation, water supply, and health education. Government health care facilities generally reach to the district or, in a few countries, even to the village level. Fragmentary evidence suggests that in total as much as six percent to ten percent of gross domestic product (GDP) is spent by the public sector and by private individuals on health care. Despite the large expenditures on health and the technical feasibility of addressing many of the most common health problems, efforts to improve health have had a modest impact on the health of the vast majority of the population in most developing countries. Health care systems in developing countries have often been patterned after those found in industrialized countries. As such, they have focused on the institutional care of sick people, often in highly sophisticated hospitals. At the same time, physicians in developing countries have been supported by fewer auxiliary health workers--nurses, technicians, clerks, administrators, and so forth--than is customary in industrialized countries. Instead of a health manpower pyramid in which a few physicians are supported by a much larger number of nurses and auxiliary workers, most developing countries have a manpower hourglass with doctors at the top, indigenous practitioners at the bottom, and few people in between. Though no't present in all developing countries, the following problems are frequently encountered: o o o o o o o o Health facilities are geographically inaccessible. Economic barriers exclude many people. Curative care is emphasized over prevention. Hospital facilities are excessive. Education of physicians neglects common local health problems. Health workers are not sufficiently trained, supported, or supervised. The availability of services is erratic. The services provided are not perceived as being efficacious by their intended beneficiaries. 1. Sections selectively excerpted from World Bank Health Sector Pol icy Paper, 1980. For the developing countries as a group, life expectancy at birth is approximately 53 years. Life expectancy at birth in Africa is now about 47 years; in S w t h Asia it is approximately 49 years; and in Latin America, approximately 61 years. In contrast, life expectancy in the developed regions is approximately 70 years. The low life expectancy in developing countries can largely be attributed to very high death rates among children. In the poorest regions of low-income countries, half of all children die during the first year of life; in Africa as a whole, the infant mortality rate is more than 100 deaths per thousand births compared with 15 per thousand in developed countries. Assessment of the health situation requires knowledge not only of death rates and life expectancy rates for all age groups but also of the distribution, by cause, of mortality and morbidity. Reliable information on patterns of disease is unavailable on a countrywide basis for most nations. Many problems arise in analyzing such data: underreporting is more common for some diseases than for others; multiple causation leads to misreporting; and many deaths are registered without identification of causes (in Thailand, for example, such deaths account for 59 percent of the total reported, and in Iraq the proportion is 44 percent). The following table from UNICEF's Assignment Children shows the variation of primary causes of infant mortality and possible reductions due to critical interventions. A. - Causes of Mortality/Morbidity in Infants Fecal-oral Diseases The most widespread diseases in developing countries are those transmitted by human feces--the intestinal parasitic and infectious diarrheal diseases--but also poliomyelitis and typhoid fever. These diseases spread easily in areas without community water supply systems. The category "all forms of dysentery'' was the most frequently noted communicable disease in ~akistan.' In Egypt, Iran, and Venezuela, the monthly incidence of diarrhea among children p f preschool age has been estimated to be between 40 percent and 50 p e r c e n t . Airborne Diseases The second major group consists of airborne diseases. The group includes tuberculosis, pneumonia, diphtheria, bronchitis, whooping cough, meningitis, influenza, measles, smallpox, and chicken pox. These diseases are spread by inhaling the airborne respiratory secretions of infected persons. A study of deaths among children five years of age in selected areas of Latin America and the Caribbean reveals that more than 70 percent of the deaths beyond the 2. World Health Organization. The Fifth Report on the World Health Situation, 1969-1972--Part I I ; Review by Country and Territory (Geneva: WHO, 1974). 3. Van Zijl, W.J. "Studies in Diarrheal Diseases in Seven Countries," Bulletin of the World Health Orqanization 35 (Geneva: WHO, 1966), pp. 249-261. 3 f B POTENTIAL REDUCTION IN INFANT NiD CUILD DEATllS WITH P R O V W DISEASE CONTROL TECUNOLOCIES ESTIMATED NO. OF DIWTIIS (in mill ions) DISEASE Diarrhea Imnuniznble diseases 3.3 ~neumonia/Lower respiratory infection Low birth weight, malnutrition TOTALS INTERVENTION:; EFFECIIVINESS (percent ) S ORT 50 - 75 -5 Vaccines 80 - 95 4 Penicillin Rohde, J.E. 2.5 3 - 3.5 - 4.5 2 Maternal supplements Treat infections Cont racept i011 1: nSource: 50 P O T W TI AL REDUCTION (in millions) 1 Assignment Childrc.1 #61-62; 35-67, 1983 ( U N I G E P / C ~ ~ ~ V ~ ) 10 perinatal period were due to fecally related diseases, airborne diseases, or malnutrition. - Vectorborne Diseases Vectorborne diseases are less widespread and figure less prominently in mortality and morbidity statistics but are, nonetheless, significant in the developing world. The most widespread of these diseases are malaria, trypanosomiasis (sleeping sickness), Chagas disease, schistosomiasis (bilharzia), and onchocerciasis (river blindness). Approximately 850 million people live in areas where malaria continues to be transmitted despite activities to control it. An additional 345 m'llion people reside in areas with little or no active malaria control efforts. 1 Malnutrition Malnutrition is also a major contributing factor in infectious disease; it impairs normal body responses to disease and reduces acquired immunity. The importance of malnutrition as a contributing cause of illness and death has been widely documented. Diarrheal diseases have resulted in large numbers of deaths among undernourished children in Guatemala. Similarly, it has been observed that mortality due to measles was 274 times as high in Ecuador as in the United States in 1960-61 prior to the development of immunization to the disease. Disease and Hygiene The fecally related and fecally transmitted diseases found throughout the developing world share a common origin: the contamination of food, water, or soil with human waste. If water is unsafe for drinking or is insufficient for personal hygiene, diarrheal disease will spread easily. Several diseases are related to personal cleanliness rather than to fecal contamination. These include trachoma, conjunctivitis, and other skin infections. The link between sanitary conditions and health is illustrated by studies that report on health improvement resulting from better water supply and sewerage facilities. Studies in several developing countries document a reduction in diarrhea{ diseases brought about by better water supply and sanitation facilities. Not all studies, however, show that improved water supply systems and sanitation facilities result in improvements in health. Several studies have concluded that the source of water supply for a family matters less than :light be expected: "The bacteriological purity of water as measured by type, city 4. World Health Organization. Malaria: Processed Report for the Special Programme for Research and Training in Tropical Diseases (Geneva: WHO, 1976). 5. Van Zijl, "Studies on Diarrheal Disease in Seven Countries," pp. 249-261. -5- or well, did not influence infection rate^."^ The answer to this paradox may possibly be found in the cultural practices of the population studied. For water is often stored in cooling jars that are nearly always example, drinking contaminated. Or families may continue to drink well or river water because of greater convenience, better taste, social reasons, or its supposed special qualities. Cases also can be found where latrines hap little effect on the prevalence of disease or even had a negative effect. Here, too, cultural habits may offer an explanation. A poorly maintained latrine may be worse than none at all. The ambiguous findings do not cast doubt on the link between sanitary conditions and disease. Rather, they point to the difficulties encountered in trying to change traditional patterns of behavior. In general, improvements in water supply, sanitation, and housing can reduce the incidence of disease and in this way affect mortality. Improved nutrition not only reduces the incidence but also decreases the effects of disease. Health care can do little to alter the incidence of many infectious and parasitic diseases common in developing countries, although it can often speed recovery. Most importantly, a growing package of new health care technologies offers the hope of saving millions of lives. The 100 million children born in developing countries this year begin facing risks the moment they are born. Because their mothers are likely to be malnourished, they are born smaller. Infants weighing less than 2,500 grams account for 50 to 80 percent of all neonatal deaths. One observer theorizes that as much as 50 7ercent of perinatal mortality may be attributable to unrecognized and inadequately managed maternal i n f e ~ t i o n . ~In countries where prenatal care is either inadequate or nonexistent, such infection is especially likely to be undetected. The lack of prenatal care also increases the danger of neonatal tetanus. Babies born in unsanitary conditions, without the protection of their mother's being immunized, face the risk of tetanus, which is often fatal. Approximately one million children die from tetanus each year. B. The Synergy BetweenDiseaseand Nutrition The synergy between disease and nutrition is responsible for killing children in developing countries. The severity of infections would not be so great if children were well nourished. The infections themselves result in food loss, food withholding, and lack of appetite. While health interventions may reduce morbidity and mortality from a specific cause, they may not have a profound impact on overall morbidity and mortality. A program in Bangladesh, 6. Stewart, William H., Leland J. McCabe, Jr., Emmarie C. Hemphill, and Thelma DeCapito. "The Relationship of Certain Environmental Factors t o t h e Prevalence of Shigella Infection," American Journal of Tropical Medicine and Hygiene, 4:718724, 1955. 7. Van Zijl, "Studies on Diarrheal Disease in Seven Countries," p. 252. 8. UNICEF, State o f t h e W o r l d l sChildren, 1985, UNICEF, New York, p. 43. for example, reduced the diarrhea case fatality rate by fpproximately 80 percent but had a negligible impact on overall mortality. A study of a measles outbreak in The Gambia found that 5 percent of the children died during the outbreak; but that 10 percent of those who survived measles were dead as a result of other causes nine months later. By focusing on the health technologies most likely to enable families to break this cycle of disease and malnutrition, health care systems will have some hope of improving chi ld survival. Once considered isolated interventions, immunization, ORT, infant and maternal feeding, growth monitoring, child spacing, and now vitamin A supplementation are being considered vital elements in a technology package. 9. Rahaman, et al., ICDDR, B, unpublished data, 1979. DIARRHEAL DISEASE CONTROL* *This paper was reviewed f o r t e c h n i c a l content by Norbert Hirschhorn, M.D., t h e John Snow P u b l i c H e a l t h Group, Inc., Boston, MA. -8- DIARRHEAL DISEASE CONTROL A. Acute I n f a n t Diarrhea The World Health Organization estimates t h a t t h e r e are some 500 m i l l i o n episodes o f i n f a n t d i a r r h e a a year which r e s u l t i n t h e deaths o f about f o u r m i l l i o n c h i l d r e n i n A f r i c a , Asia, and L a t i n America. Studies i n Guatemala i n d i c a t e t h a t a v i l l a g e c h i l d may have as many as i x t o t e n bouts o f d i a r r h e a a year, each l a s t i n g an average o f t h r e e days. n a d d i t i o n t o being a pervasive k i l l e r , d i a r r h e a i s a l s o a s i g n i f i c a n t c o n t r i b u t o r t o m a l n u t r i t i o n i n those c h i l d r e n who survive. Through increased malabsorption, reduced food i n t a k e caused by l o s s of a p p e t i t e and food withdrawal, and fever, c h i l d r e n are deprived of needed nourishment. Diarrhea i s caused by b a c t e r i a l , p a r a s i t i c and v i r a l agents, b u t t h e p r e c i s e e t i o l o g y of most s e r i o u s d i a r r h e a i n developing c o u n t r i e s i s n o t w e l l understood. B a c t e r i a l agents a r e t r a n s m i t t e d by unclean water, food and hands, w h i l e v i r a l agents are borne l a r g e l y by d r o p l e t s o f mucous o r by a i r . B a c t e r i a account f o r t h e l a r g e s t number of d i a r r h e a l episodes i n poor c o u n t r i e s and u s u a l l y peak i n t h e summer. The general c l i n i c a l p r o f i l e f o r both b a c t e r i a l and v i r a l i n f e c t i o n s i s s i m i l a r , although v i r a l cases tend t o be shorter and more severe. Unsanitary b i r t h procedures and a mother's s o i l e d hands o r breasts represent p o t e n t i a l sources of contamination f o r t h e newborn i n f a n t . As the c h i l d grows and begins t o d r i n k water and e a t weaning foods t h e r i s k o f d i a r r h e a l i n f e c t i o n increases. A d u l t s and o l d e r c h i l d r e n can discharge disease-causing b a c t e r i a l agents i n t h e i r feces and y e t m a n i f e s t no symptoms o f disease. These agents may be t r a n s m i t t e d i n a v a r i e t y of ways, i n c l u d i n g d i r e c t c o n t a c t w i t h feces through another person's d i r t y hands, o r by a c h i l d c r a w l i n g on t h e ground o r f l o o r o r i n d i r e c t c o n t a c t through contaminated water which i s then t r a n s m i t t e d t o t h e c h i l d through b o t t l e d formulas o r weaning foods prepared by those w i t h d i r t y hands. Perhaps t h e g r e a t e s t source o f i n f e c t i o n i s weaning foods. I n t r o p i c a l heat, b a c t e r i a grow r a p i d l y i n these types o f foods which r e s u l t s i n d i a r r h e a . Because s t o o l consistency and frequency vary from one c h i l d t o another, t h e mother i s probably t h e best judge o f what i s abnormal. Generally, any increase i n t h e number and l i q u i d i t y o f s t o o l s w i l l be recognized as diarrhea. I n some cases, t h e c h i l d may recover from d i a r r h e a w i t h i n 24 hours, b u t i t u s u a l l y l a s t s t h r e e t o f i v e days. I n most cases, continued d i a r r h e a w i 11 produce dehydration. The m o t h e r ' s response t o d i a r r h e a i s cu1 t u r e s p e c i f i c b u t g e n e r a l l y includes one o r a l l o f t h e f o l l o w i n g : o Withholding l i q u i d s and food i n t h e b e l i e f t h a t they caused o r may worsen t h e d i a r r h e a and t h a t t h e c h i l d ' s system needs t o "rest". o Administering a c a t h a r t i c o r l a x a t i v e t o e l i m i n a t e t h e cause of t h e diarrhea,which may be viewed as worms, p a r a s i t e s , and so forth. o Administering an antidiarrhetic, which may reduce the amount of stool but which wi 1 1 neither destroy the pathogen nor decrease the dehydration. If the child does not recover, prolonged or severe diarrhea will usually lead to dehydration and electrolyte imbalance. Dehydration in infants is particularly dangerous because the child is dependent on others to provide fluids and is more likely than adults to become dehydrated by diarrhea. -he physical signs of dehydration incTude the following: o Dryness of mouth o Loss of appetite o Decreased skin turgor o Sunken fontanel and eyes o Crying without tears o Vomiting o General listlessness Even without proper care at this stage, most children will recover but some will become more dehydrated and die. Death from diarrheal dehydration can occur within a matter of hours depending upon the type of bacterial infection, the severity of the diarrhea, the mother's response, and the child's prior nutritional level. Undernourished children tend to get more severe diarrhea. B. WHO'S Diarrheal Disease Control Proqram Perhaps the most comprehensive and certainly the most recognized program for controlling infant diarrhea is the Diarrheal Disease Control Program of the World Health Organization. This program hinges upon the discovery of a single technology, oral rehydration therapy (ORT), to treat 85 to 95 percent of cases of dehydration from diarrhea in all age groups. The oral rehydration solution does not cure diarrhea but prevents the dehydration which leads to death. ORT is used instead of intravenous therapy which requires trained personnel, sterile fluids, and expensive equipment. ORT is simpler to administer and much less expensive, thereby making it .less dependent upon highly trained health workers and fixed facilities. ORS also compensates more quickly for nutritional loss due to diarrheal disease. Oral rehydration solution is not the only element in the WHO program, however. WHO also emphasizes the need for: o Adequate feeding during and after diarrhea including breast milk, diluted formula, and usual foods given to children; o Withholding of antimicrobial agents, antispasmodics, and antidiarrheal drugs because they are unnecessary and may prolong the infection and inhibit recovery; o Support of breastfeeding for its immunological effects and because it reduces the risk of infection; o Effective water and sanitation systems along with appropriate food and personal hygiene practices; o Health education programs which build upon traditional practices and beliefs to promote positive changes in decision-makers, mothers, health personnel, and community leaders; o Epidemiological surveillance to determine the prevalence and incidence of diarrhea among populations at high risk. C. Oral Rehydration Solution While the foregoing elements play important roles in the overall WHO program, it is oral rehydration therapy which offers the hope of saving thousands of infants by moving effective treatment out of the clinic and into the community. The rationale for ORT rests upon understanding how the human digestive system operates. During diarrhea, the gut decreases its capacity to absorb sodium. Research on cholera patients demonstrated that sodium absarption is restored in the presence of glucose and that the ability to absorb bicarbonate and potassium is not lost during diarrhea. Bicarbonate is added to the formula to correct acidosis, while potassium is used to replace the potassium lost through increased stools and urine. The WHO formula is consequently composed of these four ingredients per liter of water: o Glucose o Sodium chloride o Sodium bicarbonate or Trisodium citrate dihydrate o Potassium chloride 20.Og 3.59 2.59 2.99 1.59 At the first sign of prolonged diarrhea, the child's mother should obtain a packet of premixed oral rehydration salts. She should add these salts to a one-liter container of the cleanest water available, not necessarily boiled water. She then should mix the salts until dissolved and use a spoon to administer small amounts of the solution to her child over a 24-hour period. As she administers the solution the child may have a bowel movement, potentially a- sign to the mother that the solution is causing more diarrhea which it is not. The child also may vomit if the ORS is given too quickly. During the first 24-hour period, the mother should give the child all the breast milk and/or plain water it will take. If the diarrhea continues after three days, the mother should seek medical assistance. When the child's diarrhea stops, the mother should continue to give it breast milk and solids if the child is old enough for solids, adding high calorie foods, if possible, for several days after the diarrhea. Mixing ' Overconcentration o f sodium i n i n f a n t s can cause hypernatremi'a and lead t o shock and subsequent death. The p o t e n t i a l f o r hypernatremia appears t o be increased i n dehydrated i n f a n t s . Research has n o t y e t e s t a b l i s h e d t h e p e r m i s s i b l e range of sodium v a r i a t i o n , b u t i t i s c e r t a i n t h a t m i x i n g t h e WHO formula w i t h h a l f t h e r e q u i r e d water i s dangerous and w i t h one t h i r d i s l i f e threatening. And o b v i o u s l y t o o d i l u t e a s o l u t i o n w i l l n o t be e f f e c t i v e . I n a d d i t i o n t o c o r r e c t mixing, t h e s o l u t i o n must be c o r r e c t l y administered. T h i s i n c l u d e s g i v i n g t h e c o r r e c t amount o f t h e o r a l r e h y d r a t i o n Some solution. Some mothers f e e l t h e baby w i l l n o t d r i n k so much f l u i d . mothers w i t h h o l d water and/or b r e a s t m i l k d u r i n g therapy, thus adding t o t h e danger of h i g h sodium concentrations. I n o t h e r instances, o t h e r substances a r e added t o t h e mix o r i t i s b o i l e d and o v e r - d i l u t e d o r food i s w i t h h e l d i n t h e b e l i e f t h a t t h e o r a l r e h y d r a t i o n s o l u t i o n c o n t a i n s s u f f i c i e n t n u t r i e n t s . Each o f these c o u l d p o t e n t i a l l y reduce t h e e f f e c t i v e n e s s o f t h e therapy. Oel i v e r y A l i v e l y debate continues among p h y s i c i a n s and p r a c t i t i o n e r s over t h e most- a p p r o p r i a t e d i s t r i b u t i o n , mixing, and a d m i n i s t r a t i o n o f o r a l r e h y d r a t i o n s o l u t i o n . The range o f a l t e r n a t i v e s include: o Complete f o r m u l a ( a l l f o u r i n g r e d i e n t s ) prepackaged and d i s t r i b u t e d t o h e a l t h p o s t s where i t i s mixed and administered by a h e a l t h worker. I n t h i s s e t t i n g , ORT i s s u p e r i o r t o intravenous s o l u t i o n s because i t i s cheaper, safer, and simpler. Because i t occurs i n a f i x e d f a c i l i t y , however, i t i s s t i l l l i m i t e d t o t h a t small percentage o f t h e p o p u l a t i o n which a c t u a l l y uses h e a l t h posts. o Complete formula, prepackaged and d i s t r i b u t e d t o v i l l a g e h e a l t h workers who have r e c e i v e d some simple t r a i n i n g i n m i x i n g and a d m i n i s t r a t i o n . These i n d i v i d u a l s would recognize who needs t h e formula and how much they need and know how t o mix and They would have a standard l i t e r administer i t properly. c o n t a i n e r and would understand t h e danger i n v o l v e d i n t h e therapy. Even though t h e t r a i n i n g f o r such an i n d i v i d u a l i s r e l a t i v e l y simple, many argue t h a t i t i s s t i l l t o o expensive t o t r a i n -and support such a h e a l t h worker i n every v i l l a g e . o Conrplete formula, prepackaged and d i s t r i b u t e d through some c o m e r c i a 1 o r p u b l i c system d i r e c t l y t o mothers. I n t h i s model, t h e mothers would l e a r n how t o mix and a d m i n i s t e r t h e s o l u t i o n from w r i t t e n i n s t r u c t i o n s i n c l u d e d i n t h e package, from verbal i n s t r u c t i o n s g i v e n a t t h e t i m e o f purchase, o r from r a d i o broadcasts. Although t h i s approach c o u l d ready a l a r g e number i t r a i s e s questions about safe m i x i n g and o f families, administration. . o A simple s a l t and sugar formula advocated by h e a l t h workers and mass media so t h a t mothers can a c t u a l l y make and a d m i n i s t e r t h e s o l u t i o n i n . t h e i r own home, w i t h l i t t l e o r no o u t s i d e assistance. The major s t r e n g t h of t h i s approach i s t h a t i t ensures t h e widest degree of d i s t r i b u t i o n by using substances already i n t h e home. I t a l s o introduces t h e h i g h e s t degree o f r i s k by i n c r e a s i n g t h e p o t e n t i a l f o r improper m i x i n g and a d m i n i s t r a t i o n and by excluding bicarbonate and potassium which may be c r i t i c a l t o c h i l d r e n who have been severely purged o r who have been vomiting. I n areas where sugar and s a l t are scarce i t a l s o r a i s e s problems o f a v a i l a b i l i t y and cost. The l a t t e r a l t e r n a t i v e has spawned a s e r i e s o f technologies t o h e l p reduce t h e r i s k o f improper mixing. These i n c l u d e a pinch and scoop technique, promotion o f a b o t t l e cap as a measuring spoon, and a v a r i e t y o f commercially produced double-ended spoons f o r measuring sugar and s a l t concentrations. Indeed, a good deal o f experimenting w i t h new ORS technologies i s t a k i n g place. Experiments are c o n t i n u i n g w i t h p l a s t i c packaging r a t h e r than more c o s t l y aluminum, w i t h packages which convert i n t o one l i t e r containers, w i t h t a b l e t s r a t h e r than powders, and w i t h measurements by t h e g l a s s r a t h e r than by t h e l i t e r . I n t h e p a s t few years, f u r t h e r s t u d i e s have been undertaken t o The bicarbonate anion i n v e s t i g a t e p o s s i b l e improvements i n the ORS formula. i n t h e " u n i v e r s a l " formula a v i d l y absorbs water from the environment, thereby r e s u l t i n g i n an ORS powder w i t h a reduced s h e l f l i f e ( i t cakes and d i s c o l o r s i f stored t o o long). C e r t a i n o t h e r anions have been i d e n t i f i e d which can serve the same p h y s i o l o g i c a l f u n c t i o n as bicarbonate b u t w i t h o u t t h e u n d e s i r able p h y s i c a l p r o p e r t i e s . I n p a r t i c u l a r , a formula substitut-ing sodium c i t r a t e f o r sodium bicarbonate has proven e f f e c t i v e i n f i e l d s t u d i e s sponsored worldwide by WHO. The c i t r a t e i s now recommended f o r a l l packets because i t extends s h e l f l i f e . 4. Cereal-Based ORS Other a l t e r n a t i v e s and supplements t o t h e simple sugar (glucose) i n t h e formula a l s o are under i n v e s t i g a t i o n . Rice powder (ground r i c e ) , f o r example, These starches has been used t o r e p l a c e t h e glucose i n some ORS formulas. come i n several forms, which a r e f a m i l i a r and r e a d i l y a v a i l a b l e i n developing c o u n t r i e s - - f o r example, p l a i n cooked r i c e o r a powder made from g r i n d i n g popped, unhusked r i c e ("pop r i c e " ) . Such starches have t h e advantage o f breaking down t o produce simple sugars, i n c l u d i n g glucose, and c e r t a i n amino acids, such as g l y c i n e , as w e l l as d i p e p t i d e s which enhance sodium absorption from the i n t e s t i n a l lumen. S o l u t i o n s u s i n g rice-based starches have been demonstrated t o be as e f f e c t i v e i n c o r r e c t i n g dehydration as those formulas u s i n g glucose o r sucrose and more e f f e c t i v e i n decreasing t h e volume of diarrhea. I n a d d i t i o n , t h e c a l o r i c i n t a k e i s t w i c e as h i g h w i t h r i c e f o r t i f i e d ORS as w i t h r e g u l a r ORS. 5. ORS Market P r e s e n t a t i o n s More a t t r a c t i v e p r e s e n t a t i o n o f ORS through b e t t e r packaging, packet sizes adapted t o l o c a l volume measures, ORS i n t a b l e t form, and t h e p r o v i s i o n o f premixed s o l u t i o n s i n cheap c o n t a i n e r s such as those used commercially f o r . juices or soft drinks are being commercially produced in many countries. The establishment of an ORS "line of products" ranging from homemade solutions to expensive premixed solutions in sterile water should appeal to the full spectrum of the buyi-ng public. This is important to ensure wide use at all levels of society as well as the fiscal viability of ORT programs. One delivery system promotes different treatments for different degrees of dehydration. For example, when a mother first detects signs of diarrhea, she is encouraged to avoid purges; to continue giving the child liquids and to administer the simple formula home mix. If the diarrhea continues and early signs of dehydration appear, she should use the prepackaged ORS formula available from a store, health center, midwife, etc., and administer it as required over a 24-hours and up to three days if necessary. During this time, she should continue to breastfeed, give extra water, and feed the child soft foods. If the dehydration becomes more serious, she should seek medical assistance. Oral therapy should be available through all community health workers and in all health centers and hospitals in the country. Intravenous therapy should only be used in cases of shock. In the above system, the least dehydrated child gets the highest risk ORS As formula. Most episodes probably end without further complication. dehydration increases, safer but less available packets are used and probably prevent most of the remaining episodes from becoming more serious. In the re1 ati vely few cases where diarrhea and dehydration continue, either because the previous treatment failed to work or because it was administered improperly, the least available treatment alternative becomes necessary and the child must be taken to the clinic. The principal difficulties with this seemingly ideal model are that: o The teaching burden is heavy because all regimens must be taught to all people. o Those most likely to need the packets and the health facilities are those least likely to have access to them because they are the poorest and most isolated. 6. Comnunication Issues and ORT From a communication viewpoint, the behavioral changes required to make ORT effective raise critical questions which must be answered within the context of a specific cultural group. They include: Prevention-Re1 ated Issues o What personal hygiene practices, for instance hand washing, will be accepted and will help reduce contamination? o Can acceptable breastfeeding practices be introduced which will help reduce the risk of contamination and provide nourishment during diarrhea? o What practical weaning practices will reduce contamination and provide catch-up growth after diarrhea? The appl ication of ORT and sodium concentrations in WHO prepackaged formu1 a - o Does a common standard liquid volume container exist in the target area? o Does the target community have the experience and ability to follow verbal mixing instructions? o Does sufficient experience exist with liquid remedies to make home administration practical? o Does the target population's attitude toward medicine suggest that double or triple concentrations of the salts will be common? Excessive sodium concentration in home made simple sugar and salt solution o Are sugar and salt commonly available in the target area? o What measuring instrument will be needed to ensure accurate concentrations of salt and sugar? o Does the population's attitude toward salt and sugar permit these ingredients to be mixed In the appropriate manner? Importance of Potassium o Do members of the intended audience usually give purges as a remedy for infant diarrhea? o Does vomiting occur frequently as part of the diarrheal episode? o Is there an available source of potassium in the village? Recognition of the Problem o What immediate outcome does the target population expect from a remedy for diarrhea? o Will the fact that ORT does not halt diarrhea deter the target population from continued administration of the solution? o Does the population prefer medicines which are foreign and modern or those which are traditional and familiar to them? o Do members of the intended audience accept diarrhea as a serious problem for which they desire some help? o Do members of the target population recognize dehydration and can they differentiate levels of severity? De 1 iv e r y o Who i s t h e most c r e d i b l e source o f d i a r r h e a among t h e t a r g e t p o p u l a t i o n ? information on infant o What i s t h e most e f f e c t i v e d i s t r i b u t i o n p o i n t f o r prepackaging ORT i n a r u r a l v i l l a g e ? ORT S t a t u s Today Over t h e p a s t f i v e years d i a r r h e a l disease c o n t r o l programs have begun i n 52 c o u n t r i e s . With assistance from WHO and t h e Centers f o r Disease Control o f t h e United S t a t e s P u b l i c H e a l t h Service, 677 h e a l t h system managers from 117 developing c o u n t r i e s have been t r a i n e d i n i n t e r n a t i o n a l t r a i n i n g courses i n d i a r r h e a l disease c o n t r o l , planning, and management. Another 410 workers have been t r a i n e d i n supervisory and f i e l d worker courses. More than 50 m i l l i o n packets o f ORS have been produced and d i s t r i b u t e d throughout t h e world. UNICEF has provided 29 m i l l i o n packets, t h e U. S. Agency f o r I n t e r n a t i o n a l Development has provided approximately n i n e m i l l i o n packets, and 38 developing c o u n t r i e s produce t h e i r own ORS. Even if u n i f o r m l y d i s t r i b u t e d , these packets would have t r e a t e d fewer t h a n one i n t e n cases of diarrhea, b u t combined w i t h t h e a p p r o p r i a t e use o f homemade s o l u t i o n s , t h i s l a r g e q u a n t i t y o f ORS packets can be expected t o have an important e f f e c t and save t e n s o r even hundreds o f thousands o f l i v e s . 0. D i e t a r y Management o f D i a r r h e a l Disease ..,. The a p p r o p r i a t e emphasis on o r a l r e h y d r a t i o n s o l u t i o n t o prevent death from acute d e h y d r a t i o n has u n f o r t u n a t e l y been associated w i t h widespread n e g l e c t o f t h e n u t r i t i o n a l o r f e e d i n g component of ORT. F a i l u r e t o emphasize o f therapy can be l a r g e l y a t t r i b u t e d t o both t h e t h e n u t r i t i o n a l aspec:. r e l u c t a n c e by c a r e t a k e r s and h e a l t h p r o f e s s i o n a l s t o feed c h i l d r e n d u r i n g i l l n e s s , t o t h e l i m i t e d s c i e n t i f i c knowledge r e g a r d i n g t h e a b i l i t y o f c h i l d r e n t o consume and t o l e r a t e s p e c i f i c foods d u r i n g and a f t e r i l l n e s s , and t o t h e almost t o t a l ignorance o f t h e c l i n i c a l and n u t r i t i o n a l e f f e c t s o f s p e c i f i c d i e t a r y regimens. The adverse consequences o f d i a r r h e a on n u t r i t i o n a l s t a t u s and prolonged episodes o f i l l n e s s have been w e l l documented i n t h e l i t e r a t u r e . The n u t r i t i o n a l c o s t o f i n f e c t i o n i n general, and d i a r r h e a s p e c i f i c a l l y , can be a t t r i b u t e d t o decreased d i e t a r y i n t a k e and i n t e s t i n a l malabsorption d u r i n g diarrheal illness. The approach t o n u t r i t i o n a l management o f d i a r r h e a l i l l n e s s by t h e h e a l t h community has been t o reduce o r e l i m i n a t e food i n t a k e d u r i n g t h e i l l n e s s and t o compensatory "overfeeding" d u r i n g t h e recovery period. The appropriateness o f t h i s therapy has r e c e n t l y been questioned by h e a l t h p r o f e s s i o n a l s who advocate continued f e e d i n g d u r i n g d i a r r h e a l i11ness. The c o r r e c t t h e r a p e u t i c approach i s s t i l l b e i n g debated, because w e l l - c o n t r o l l e d s t u d i e s o f t h e a l t e r n a t i v e s have been l a c k i n g . E. D i a r r h e a l Disease P r e v e n t i o n As succe-ssful as ORT i s i n r e d u c i n g d i a r r h e a l m o r t a l i t y , Feachem and others p o i n t out t h a t i t i s only a p a r t i a l solution t o t h i s serious health problem. To b e g i n w i t h , ORT s u c c e s s f u l l y reduces m o r t a l i t y b u t has l i t t l e o r no impact on d i a r r h e a l m o r b i d i t y r a t e s . ORT i s a c u r a t i v e measure, b u t o t h e r i n t e r v e n t i o n s , such as improved maternal and c h i l d n u t r i t i o n o r improved water supply and s a n i t a t i o n and improved personal and domestic hygiene are e f f e c t i v e i n preventing diarrhea. Back-up i n t e r v e n t i o n s a r e necessary f o r an e f f e c t i v e d i a r r h e a l disease c o n t r o l program. Thus f a r , s i x p o t e n t i a l a n t i d i a r r h e a l i n t e r v e n t i o n s have been reviewed by Feachem:* (a) measles immunization, (b) supplementary f e e d i n g programs, ( c ) low b i r t h weight, (d) b r e a s t f e e d i n g , ( e ) personal and domestic hygiene, and ( f ) chemoprophylaxis. Measles I m n i z a t i o n The r o l e o f measles immunization i n c o n t r o l l i n g d i a r r h e a l disease seems s i g n i f i c a n t enough t o w a r r a n t t h e a t t e n t i o n o f n a t i o n a l program planners. T h e o r e t i c a l c a l c u l a t i o n s e s t i m a t e a one p e r c e n t t o seven p e r c e n t i n c i d e n c e o f measles-associated d i a r r h e a ; f i e l d s t u d i e s i n N i g e r i a and Guatemala r e p o r t a s i x p e r c e n t m o r b i d i t y . The e s t i m a t e d percentage o f deaths caused by measlesassociated d i a r r h e a a r e t h e o r e t i c a l l y e s t i m a t e d t o be n i n e p e r c e n t t o 77 percent. One f i e l d s t u d y i n Bangladesh suggests 37 p e r c e n t of d i a r r h e a l deaths a r e measles associated. The e t i o l o g y o f t h e d i a r r h e a a s s o c i a t e d w i t h measles i s unknown. Some evidence, however, i n d i c a t e s t h a t s h i g e l l o s i s ( b a c i l l a r y d y s e n t e r y ) and o t h e r forms o f d y s e n t e r y may be t h e most common c u l p r i t s . Data from f i e l d s t u d i e s and t h e o r e t i c a l c a l c u l a t i o n s i n d i c a t e t h a t measles immunization can s u b s t a n t i a l l y reduce d i a r r h e a l m o r t a l i t y among c h i l d r e n from b i r t h t o f i v e years. Feachem e s t i m a t e s t h a t measles immunization a t t h e age o f n i n e t o 11 months, w i t h a 45 percent t o 90 p e r c e n t coverage w i l l a v e r t 44 p e r c e n t t o 64 p e r c e n t o f measles cases, 3.8 p e r c e n t t o 9.6 p e r c e n t o f d i a r r h e a a t t a c k s , and s i x p e r c e n t t o 26 p e r c e n t o f d i a r r h e a deaths among c h i l d r e n f i v e y e a r s o l d and under. Although s t u d i e s a r e r e p o r t e d l y under way i n Bangladesh, t h e r e a r e no f i e l d r e p o r t s t h a t can v e r i f y these t h e o r e t i c a l assessments. The c o n s i d e r a b l e h y p o t h e t i c a l impact o f measles immunization on d i a r r h e a m o r t a l it y ( s i x p e r c e n t t o 26 p e r c e n t ) should, however, w a r r a n t f i e l d s t u d i e s t o assess t h e r o l e o f measles immunization i n reducing d i a r r h e a l m o r t a l i t y . Community research i s needed t o t e s t these t h e o r e t i c a l s u p p o s i t i o n s , t o determine t h e e t i o l o g y o f measles-associated d i a r r h e a , and t o determine t h e c o s t - e f f e c t i v e n e s s o f measles immunization as an i n t e r v e n t i o n f o r an e f f e c t i v e n a t i o n a l d i a r r h e a l disease c o n t r o l program. * Feacham, R.G, R.C. Hogan, and M. H. Merson, "Diarrhoea1 Disease C o n t r o l : Review o f P o t e n t i a l I n t e r v e n t i o n s , " WHO B u l l e t i n , 6 1 (4), 1983. Suppl enkntary Feeding Supplementary feeding programs for preschool children have a dubious impact on diarrheal- morbid1 ty among this age group. Associations have frequently been reported between poor nutritional status and increased diarrheal morbidity, severity and mortality. Evidence exists that poor nutritional status makes children susceptible to more severe diarrhea and to higher case fatality rates and that supplementary feeding programs can reduce diarrhea severity and mortality. Diarrheal morbidity, however, seems unaffected, particularly since supplementary feeding programs are ineffective among the age group at highest risk for diarrhea, children six months to 23 months old. The nutritional status of this age group seems to be unaffected by supplementary feeding programs probably as a result of traditional late weaning and maternal attitudes toward feeding. Feachem suggests attention might, therefore, be better focused on improving weaning practices and on modifying maternal attitudes. In addition to having a dubious impact on mortality and no impact on morbidity, supplementary feeding programs also are expensive and require considerable logistical and managerial talents. Consequently, a supplementary feeding program is un1 i kely to be a cost-effective intervention for the reduction of diarrhea morbidity. Prospective studies on the relationsh-ip of nutrition status to the severity of diarrhea are, nevertheless, warranted. Low Birth Weight Low birth weight (LBW) is a major determinant of infant mortality in developing countries. Although no satisfactory evidence has yet been gathered to indicate that LBW causes diarrheal mortality or morbidity, Feachem theoretically asserts that in those developing countries where diarrhea is a major cause of infant deaths, there is likely to be a causal link between LBW and diarrheal mortality. An estimated 20 million LBW infants (weighing less than 2,5009 at birth) are born each year. This constitutes 16 percent of all births around the world. Recent reports indicate that although only six percent of the infants born in the United States have LBW, they make up the largest proportion of infant deaths--as much as 55 percent. Similar findings are expected in developing countries. The prevalence of LBW seemingly can be reduced once exacerbating factors are alleviated. These include poor maternal nutrition, certain infections, pre-eclampsia, arduous work after mid-pregnancy, short birth intervals, teenage pregnancy, cigarette smoking, and alcohol consumption. Maternal food supplementation has received the most attention as an intervention to prevent LBW. One maternal food supplementary program sponsored by the U. S. Department of Agriculture resulted in increased weight gain during pregnancy, increased birth weight, and a reduction in the prevalence of LBW, from ten percent to six percent. Similar studies need to be conducted and carefully documented in developing countries. A maternal food supplementation program can be an expensive endeavor, however, and further research is necessary to verify the results of programs. If maternal nutrition, health, and lifestyles can be improved in developing countries, it is theoretically possible that the prevalence of LBW would fall from 30 percent to 15 percent. Infant mortality rates could be expected to fall about 26 percent. Feachem asserts the fall in infant diarrhea mortality might be similar. Prospective studies are needed to investigate these theoretical suppositions. Research is also required to clarify the etiology of LBW, to determine which interventions are most effective, and to determine whether those interventions can be cost-effective strategies for reducing infant mortality. Whatever the relationship with diarrhea, LBW should receive greater attention in developing countries simply because it is a major cause of infant mortality. Breastfeeding Little reliable data exist to support the argument that breastfeeding reduces diarrheal mortal i ty. Nevertheless, there is significant evidence, as Feachem stresses, to indicate that breastfeeding does decrease diarrheal morbidity. Breastfed children may also be less likely to suffer from severe or prolonged diarrhea. This protection is caused not only by increased nutritional benefits afforded by breastfeeding but also by immunological properties found in breast milk, the presence of intestional flora exclusively found in breastfed infants which may inhibit colonization by specific diarrheal pathogens and the lack of food contamination often found when bottle milk is used. In addition, breastfeeding leads to increased intestinal absorption. - Theoretical calculations and a recent study in Costa Rica reveal a dramatic impact of the promotion of breastfeeding on neonatal diarrheal morbidity and mortality. During a four-year period (1976-1980), a hospital in Costa Rica promoted early breastfeeding and close mother-child contact. Neonatal diarrhea1 morbidity fell from 17.7 to 1.6 cases per 1,000 live births; mortality fell from 3.9 to 0 deaths per 10,000 live births. Appropriate promotional activities have proven to be particularly effective in increasing the prevalence of breastfed infants. To promote breastfeeding, evidence indicates that changes in hospital routines are necessary, along with the development of information and support programs for mothers. The cost-effectiveness of breastfeeding promotion has not been documented, but it is probably lower than most other antidiarrheal interventions. On the basis of current evidence, Feachem now encourages the promotion of breastfeeding. At the same time, however, research is needed to determine the cost-effectiveness of breastfeeding promotion in developing countries. Research also is needed to clarify the levels of protection afforded by breastfeeding against diarrheal mortality,, to determine the effectiveness of breastfeeding promotion, and to discern the most suitable design for a breastfeeding program. Despite limited mortality data and the need for continued research, evidence suggests that breastfeeding protects young infants against diarrhea and should be implemented as an antidiarrheal intervention. Future research will present new findings that will improve the effectiveness of a program to promote breastfeeding. Improved Personal and Domestic Hygiene Improved personal and domestic hygiene interrupts the direct fecal-oral transmission of diarrheal pathogens. Low education levels, certain religious customs, and s p e c i f i c behavior promote t h e t r a n s m i s s i o n o f e n t e r i c pathogens. Handwashing i s one s p e c i f i c behavior most studied. Washing w i t h soap and water can be as much as 90 percent t o 100 percent e f f e c t i v e i n remov ing bacter ia. Appropriate hygiene education programs can a l t e r behavior and thereby decrease t h e transmission of d i a r r h e a l pathogens. The r e s u l t s o f t h r e e s t u d i e s i n Bangladesh, t h e United States, and Guatemala document t h e impact o f hygiene education on d i a r r h e a l m o r b i d i t y . I n Bangladesh, t h e use o f soap and water r e s u l t e d i n a 35 percent r e d u c t i o n i n t h e incidence o f s h i g e l l o s i s among A 37 percent r e d u c t i o n i n a a l l ages i n t h e urban f a m i l i e s studied. n o n s h i g e l l a d i a r r h e a was observed. The U.S. study a l s o promoted handwashing i n day care c e n t e r s among attendants and c h i l d r e n aged s i x t o 29 months. The r e s u l t s were a 48 percent r e d u c t i o n i n t h e i n c i d e n c e r a t e of a l l d i a r r h e a among t h e c h i l d r e n . I n t h e Guatemala v i l l a g e study, t h e promotion of h e a l t h awareness and h y g i e n i c behavior r e s u l t e d i n a 14 p e r c e n t r e d u c t i o n i n r a t e s o f d i a r r h e a throughout t h e year among c h i l d r e n aged 0 t o 71 months and a 32 t o 36 percent r e d u c t i o n d u r i n g t h e peak d i a r r h e a seasons. These s t u d i e s suggest hygiene education ( p r i m a r i l y t h e promotion of handwashing) has a marked impact on d i a r r h e a m o r b i d i t y . Feachem .emphasizes t h r e e general p o i n t s . General education and diseases p e c i f i c education can o f f e r increased p r o t e c t i o n a g a i n s t d i a r r h e a . Hygiene education can s u c c e s s f u l l y increase hygiene and decrease d i a r r h e a m o r b i d i t y r a t e s by 14 t o 48 percent. And f i n a l l y , hygiene education seems p a r t i c u l a r l y a t t r a c t i v e i n terms o f c o s t e f f e c t i v e n e s s i n comparison t o water supply and s a n i t a t i o n p r o j e c t s . Hygiene education programs a r e cheaper and have a l a s t i n g , s u b s t a n t i a l impact. I n conclusion, 'eachem encourages research t o determine t h e c o s t e f f e c t i v e n e s s o f hygiene education. More i n f o r m a t i o n i s needed on t h e a s s o c i a t i o n between s p e c i f i c behaviors and r i s k s of d i a r r h e a l m o r b i d i t y and mortality. Operational research i s needed t o c l a r i f y t h e most e f f e c t i v e and f e a s i b l e types o f hygiene education. F i n a l l y , i t i s important t o c l a r i f y t h e impact on d i a r r h e a o f c a r e f u l l y designed hygiene education programs. Hygiene education programs a r e an e f f e c t i v e a n t i d i a r r h e a i n t e r v e n t i o n and should be launched i n a l l c o u n t r i e s t h a t want a successful n a t i o n a l d i a r r h e a l disease c o n t r o l program. Chemoprophylaxis L i t t l e evidence e x i s t s t o i n d i c a t e t h a t chemoprophylaxis i s e f f e c t i v e i n reducing d i a r r h e a l m o r b i d i t y and m o r t a l i t y , except perhaps i n t r a v e l e r s . The main use of drugs i n t h e c o n t r o l o f d i a r r h e a l disease i n developing c o u n t r i e s i s t o prevent c h o l e r a o r s h i g e l l o s i s i n households o f known cases. 'Theoretical c a l c u l a t i o n s suggest t h a t chemoprophylaxis o f households w i t h known c h o l e r a cases i n Bangladesh might reduce t h e d i a r r h e a i n c i d e n c e i n c h i l d r e n under f i v e years o f age by 0.02 t o 0.06 percent and d i a r r h e a m o r t a l i t y r a t e s by 0.4 t o 1.2 percent. For s h i g e l l o s i s , d i a r r h e a i n c i d e n c e might be reduced by 0.15 t o 0.35 percent and m o r t a l i t y by 0.3 t o 0.7 percent. The success o f chemoprophylaxis, however, depends on s k i l l s and resources t h a t a r e scarce i n developing c o u n t r i e s f o r b o t h t h e c o r r e c t i d e n t i f i c a t i o n o f c h o l e r a and s h i g e l l o s i s and t h e r a p i d a d m i n i s t r a t i o n o f drugs to all households with either disease. In addition, chemoprophylaxis causes side-effects and can contribute to the widespread emergence and dissemination of antimicrobial resistance. All of the available evidence thus suggests that chemoprophylaxis is not feasible in many settings, and, even if adequately implemented, it is not a cost-effective intervention for national diarrheal disease control programs. IMMUNIZATION* * This paper was reviewed for technical context by Stanley Foster, M.D., Centers for Disease Control, U S P k A t l a n t a , GA -22- IMUNIZATION I t i s estimated t h a t , i n t h e developing world, s i x i n f e c t i o u s diseases k i 11 some f i v e m i 1l - i o n c h i l d r e n annual l y . These diseases are preventable through immunization, which i s a much more e f f i c i e n t use o f scarce medical re'sources than attempting t o t r e a t these diseases a f t e r they occur. The e s s e n t i a l components o f an immunization program i n c l u d e t h e a v a i l a b i l i t y of safe, e f f e c t i v e vaccines, t h e maintenance of t h e potency o f t h e vaccines from t h e p o i n t o f manufacture through d i s t r i b u t i o n throughout t h e country u n t i l t h e i r a p p l i c a t i o n , t h e i r c o r r e c t a d m i n i s t r a t i o n , and t h e e f f i c i e n t management o f program resources t o achieve maximum immunization coverage. Great advances have been made i n t h i s century i n developing and i r ~ p r o v i r l g vaccines a g a i n s t t h e major i n f e c t i o u s diseases. As developing c o u n t r i e s strengthen t h e i r h e a l t h care systems and extend immunization s e r v i c e s t o a l a r g e r p r o p o r t i o n of t h e i r populations, they encounter problems d i f f e r e n t from those experienced by t h e i n d u s t r i a l i z e d nations--problems such as t r o p i c a l temperatures, lack o f e l e c t r i c i t y , inadequate t r a n s p o r t a t i o n , shortages o f t r a i n e d - p e r s o n n e l and equipment, and low l e v e l s o f l i t e r a c y among t h e i r populations. I n r e c o g n i t i o n o f t h e seriousness o f t h e problem o f i n f e c t i o u s childhood diseases and t h e g r e a t b e n e f i t s o f immunization, t h e World Health O r g a n i z a t i o n i n s t i t u t e d t h e Expanded Programme on Immunization (EPI) i n 1974. E P I ' s goal i s t o make b a s i c immunizations a v a i l a b l e t o a l l t h e c h i l d r e n o f t h e world by 1990, w i t h s p e c i a l p r i o r i t y g i v e n t o those i n developing c o u n t r i e s . The E P I covers s i x major k i l l e r s o f c h i l d r e n i n t h e developing world: d i p h t h e r i a , whooping cough ( o r p e r t u s s i s ) , tetanus, measles, p o l i o , and tuberculosis. Because many cases o f these diseases, and o f t e n t h e most serious complications, occur i n t h e f i r s t year o f l i f e , E P I has focused i t s e f f o r t s on reaching i n f a n t s under one year o f age and pregnant women ( t h e l a t t e r f o r immunizing t h e mothers and thus t h e i r newborn babies a g a i n s t tetanus). Measles i s a p a r t i c u l a r l y important k i l l e r o f small c h i l d r e n . A case f a t a l i t y r a t e o f 20 percent i n A f r i c a n h o s p i t a l s suggests t h e magnitude o f the problem. I n developed countries, t h e case f a t a l i t y r a t e i s l e s s t h a n one p e r c e n t . A. Vaccines An understanding o f how t h e immuni z a t i o n process works can p r o v i d e i n s i g h t i n t o many o f t h e t e c h n i c a l problems o f d e l i v e r i n g e f f e c t i v e immunization services. Immunity can be o f two b a s i c types, a c t i v e and passive. I n a c t i v e immunity, t h e body develops i t s own a n t i b o d i e s i n response t o t h e presence o f a f o r e i g n antigen. Passive immunity r e s u l t s when a person r e c e i v e s a n t i b o d i e s developed i n another host. Vaccines are prepared from m o d i f i e d antigens t h a t are r e l a t i v e l y safe y e t cause t h e body t o produce a n t i b o d i e s against t h e disease thereby causing antigens. These m o d i f i e d antigens must remain unchanged t o guarantee s t i m u l a t i o n o f antibody p r o d u c t i o n (vaccine potency). Some vaccines are s e n s i t i v e t o heat and if exposed t o higher temperatures w i l l change and no longer s t i m u l a t e antibody p r o d u c t i o n ( a r e u n s t a b l e o r heat l a b i l e ) . Each vaccine has i t s own c h a r a c t e r i s t i c s regarding safety, e f f e c t i v e n e s s , and s t a b i l i t y . These are determined i n p a r t by the n a t u r e o f t h e disease organism i t s e l f , i n p a r t by t h e type o f vaccine ( l i v e , k i l l e d , o r t o x o i d ) and i n p a r t by t h e manufacturing p r a c t i c e used. D i p h t h e r i a Toxoid Serious disease caused by t h e C d i p h t h e r i a bacterium i s due t o t o x i n s result i n neurologic and c a r d i a c produced b y t h e - organism t h a t abnormalities. D i p h t h e r i a t o x o i d i s u s u a l l y g i v e n i n combination w i t h t e t a n u s t o x o i d (DT) o r i n a t r i p l e a n t i g e n vaccine (DPT) w i t h p e r t u s s i s and tetanus. D i p h t h e r i a t o x o i d i s a safe and r e l a t i v e l y s t a b l e vaccine. Few r e a c t i o n s t o t h e vaccine occur among i n f a n t s and young c h i l d r e n . To avoid r e a c t i o n s i n c h i l d r e n s i x years and o l d e r and f o r a d u l t s , a lower dose i s recommended ( l e s s The t h a n 2 L f u n i t s r a t h e r than t h e 10 L f u n i t s o r more g i v e n t o i n f a n t s ) . t o x o i d can be s t o r e d s a f e l y f o r several years a t 4" t o 8"C, b u t i t must n o t be allowed t o freeze. Measles Measles i s a h i g h l y contagious disease and can spread r a p i d l y through crowded populations. It can be associated w i t h s e r i o u s c o m p l i c a t i o n s such as pneumonia and e n c e p h a l i t i s . L i v e attenuated measles v i r u s vaccine i s a safe, h i g h l y e f f e c t i v e vaccine, b u t i t r e q u i r e s c a r e f u l h a n d l i n g and storage t o prevent damage due t o excessive heat o r 1i g h t exposure. Since 1967, when t h e l i v e vaccine replaced a much l e s s e f f e c t i v e , k i l l e d vaccine i n t h e U.S.A., t h e deaths and d i s a b i l i t y associated w i t h measles have been g r e a t l y reduced. One dose r e s u l t s i n t h e development o f a n t i b o d i e s i n 95 percent o f those vaccinated and i s known t o p r o t e c t a g a i n s t measles f o r a t l e a s t 15 years, perhaps even f o r l i f e . I t i s recommended t h a t i n f a n t s i n developing c o u n t r i e s be vaccinated a t younger ages--as soon a f t e r n i n e months as p o s s i b l e - - t o provide e a r l i e r protection. Fear t h a t measles vaccine may n o t be e f f e c t i v e f o r malnourished c h i l d r e n has n o t been supported i n f i e l d s t u d i e s , s i n c e these c h i l d r e n a l s o develop immunity a f t e r vaccination. N i n e t y - f i v e percent o f unvaccinated c h i l d r e n i n developing c o u n t r i e s have had t h e disease by age f o u r . Both measles and p e r t u s s i s c o n t r i b u t e t o t h e m a l n u t r i t i o n c y c l e and 30 percent o f measles episodes are associated w i t h d i a r r h e a l episodes. Pertussis P e r t u s s i s (whooping cough) i s a h i g h l y contagious r e s p i r a t o r y disease. It has been estimated t h a t , i n an unvaccinated population, a t l e a s t 80 percent I n developing c o u n t r i e s , one t o t h r e e o f c h i l d r e n w i l l g e t t h e disease. percent o f these c h i l d r e n w i l l d i e from p e r t u s s i s , even i f t h e y r e c e i v e medical care, and many more w i l l s u f f e r s e r i o u s i l l n e s s o r permanent disability. The vaccine used f o r p e r t u s s i s i s a s a l i n e suspension B o r d e t e l l a p e r t u s s i s b a c t e r i a . The vaccine i s u s u a l l y administered t h e t r i p l e DPT vaccine. The vaccine i s 80 percent e f f e c t i v e i n m o r b i d i t y due t o p e r t u s s i s b u t i s c l o s e t o 100 percent e f f e c t i v e i n m o r t a l i t y due t o p e r t u s s i s . of killed as p a r t o f preventing preventing I n o r d e r t o understand t h e i s s u e o f s a f e t y r e g a r d i n g p e r t u s s i s vaccine, one must compare t h e s i z e and n a t u r e o f t h e r i s k s o f vaccine r e a c t i o n s t o t h e r i s k s o f c o n t r a c t i n g whooping cough and i t s complications. R e l a t i v e l y mild, temporary r e a c t i o n s r e p o r t e d i n c l u d e l o c a l p a i n and s w e l l i n g a t t h e i n j e c t i o n s i t e , f e v e r , i r r i t a b i l i t y , vomiting, and l o s s o f a p p e t i t e . Prolonged, uncontrollable crying, excessive sleepiness, and, even more r a r e l y , convulsions~ shock1 i ke state, and encephal i tis are among the more serious conditions reported in association with pertussis vaccination. Convulsions, the most frequent immunological reaction following DPT injection, occurred 100 to 3,000 times mdre often during whooping cough than following DPT immunization. It appears, then, that the risks of the illness far outweigh the risks of vaccine complications. In the DPT form, pertussis vaccine is convenient and stable as long as it is refrigerated at 4" to 8°C (it must not be frozen); it has the additional advantage of acting as an adjuvant for diptheria and tetanus toxoids. Pol i o Polio is an acute viral disease that results in permanent paralysis in approximately one percent of the children infected; ten percent of these result in death. In developing countries, paralysis due to polio has been observed in four out of 1,000 children between the ages of five and nine years. The paralysis is permanent and quite disabling, often resulting in a loss of productivity. Two types of polio vaccine are available: a live, attenuated vaccine given orally (Sabin) and a ki 1 led inactivated vaccine injected intramuscularly (Salk). Both types of vaccine are quite safe. As with any live vaccine, oral polio is sensitive to excessive heat and light. It should be stored frozen at minus 20°C or kept refrigerated at 4" to 8°C. The killed vaccine is more stable and needs only careful refrigeration at plus 4" to 8°C. Because of the high cost of killed polio vaccine WHO/EPI currently recommends oral polio vaccine for routine use in developing countries. Tetanus Tetanus toxoid is safe and relatively stable. The few side effects reported are usually due to impurities or allergy and can be avoided by using highly purified toxoid and not giving boosters too frequently. The three doses of DPT given to infants provide long-lasting protection against tetanus. The two doses o f t e t a n u s t o x o i d g i v e n t o p r e g n a n t women d u r i n g t h e second half of pregnancy protect both the mother during childbirth and the baby, because the mother's antibodies pass through the placenta. During the first month of life, neonatal tetanus has a fatality rate of 85 percent and is common in many developing countries; thus, the health benefits to be gained from widespread tetanus immunization of pregnant women are significant. Neonatal tetanus results from nonhygienic treatment of the umbilical cord during delivery and the first week of life. BCG The bacillus of Calmette and Guerin (known as BCG) was derived from bacteria (Mycobacteria bovis) which are closely related to the bacteria (M.tuberculosis) that cause tuberculosis (TB). There have been two important recent developments related to BCG: the availability of a freeze-dried form and the publication of data from India raising serious questions about the value of BCG in protecting against tuberculosis. Data suggest that BCG may protect infants against the more serious life-threatening and meningeal forms of disease. As with other live vaccines, BCG is sensitive to sunlight and warm temperatures. The new freeze-dried vaccine represents a great improvement over the old liquid form because it is more heat stable. The old form, however, is sti 1 1 being produced by some companies, but is generally not recommended for use. When kept at 4°C to 8"C, freeze-dried BCG can be stored safely for one to two years. BCG also can be kept frozen. If it is not kept refrigerated, it will gradually lose its potency. The higher the temperature, the more rapidly potency decreases. The reconstituted vaccine is unstable and, therefore, must be used within eight hours of reconstitution. Overall, BCG is considered a safe vaccine. Mild ulcers are occasionally reported at the site of the intradermal injection. More rarely, inflamed lymph glands are observed, particularly among infants. Serious local reactions can occur when administered subcutaneously and, therefore, the technique of administration is an important factor in its safety. B. Imnrnization Schedules Immunization schedules are deterrnined by considering the health needs of the population, the requirements and costs of the particular vaccines chosen, the resources available, and the way in which services are structured. It i s seldom possible to achieve the ideal schedule because of conflicting needs; therefore, many compromises are necessary. The immunological requirements of the ~accinesmust also be taken into account. Because maternal antibodies can pass through the placenta and the breast milk, they may interfere with an infant's ability to respond to a vaccine and to produce his or her own antibodies. The OPT vaccine, for example, should not be given before the age of six weeks and measles not until nine months of age. A delicate balance is involved, because the goal of completing the series of doses in time to protect the child at high risk may conflict with the goal of delaying vaccination until maternal antibodies subside so the vaccine will "take" well. Much controversy has arisen regarding the best age at which to give measles vaccine. In developed countries, where measles usually occurs after 18 months of age, the vaccination is given around age 15 months. In many developing countries, though, where the incidence of and mortality from measles are high in the first year of life, the age for immunization recommended by the EPI is as soon as possible after nine months of age. Programs that have tried vaccinating for measles at six months have found that a reinforcing dose after the age of one year is often needed to obtain long-lasting immunity. The EPI recommendation is based on a balance of factors such as maternal antibodies, the pattern of weaning, the rates of measles occurrence, and the effectiveness of the vaccine at different ages. For multiple-dose vaccines, the interval between doses presents a similar dilemma. The longer the interval, the better the "take," but completion of the schedule is delayed. For OPT, oral polio, and tetanus toxoid, the minimum interval between sequential doses is one month. The resources available (including the existing health care system) determine the type of schedule that is workable. Because each visit is costly in terms of personnel and transport, the goal is to limit the number of times a child must return for immunizations. Several types of vaccinations can be given at the same time, but the minimum interval between doses must still be observed. When services are organized around mobile teams or special campaigns, six-month intervals are the longest that can be used without leaving too many infants unprotected during the first year of life. Many programs have developed immunization cards which are retained by the parents (often in a plastic envelope) and contain a record of the child's vaccinations and the date of needed return visits. C. Vaccination Equipment For injectable vaccines, supplies of needles and syringes and a method of sterilizing them are needed. Although disposable, presterilized needles and syringes seem convenient, they often pose considerable storage and distribution problems. Reusable glass or nylon syringes work well, and with correct sterilization techniques are quite safe. Alternative means of administering vaccines, other than standard needles and syringes, have also been investigated. For example, a bifurcated (two-lined) needle, originally developed for use in smallpox vaccination campaigns, has been used to administer BCG. It is simpler to use than a standard intradermal needle and syringe, but it seems to produce less effective immunity than intradermal injections and requires a more concentrated and costly form of BCG. Jet injectors which force vaccines through the skin in a pressurized spray without the use of a needle have been tried with BCG, DPT, and measles with varying degrees of success. Concerns about their ability to deliver uniform doses have led to recommendations against their use, especially with BCG vaccine. D. Cold Chain Equipment The cold chain refers to the maintenance of temperature requirements during distribution of heat-sensitive vaccines from the manufacturer to the national vaccine store and eventually to the health workers who give the vaccinations. Numerous challenges exist in maintaining an effective cold chain under the special circumstances often found in developing countries: the lack of reliable electrical power, high temperatures, the variety of transport used to carry vaccines and the time needed to reach remote areas, the shortage of trained equipment maintenance personnel, the difficulties of communication and transportation when repairs or spare parts are needed, and the limited funds available. In recent years, WHO/EPI has played a major role in aiding the development, adaptation, and field testing of equipment to meet these conditions and in disseminating practical information about the results of these activities. The principal elements in the cold chain include: o Cold rooms for bulk storage of vaccine, o Vehicles and systems for refrigerated bulk transport of vaccine, o Refrigerators and freezers for the storage of vaccines, o Cold boxes, carriers, and vaccine packaging, o Ice packs and cold packs for cooling insulated containers, o Thermometers and thermorecorders for monitoring vaccine storage, o Accessories, including alarm systems. E. Increasing Imnunization Coverage Several factors are important in improving coverage. Whenever and wherever infants and pregnant women come in contact with the health system, they should be immunized. Attendance at health facilities in most developing countries tends to occur only at times of illness. Therefore, the World Health Organization recommends immunization of sick children as well as health children, except for those critically i l l and requiring hospitalization. From the standpoint of measles epidemiology, measles immunization during the first contact at, or after, nine months of age is especially important. Most immunizations in the developing world are administered by nurses or paramedical personnel. The interest, however, that the supervisor (physician/nurse) takes in what is done, how it is done, and who is doing it determines in part its success. Where supervisors themselves are involved in immunization, programs usually succeed. When trying to improve coverage, reorienting supervisors' attitudes is important. In the 1970s, logistic problems of vaccine supply and cold chain maintenance were frequently cited as constraints on immunization. As few as 17 out of every 100 measles injections were, in fact, protective. Although there are still areas where there is neither fuel for transportation of vaccine nor kerosene to refrigerate it, immunization is feasible today in most areas of the developing world. Vaccine costs to fully immunize a child are approximately US $1.00. In addition, UNICEF frequently assists in the procurement of appropriate cold chain equipment and immunization supplies. Recognizing that most of the obstacles to successful immunization programs are managerial rather than technical, EPI trains senior and mid-level staff in planning, logistics (including cold chain management), supervision, and evaluation. Additional constraints to coverage include a low demand for these services and superstitions that vaccines are harmful to well children. Parents do not understand the concept of prevention. Further, when a reaction occurs after the first dose of OPT, parents refuse to return for more doses since it made the child i l l , even if the illness was a mild fever. This child will not complete the OPT series or the ClPV and measles series. A mutual understanding of goals among managers, health workers, and communities is essental to success in immunization. When the importance of measles immunization for all infants nine to eleven months of age is recognized and such children are monitored, the probability of success is increased. Communication with and understanding by the public are important. When success is achieved, it needs to be documented and recognized. When quantitative goals are not reached, problems need to be identified and solved. NUTRITION-RELATED TECHNOLOGIES* * This paper was reviewed f o r technical content by A l f r e d Sommer, M.D., I n t e r n a t i o n a l Center f o r Epidemologic and Preventive Ophthalmology, Wilmer I n s t i t u t e , Johns Hopkins U n i v e r s i t y , and Kenneth Brown, M.D., School o f Hygiene and Public Health, Johns Hopkins U n i v e r s i t y , Baltimore, MD. NUTRITION-RELATED TECHNOLOGIES The synergy between i n f e c t i o n and m a l n u t r i t i o n i s now w e l l accepted. There are a s e r i e s of n u t r i t ion-re1 ated technologies and approaches which seem promi sing f o r reducing the consequences of t h i s i n t e r a c t ion. They are d i v i d e d i n t o the f o l l o w i n g areas: A. 1. Growth Monitoring and E a r l y Childhood N u t r i t i o n 2. Breastfeeding and Appropriate Weaning 3. Vitamin A Therapy 4. Food Supplementation and Weaning Foods 5. P o s i t i v e Deviance Studies. Growth Monitorinq and E a r l y Childhood N u t r i t i o n 1 The growth c h a r t i s l i k e an a s t r o l o g e r ' s p r e d i c t i o n f o r your c h i l d ; buy one f o r him. Quoted from an I n d i a n mother The growth c h a r t i s a t o o l f o r both preventive and c u r a t i v e care. In developing countries, the c h i l d i s subjected t o m u l t i p l e i n f e c t i o n s s t a r t i n g a t the age o f s i x months and continuing throughout a l l t h e pre-school years, although they are g r e a t e r i n under threes. These i n f e c t i o n s o f t e n impair growth because they may reduce a p p e t i t e o r i n t e r f e r e w i t h food absorption. Growth can be monitored w i t h a growth c h a r t and t h e information can be used t o improve t h e c h i l d ' s n u t r i t i o n a l status. The major r o l e o f a growth c h a r t i s t o focus the a t t e n t i o n o f h e a l t h workers on promotion o f adequate growth and t o teach mothers. The growth c h a r t i s p a r t i c u l a r l y u s e f u l i n promotion o f adequate growth, but i t i s a l s o u s e f u l f o r i d e n t i f y i n g and managing many childhood diseases. Adequate growth can be achieved o n l y i f the c h i l d i s adequately nourished. I t i s o f t e n assumed i n a r u r a l s o c i e t y t h a t breastfeeding alone w i l l ensure adequate growth up t o the f o u r t h o r even s i x t h month o f l i f e . Research, however, suggests t h a t many c h i l d r e n might be growing inadequately by the t h i r d month. Although c o n t r o v e r s i a l , some studies have shown t h a t c h i l d r e n under s i x months o l d recovering from m a l n u t r i t i o ' n f a i l e d t o catch up i n t h e i r mental development. Measurement o f h e i g h t alone i s o f l i t t l e use i n making day-to-day decisions regarding c h i l d care. Because i t i s d i f f i c u l t t o measure height accurately, t h i s measurement i s n o t s e n s i t i v e t o small changes which might be c r i t i c a l i n diagnosing inadequate growth. Even when a c h i l d i s acutely ill, he does not l o s e h e i g h t i n t h e way he loses weight. Weight changes can be 1. S e l e c t i v e l y excerpted from See How They Grow, Morley & Woodland, 1983. - 30- easily identified. Weight i s a much more n u t r i t i o n a l complications o f i n f e c t i o n . sensitive indicator o f the - Stages of Growth U n t i 1 r e c e n t l y , t h e r e has been i n s u f f i c i e n t research avai l a b l e f o r designing n u t r i t i o n education programs. Recent s t u d i e s on stages o f growth have r e s u l t e d i n important suggestions f o r n u t r i t i o n education. B i r t h t o Three Months: The f i r s t t h r e e months o f l i f e are t h e most important f o r breastfeeding which, however, should r e a l l y continue f o r a t l e a s t two years. The l i f e of t h e c h i l d i n u n d e r p r i v i l e g e d communities depends almost e n t i r e l y on q u i c k l y e s t a b l i s h i n g breastfeeding. The normal c h i l d should g a i n more than 0.5 kg per month d u r i n g t h e f i r s t t h r e e months o f l i f e . I n many communities, a c h i l d begins t o r e c e i v e o t h e r Months 4 t o 6: foods a t about t h i s age although t h i s v a r i e s widely across c u l t u r e s . Weight m o n i t o r i n g i s p a r t i c u l a r l y useful between t h e months t h r e e and s i x t o i d e n t i f y t h e a p p r o p r i a t e time t o supplement breast m i l k . Mothers need t o be encouraged t o g i v e a wide v a r i e t y o f foods. Advice i s needed on h i g h energy foods and t h e i r preparation. Months 7 t o 12: A t t h i s age, t h e signs o f poor growth o f t e n become more obvious. Breast m i l k by i t s e l f i s no longer an adequate source o f energy. The c h i l d no longer has t h e p r o t e c t i o n g i v e n by a n t i b o d i e s t r a n s f e r r e d b e f o r e b i r t h , and r a t e s o f i n f e c t i o n increase. Up t o t h e end o f t h e f i r s t year, b r e a s t m i l k normally contr-ibutes 75 percent o f a c h i l d ' s c a l o r i e s . Mothers must be c o n t i n u a l l y advised t o m a i n t a i n f r e q u e n t breastfeeding. During months seven t o twelve, however, t h e c h i l d should be o f f e r e d d i f f e r e n t foods. Months 13 t o 18: During t h e second year o f 1i f e , t h e l e v e l o f energy I f a c h i l d eats o n l y one l a r g e meal per i n t a k e i s p a r t i c u l a r l y important. Even t h r e e l a r g e meals per day may day, he w i l l be d e f i c i e n t i n c a l o r i e s . be i n s u f f i c i e n t . Research has demonstrated t h a t a c h i l d t y p i c a l l y reduces h i s c a l o r i c i n t a k e by 25 percent when breastfeeding stops. A c h i l d needs a t l e a s t t h r e e l a r g e meals a day as w e l l as snacks. F i n a l l y , the c h i l d should be g i v e n foods t h a t have a h i g h c o n c e n t r a t i o n o f c a l o r i e s t o overcome t h e b u l k problem and balanced n u t r i e n t s . I n t h e second year o f l i f e , t h e c h i l d i n a developiug country i s l i k e l y t o have a t l e a s t two bouts o f s i g n i f i c a n t d i a r r h e a and between f i v e t o t e n times as many i n f e c t i o n s as a c h i l d i n an i n d u s t r i a l s o c i e t y . Many o f these episodes a l s o are l i k e l y t o be more severe and prolonged. Months 19 t o 24: During t h i s period, s p e c i a l a t t e n t i o n must be p a i d t o breastfeeding. Many advantages are t o be r e a l i z e d i f b r e a s t f e e d i n g continues and few, i f any, disadvantages. Unfortunately, many h e a l t h workers s t i l l advise mothers t o stop breastfeeding a f t e r 18 months. Emphasis must continue t o be placed on high-energy foods, especial l y i f t h e mother discontinues breastfeeding. b n t h s ' 2 5 t o 36: During t h e t h i r d year of l i f e , i n f e c t i o n s become l e s s frequent. An East A f r i c a n study showed, however, t h a t energy i n t a k e as a p r o p o r t i o n of needs was lower d u r i n g t h i s p e r i o d than a t any o t h e r p e r i o d d u r i n g chilhood. The c h i l d should have t h r e e n u t r i t i o u s meals a day as w e l l as snacks. Weighing C h i l d r e n Weighing must occur a t an e a r l y stage o f development. It i s t h e h e a l t h w o r k e r ' s f i r s t s u b s t a n t i a l c o n t a c t w i t h t h e mother. As such, t h e a t t i t u d e s o f t h e weigher are important and t h e weigher must speak w i t h t h e mother i n a r e a s s u r i n g manner. L i t t l e thought has been g i v e n t o how a mother views weighing and c h a r t i n g . Many mothers do n o t understand t h a t t h e weight and r a t e of growth o f t h e i r c h i l d r e n are r e l a t e d t o t h e i n t a k e o f b r e a s t m i l k and o t h e r foods. I n some c u l t u r e s , t h e r e may even be a resentment a g a i n s t weighing c h i l d r e n , as t h e mothers may associate weighing w i t h s e l l i n g . Hence, e x p l a n a t i o n should be f u r n i s h e d r e g a r d i n g t h i s important i n t e r v e n t i o n . While t h e weighing i s t a k i n g place, t h e weigher should take t h e o p p o r t u n i t y t o f i n d o u t about t h e c h i l d ' s d i e t , t o discuss what foods are a v a i l a b l e , and t o educate t h e mother concerning t h e c h i l d ' s d i e t i n t h e future. I n instances where weight i s inadequate, i n f o r m a t i o n should be f u r n i s h e d on t h e importance o f adequate food i n t a k e . The w e i g h e r ' s a t t i t u d e must be pleasant and encouraging. An e f f o r t should be made t o ensure t h a t a1 1 c l i n i c workers demonstrate t h a t t h e y are pleased t o see t h e mothers and children. I n a d d i t i o n , t h e a b i l i t i e s and shortcomings o f mothers must be accepted and understood. Because t h e need i s f o r one s c a l e f o r approximately 2,000 people, scales c l e a r l y r e p r e s e n t a major i t e m o f h e a l t h s e r v i c e s expenditure. As such, g r e a t care i s needed i n s e l e c t i n g which t y p e t o use. Several major types o f scales a r e a v a i l a b l e b u t hanging scales and beam balances are t h e o n l y ones s u i t a b l e f o r f i e l d use. Hanging Scales. This type o f scale consists o f a spring t h a t stretches when weight i s hung on it. The e x t e n s i o n o f t h e s p r i n g moves a needle along t h e weight scale. I n t h e past, i t was l i k e l y t o become inaccurate, because t h e s p r i n g ' s c h a r a c t e r i s t i c s change w i t h use. Recent advances i n t h e technology o f s t e e l springs, however, have r e s u l t e d i n improved accuracy and reliability. Modern hanging scales a r e i d e a l f o r weighing l a r g e numbers o f children. Many types o f hanging scales a r e a v a i l a b l e . New d i g i t a l , s e l f z e r o i n g scales o f f e r g r e a t use, r e l i a b i l i t y , and c o s t advantages. The hanging s c a l e can be hung from a r a f t e r , a hook i n t h e doorway, t h e c e i l i n g , o r a t r e e . It should be hung so t h a t t h e d i a l i s on t h e same l e v e l as t h e w o r k e r ' s eyes. Whatever methods o f suspension and m a t e r i a l s f o r h o l d i n g t h e baby, i t i s important t h a t t h e y be based on l o c a l technology and p r a c t i c e . Beam Balance Scales. The major drawback o f t h e beam balance s c a l e i s i t s h i g h purchase price--between US$lOO and $150. Other m i nor disadvantages i n c l u d e t h e d i f f i c u l t y o f weighing o l d e r c h i l d r e n and t h e problem o f h o l d i n g c h i l d r e n s t i l l and p r e v e n t i n g them from t r y i n g t o g e t o f f t h e s c a l e w h i l e t h e weights a r e balanced. Using Growth Charts The growth c h a r t i s d i f f i c u l t t o use c o r r e c t l y . One must ensure t h a t r e l e v a n t i n f o r m a t i o n i s being c o l l e c t e d , t h a t the i n f o r m a t i o n i s entered co,rrectly, and t h a t the h e a l t h worker does n o t f a i l t o e n t e r any o f t h e information. Problems a l s o e x i s t regarding t h e use of i n f o r m a t i o n entered on t h e weight c h a r t . Experience has shown t h a t the concepts necessary f o r understanding and making the appropriate decisions are the most d i f f i c u l t t o teach. Therefore, i t i s necessary t o t r a i n h e a l t h workers thoroughly and carefully. Recording I n f o r m a t i o n The most important i n f o r m a t i o n i s t h e d i r e c t i o n of t h e c h i l d ' s growth curve. The f o l l o w i n g i n s t r u c t i o n s are the b a s i s f o r teaching. F i r s t Weighing o F i n d o u t t h e month and year o f b i r t h o f t h e c h i l d . o W r i t e t h e month and year o f b i r t h on t h e weight c h a r t . o A f t e r w r i t i n g t h e b i r t h month i n t h i s f i r s t box, w r i t e t h e same month i n t h e boxes w i t h a heavier o u t l i n e . o Record t h e months i n between. o Weigh t h e c h i l d . o Place a l a r g e dot on t h e graph on t h e same l e v e l as the weight: on t h e same h o r i z o n t a l l i n e d i r e c t l y above the month and on the same v e r t i c a l l i n e as t h e date o f weighing. L a t e r Weighings o Weigh the c h i l d . o Find t o d a y ' s date along t h e bottom o f t h e graph. o Put another d o t on t h e graph, today, and above t o d a y ' s date. o J o i n t o g e t h e r t h e dots f o r t h e two weighings. opposite the c h i l d ' s weight Interpretation o Look a t t h e Growth Line. o If t h e Note t h e change i n weight between t h e two weighings. weight has increased, t h i s i s good. I f t h e weight has stayed t h e same o r gone down, t h i s i s n o t good. o e. B. If'the child's weight, as marked by the dot, is below the lower line, encourage the mother to increase his food intake and bring him next month. Constraints o For growth monitoring to be effective, children have to be weighed frequently. This requires the use of a scale which is not always culturally acceptable. It also requires that the child be brought to the scale, a journey that may be costly both in terms of money and time. o Growth monitoring has no immediate benefit and is not limited to sick children. It may be inconvenient or even difficult for families to bring a healthy child to the weighing center. o Growth monitoring does not contribute to the profile of a country's health care system and so may not be attractive to political decision-makers. o Unlike ORT and immunization, it is not considered part of the world of "medicine" and, therefore, is frequently neither supported nor understood by medical professionals. o Growth monitoring requires that mothers do something that is frequently costly in terms of either time or resources and has no quick, tangible satisfaction or reinforcement. o Growth monitoring asks mothers to invest considerable time in a well child. o The growth monitoring "product" (the growth chart) is now geared toward health workers more than mothers and is generally not useful or even understandable to most users. o Growth monitoring is a relatively expensive intervention which appears to have few immediate health status benefits. o The actual weighing frequently goes against cultural taboos or restrictions. For example, in Bangladesh, some fathers do not permit their children to be weighed because they believe the fright the child feels hanging in the weighing bag causes i 1 lness. Breastfeeding and Appropriate Weaning Up until approximately 100 years ago, infants worldwide were totally dependent on breast milk for their survival. The introduction of refined milk-based products has presented an alternative to breast milk. Human milk is ideally suited to the needs of the human infant. It provides all of the nutrients an infant needs during its first few months. The colostrum, which is produced in the first week after birth, contains more protein, sodium, zinc, immunoglobulin A, lactoferrin, Vitamin A, and white blood cells and less fat and lactose than mature milk. Breast milk also protects the infants against certain bacteria and viruses. The proport ion of women choosing to breastfeed their infants has been declining in some developing countries. This may in part be because of increasing female employment and lack of provision for feeding during the day. Breast milk substitutes provide adequate and safe nutrition for infants if they are given in sufficient quantities, mixed in the correct proportions with clean water using sterile equipment, and kept cool and free of contamination until used. However, these conditions are extremely difficult to meet in most developing countries. Breast milk substitutes also are expensive. A recent study shows that formula to feed a two-month-old infant costs 40 percent of the salary of a ministry clerk in Burma, 51 percent in Indonesia, Families substituting formula for breast milk are and 13 percent in yemen.' significantly reducing the amount of money available for other essentials. Mothers choosing to breastfeed need family and community support. Their nutritional requirements increase, they need to be with the infant often during the day and night, and they may need to reduce their stress and workload. Most of all, however, they need positive reinforcement and encouragement at the time of birth and throughout lactation. Breastfeeding and appropriate weaning have been demonstrated to have a dramatic impact on infant and child health. The list of benefits is long and well known to public health specialists. Benefits Protection Against Disease: It has long been recognized that the breastfed infant is better protected against infections, especially diarrheal diseases, and has a better chance of survival than a bottle-fed baby. Only recently have the reasons for this difference been established. Studies of breast milk and its affect on the intestine have demonstrated that properties such as lactoferrin, immunoglobulins, lysozyme, white blood cells, and other factors discourage the growth of harmful bacteria, certain viruses, and some parasites. Studies in Brazil, the Philippines, Egypt, and Honduras have demonstrated that breastfed children have lower diarrhea morbidity and lower mortality than their bottle-fed counterparts. Even in the developed world, studies have demonstrated that breastfed babies are healthier. In Britain, o f the 609 infants treated for gastroenteritis at the Queen Elizabeth Hospital in London, only two were breastfed. The link between bottle-feeding and malnutrition also has been demonstrated. For example, in Brazil, among a sample of urban poor school-age children 32 percent of the children who were bottle-fed were malnourished, while only nine percent of the children who had been breastfed for more than six months were malnourished. Lowered Fertility: Breastfeeding, particularly without supplements, tends to increase the period of infertility after delivery. In fact, breastfeeding has a greater impact on birth spacing in developing countries than many family planning programs. Lactating women generally resume menstruation several months later than nonbreastfeeding mothers although there are wide variations. 2. M. Cameron and Y. Hofvander, Manual on Feeding Infants and Young Children, Oxford Medical Publications, Delhi & Nairobi, 1983, p. 87. Protection from Allergies: Breast milk a1 so offers protection from a1 lergic diseases such as infanti le eczemas. Conversely, some a1 lergic diseases and s o m e cases of colic may be provoked by an early introduction of cow's milk. Breastfeeding and Cancer: In developing countries, where the breastfeeding period is usually longer, the rate of breast cancer is considerably lower. Preliminary studies indicate that prolonged and repeated lactation may diminish the risk of breast cancer. Breastfeeding and Mother-Child Bonding: Breastfeeding immediately after birth has been demonstrated to strengthen mother-child bonding in both developing and developed countries. Despite the proven benefits, the reality is that breastfeeding is declining throughout the Third World. Some of the most startling figures come from Chile where 25 years ago 95 percent of the mothers breastfed their children for one year. Now only 20 percent of the women are breastfeeding. The reasons for this decline reflect the realities of the 20th century. Women are increasingly part of the labor force and must work part or full time out of the home. Most of these work situations are not conducive to breastfeeding--working hours are rigid and long and there are usually no nurseries at the workplace. Family structures are changing and the support traditionally provided by grandmothers and older women in extended families does not exist in the urban, semiurban, migrant, or single-parent home. This has resulted in women having less support for breastfeeding. Finally, women's decisions regarding breastfeeding are greatly influenced by attitudes and images. The public health community is well aware of the success of the infant formula companies marketing bottle-feeding as more modern, statusgiving, and "sexy" than breastfeeding. Public health communications incorporating marketing techniques which have been used so effectively to "sell" bottle-feeding has been applied to changing and supporting correct breastfeeding and weaning behaviors. Most breastfeeding campaigns, however, have been used to simply promote the concept that "breast is best," without considering some of the socioeconomic and cultural constraints that motivate mothers to bottle-feed. In addition, although many physicians agree that "breast is bestn they recommend practices that interfere with breastfeeding, i.e., timed feedings and early supplements. Potential Audiences Decision-makers: Public health communications should be used to educate and motivate decision-makers to support mothers of infants through codes and regulations. Ideally, provisions for maternity leave, flexible working hours, part-time work options, breastfeeding breaks, nurseries in the work place and day care facilities for older children are potential objectives for public health communications programs. Public health communications can also assist women to know their rights in countries where legislation already exists. (Unfortunately in some places the results of such laws have been to reduce work opportunities for women.) Medical Professionals: The infant formula companies have done an excellent job of marketing their products both to and through medical professionals. Complimentary milk samples in hospitals, gifts, free trips, and additional training for medical professionals have all been used to involve these important opinion leaders in promoting bottle-feeding. Even in those countries where these practices have been regulated and changed due to the International Marketing Code, Western-trained professionals use drugs to relieve pain or induce labor, which can interfere with the baby's sucking and make the start of breastfeeding difficult. In most hospitals, babies are still separated from their mothers for at least 24 hours so that "the mother can rest." Recent work in hospitals in Indonesia and Honduras have demonstrated a dramatic increase in breastfeeding where public health communications are linked with changes in hospital practices. Families: Breastfeeding is not carried out in a vacuum, but rather within the complex socioeconomic context of modern life. One study in Honduras demonstrated that urban mothers began bottle-feeding, not because they felt that it was healthier for their child, but because the supply of powdered milk was a way that migrant fathers demonstrated they cared about their wives and children. Fathers and children must be educated and motivated to provide a "community of support" to replace that which was traditionally provided by the extended family or the tribe. The MMHP Project in Honduras, for example, targeted fathers for specific behavior to support mothers while they were breastfeeding. Primary health care workers, clinic staff, and upbeat spots taught fathers that the "breastfeeding mother is special and needs special care--additional food, liquids, and tenderness while she is breastfeeding." Mothers Due in part to the marketing success of the infant formula, breastfeeding is suffering from an image problem. Social marketing has been effectively used in several countries to begin to change the image of bottlefeeding as modern. Extensive work in social marketing of breastfeeding demonstrates, however, that even many mothers who believe that "breast is best" do not have either the knowledge or the skills to breastfeed effectively. In Honduras for example, the MMHP project found that virtually no mothers understood the relationship between suckling and milk production and so would bottle-feed if they felt their child was still hungry. They were also breastfeeding incorrectly--usually for just a few moments whenever the child cried. The resulting strategy focused on teaching mothers the relationship between suckling and milk production and specific skills such as emptying the breast at each feeding and feeding from both breasts to increase milk production. Constraints o Promotion of breastfeeding requires counteracting the promotion of breast milk substitutes. The International Code establishes principles agreed to by most governments, but health care providers, pol it ical 1 eaders, and local shopkeepers may not be aware of the dangers of the incorrect use of substitutes and the advantages of breastfeeding. o Mothers may choose not to breastfeed or stop breastfeeding too soon because of their income-generating responsibilities. Employers, other members of cooperative organizations, and other income earners in the family need to be flexible about t h e demands they place on breastfeeding mothers although t h i s may be d i f f i c u l t t o implement. o ~ e c h n i ~ uon e how t o breastfeed, qua1 i t y o f breastfeeding, how much i s given, where o t h e r foods are introduced, and t h e use o f colostrum are c r i t i c a l . It i s n o t enough t o promote general messages such as " b r e a s t i s best." Careful analysis o f b r e a s t f e e d i n g p r a c t i c e s must lead t o more s p e c i f i c messages aimed a t p a r t i c u l a r problems. V i t a m i n A Therapy It i s estimated t h a t 500,000 c h i l d r e n i n developing c o u n t r i e s a r e b l i n d e d S i g n i f i c a n t l y higher i n f a n t each year because o f Vitamin A d e f i c i e n c e s . m o r t a l i t y r a t e s among c h i l d r e n one t o f i v e years o l d w i t h m i l d V i t a m i n A d e f i c i e n c i e s , o r xerophthalmia (on average f o u r time? h i g h e r t h a n m o r t a l it y r a t e s o f normal c h i l d r e n ) , have a l s o been observed. D r . Sommer estimates t h a t as much as 20 t o 30 percent o f i n f a n t deaths i n developing c o u n t r i e s may be associated w i t h m i l d xerophthalmia. I n s u f f i c i e n t Vitamin A r e s u l t s i n t h e k e r a t i n i z a t i o n (abnormal maturation) o f n o t o n l y t h e cornea, t h u s causing blindness, b u t a l s o o f important mucous membranes found i n t h e surface 1 i n i ngs o f r e s p i r a t o r y , u r i n a r y , and i n t e s t i n a l t r a c t s . This insufficiency impairs the surface l i n i n g ' s a b i l i t y t o keep o u t b a c t e r i a and e v e n t u a l l y p r o v i d e s an e x c e l l e n t breeding ground f o r b a c t e r i a . Consequently, m i l d xerophthalmia predisposes c h i l d r e n t o two t o t h r e e times more a t t a c k s of d i a r r h e a and r e s p i r a t o r y diseases. Indeed, r e s u l t s from a f i e l d t r i a l conducted by D r . Sommer i n Indonesia demonstrate t h a t V i t a m i n A d e f i c i e n c y i s more i m p o r t a n t t o t h e development o f d i a r r h e a and r e s p i r a t o r y diseases t h a n i s t h e o v e r a l l n u t r i t i o n a l status. Benefits Xerophthalmia i s e f f e c t i v e l y t r e a t e d and prevented by V i t a m i n A, which can be administered i n a v a r i e t y o f ways. V i t a m i n A i s present i n n a t u r a l foods, such as dark green, l e a f y vegetables, y e l l o w f r u i t s and a l s o can be prepared i n capsule form o r added t o common foods (such as sugar, wheat f l o u r , maize meal, m i l k powder, f a t s o i l s and weaning foods and seasonings (monosodium glutamate and s a l t ) I n Indonesia, D r . S o m e r administered two Vitamin A capsules (each capsule c o s t s between two t o f o u r c e n t s ) s i x months a p a r t and observed a r e d u c t i o n i n m o r t a l i t y among t h e c h i l d r e n who r e c e i v e d S t u d i e s i n Guatemala and Costa t h e Vitamin A o f approximately 30 percent. Rica demonstrate t h e e f f e c t i v e n e s s o f sugar f o r t i f i e d w i t h V i t a m i n A. Prior .' 3. Somer, A., Tarwotjo, I.,Hussaini, G., Susanto, D., "Increased M o r t a l i t y i n M i l d Vitamin A Deficiency," Lancet, 2, 1983, pp. 585-588. 4. Bauernfeind, J.C., The Safe Use o f V i t a m i n A - A Report I n t e r n a t i o n a l Vitamin A C o n s u l t a t i v e Group (IVACG), 1980, p. 10. of the to fortification, 18.2 percent of Guatemala's preschool children had low Vitamin A levels; after two years of fortification, this figure dropped to 0.3 percent. Costa Rica,had a 32.5 percent incidence of Vitamin A deficiency in 1966 which dr pped to 2.3 percent in 1978 after three years of Vitamin A fortification.! As indicated earlier, Vitamin A will not only treat xerophthalmia and prevent blindness, but it may alsa reduce susceptibility to other major causes of childhood mortality--notably diarrhea and respiratory diseases. If this is true in countries other than Indonesia, then it will be evident that Vitamin A can become yet another powerful and complementary tool in reducing infant mortality throughout the world. Constraints 0. o Large doses of Vitamin A are toxic if given too frequently. Unless a child shows signs of xerophthalmia, capsules should not be given more than once every two or three months, though once every four to six months will prevent most blindness and deaths. This schedule may be difficult to maintain where health care iystem coverage is meager. o In many societies, the early signs of xerophthalmia are not recognized as abnormal. Children with mild xerophthalmia who do not receive Vitamin A will move fairly rapidly into a stage where the disease cannot be cured and partial or complete blindness will follow. Food Supplementation and Weaning Foods Malnutrition in early childhood, primarily due to deficiences of protein and calories, is considered by many experts to be the world's number one public health problem. In addition to protein-calorie malnutrition (PCM), other forms of severe malnutrition are widespread among children in some developing countries, notably iron-deficiency anemia and Vitamin A deficiency, which is the most common cause of blindness in severely affected areas (see above). Up to two-thirds of the 400 million children in the world below the age of five suffer from malnutrition, which is not dramatically apparent, but which markedly diminishes their ability to withstand infections and hinders their normal growth and development. A major proportion of weaning malnutrition is caused by lack of education, incorrect food and health beliefs, and poor feeding and health practices. For example, in Burma a review of several surveys indicates that Burmese women, particularly in rural areas, withhold primary protein sources from children being weaned, believing the foods will cause allergies, and purges also are used because of cultural beliefs. - 5. Caplan, E., "Vitamin A Decreases Death Rate", Frontlines, March 1985. - 39- Poor communities exist in many LDC's where nutrition education cannot be effective without simultaneous increases in real income. Nutrition education teaches better use of resources already available to the family. If these resources do not exist, redistribution efforts will not help. Zeitlin (1978) has calculated that if the family cannot afford the three to five percent of total family caloric intake required by the youngest child, nutrition education probably will have little effect. Improved food availability by gardening or other agricultural activities is obviously a necessary component of improved child nutrition. The challenge of food supplementation for young children is to determine the best mix of methods to improve weaning food behavior and practices, given the diversity of causes of infant and early childhood malnutrition and death. The introduction of other foods (together with breast milk) which are the most appropriate for the particular culture is the primary goal. This will require scientific research on the quality and availablility of such foods and on methods of preparing them and must consider local circumstances, culturally acceptable and available foods, available cooking facilities, and current weaning food beliefs and practices, to name just a few. In addition, where there is a cash economy, particularly in urban areas, it will be important to advise mothers about the most nutritious and least expensive weaning foods., - Ideally, a child should be gradually weaned to well-cooked nutritious mashed and/or chopped foods. During this period, the infant will adjust to the mechanics of chewing, to new tastes and textures, and to the nonsterile nature of the new foods. In some parts of the world, however, breastfeeding can be stopped abruptly or prolonged for up two years by those who do not realize the connection between such practices and infant and child malnutrition. In other parts of the world, certain nutritious and available products are not fed to children because of traditional be1 iefs and taboos. In addition, many traditional societies reserve the most nutritious foods for the adult males within the family or distribute the food in a hierarchical order that leaves women and young children ti 1 1 the end. Finally, food bulk may limit the amount of food a child's stomach can comfortably hold. Because cereals absorb two to three times their volume of water when cooked, young children on cereal-grain diets are unable to eat enough to support growth. The problem of bulkiness can be solved either by providing smaller, more frequent feedings or by increasing the density of nutrients in the food. Usually, weaning foods are not offered to the child frequently enough. Field workers in India have been successful in educating mothers to feed the child its total daily ration in smaller, more frequent meals. As a result, preschoolers have been able to eat sufficient calories and protein to support growth. The general characteristics of good weaning food or diet include high energy and protein content, good supplementary micro-nutrients, acceptability to parents and infant, locally produced with local ingredients, available in dry form which is easily stored in tropical environments and which can be easily prepared by boiling or by the addition of freshly boiled water, and minimum bulk and maximum availability of nutrients. Methods of weaning food production general ly may be characterized as conimercial , v i 1 1 age (or community), and home. Each of these approaches is discussed briefly below. -., ~omnercial Production: Commercially processed foods involve more sophisticated and costly technology than is used in home or village production and allows production on a large scale. In addition, vitamin and mineral mixes may be added to the these foods more easily than is to foods prepared at home. Village Production: Village production of food is similar to home production, with the exception that the local miller prepares the ingredients. The actual weaning food continues to be prepared at home. Village-level blends cost significantly more than an equivalent quantity of staples, even per unit of protein. The cost differential represents the price of the improved quality (usable protein and nutrient density) achieved through the application of food technology. A combination of industrially processed ingredients distributed in bulk to villages for mixing also deserves consideration. Home Production: From a technological point of view, home production is the simplest method of developing a weaning food; home production relies on ordinary techniques of food preparation and thus can be easily implemented. This approach decreases costs to the needy population and increases community participation. Locally available foods, such as cereals and legumes may be combined with a dark green leafy vegetable to provide a nutrient-dense diet for the child. A number of countries have developed recipes for multimix dishes that make use of nutritionally adequate foods that are available local ly. Recipes for weaning foods stress the use of low-cost, locally available foods. A recipe that is practical in one season, however, may not be in another season because the basic ingredients are unavailable. If interventions are to be successful, a series of weaning recipes may need to be developed to reflect seasonal variations in the availability of certain foods. In addition, .hygiene will remain an important, unresolved problem unless carefu1,attention is given to proper instruction. In addition to the problem of malnourished infants, food supplementation strategies can and must address the problem of maternal undernourishment and low birth weight (LBW) infants. As noted previously, an estimated 20 million LBW infants--90 percent of them in developing countries--are born each year and are more than three times as likely to die in infancy than bpbies of normal weight. The most important factor in LBW is the mother's own level of nutrition; quite simply, if the mother does not have enough to eat--roughly 2,500 calories a day--then the growing fetus will not receive the nourishment it needs. Preventing LBW by supplementing the diet of at-risk pregnant mothers promises to be one of the most effecti've ways of breaking into the infectionmalnutrition cycle. A total supplement of 10,000 calories for a severely malnourished pregnant woman during the last trimester can increase her baby's birth weight by 50 grams. An average of 600 calories per day for those three months could lead to an increase of approximately 300 grams. To date, however, maternal food supplementation programs have not been particularly successful. Many tend to be expensive, logistically complicated, and limited in effectivs coverage. Alternative delivery approaches using community d i s t r i b u t i o n mechanisms and l o c a l p r o d u c t i o n as much as p o s s i b l e must be developed and tested. p o s i t i v e Deviance Studies Mechanisms which enable some households i n impoverished environments t o b r i n g up h e a l t h y w e l l nourished c h i l d r e n have been r e f e r r e d t o under t h e name " p o s i t i v e deviance." The p o s i t i v e d e v i a n t i s t h e young c h i l d who d e v i a t e s f a v o r a b l y from expected norms of poor growth and ill health. Most previous n u t r i t i o n research i n developing c o u n t r i e s has focused on t h e problems o f m a l n u t r i t i o n from a c u r a t i v e p e r s p e c t i v e and has n o t s t u d i e d t h e w e l l nourished. The few s t u d i e s comparing w e l l nourished and malnourished c h i l d r e n p o i n t t o t h r e e types o f v a r i a b l e s associated w i t h good growth under c o n d i t i o n s o f socioeconomic underdevelopment and poverty: o Psycho-social and behavioral interaction, t h e i r individual network s u p p o r t i n g t h e dyad; aspects o f t h e mother-child temperaments, and t h e s o c i a l o Known sociodemographic c o r r e l a t e s o f m a l n u t r i t i o n , such as mother's education, f a m i l y s i z e and b i r t h spacing, u t i l i z a t i o n o f modern h e a l t h services, and o t h e r f a c t o r s associated w i t h growth s t a t u s i n low income environments; o P h y s i o l o g i c a l determinants o f growth, i n c l u d i n g maternal h e i g h t and weight, m o r b i d i t y , d i e t a r y i n t a k e of n u t r i e n t s , and so forth. The main purpose o f s t u d y i n g p o s i t i v e deviance i s t o l e a r n from adaptive c h i l d c a r e and f e e d i n g behaviors and t h e s o c i a l networks t h a t support them and t o develop programs t h a t t r a n s f e r these adaptive mechanisms a t low c o s t t o t h e f a m i l i e s o f t h e malnourished. F i n d i n g s Already Appl i c a b l e t o Program Design: o C h i l d b i r t h r o u t i n e s t h a t p e r m i t a neonatal "bonding" experience i n which t h e i n f a n t i s p u t d i r e c t l y t o t h e mother's b r e a s t may reduce t h e r i s k o f l a t e r n e g l e c t f u l o r harmful c h i l d c a r e p r a c t i c e s f o r h i g h r i s k mothers whose b o r d e r l i n e p s y c h o l o g i c a l readiness f o r motherhood predisposes them t o such harmful behav- io r . o P r a c t i c e s o f a b r u p t l y sending o l d e r i n f a n t s and newly weaned t o d d l e r s away from home t o lrive w i t h "grannies" o r i n o t h e r f o s t e r i n g arrangements should be discouraged. o E a r l y childhood i n t e r v e n t i o n s t h a t teach mothers t o s t i m u l a t e t h e i r i n f a n t ' s p s y c h o l o g i c a l development should a l s o have a A nutrition/health b e n e f i c i a l e f f e c t on growth s t a t u s . component i n these programs should enhance t h i s e f f e c t . . o Prenatal n u t r i t i o n programs t h a t increase b i r t h weight and reduce p r e m a t u r i t y are favorable t o an i n f a n t ' s behavioral competence .and increase i t s abi 1 i t y t o o b t a i n food and psychological s t i m u l a t i o n from the mother. o Postnatal n u t r i t i o n programs a l s o enhance t h e i n f a n t ' s behavioral c o n t r i b u t i o n t o a p o s i t i v e outcome by i n c r e a s i n g i t s energy l e v e l and t h e s t r e n g t h of i t s food e l i c i t i n g behaviors. o E x i s t i n g program types, such as primary h e a l t h care, growth m o n i t o r i n g , f a m i l y planning, female education, women's income generating a c t i v i t i e s , and so f o r t h , support the psychosocial c h a r a c t e r i s t i c s t h a t c h a r a c t e r i z e t h e mothers o f p o s i t i v e deviant children. o N u t r i t i o n programs r e l y i n g on v o l u n t a r y v i l l a g e workers may be most successful i f they e n l i s t p o s i t i v e d e v i a n t mothers t o organize mothers' c l u b s and t o p r o v i d e outreach t o the e n t i r e community, w i t h a focus on reaching t h e most e l u s i v e and secluded. o Social l e g i s l a t i o n t h a t obligates fathers t o f i n a n c i a l l y support t h e i r c h i l d r e n i s badly needed i n r a p i d l y modernizing areas where customary l e g a l and moral o b l i g a t i o n s have broken down. o Where churches, o t h e r r e l i g i o u s groups, o r o t h e r e x i s t i n g community organizations are strong and a l t r u i s t i c in o r i e n t a t i o n , they should be encouraged t o reach o u t t o u n e n r o l l e d community members. BIRTH SPACING I N DEVELOP1 NG COUNTRI E S Prepared by Margot L. Zimnennan Danusia Szumowski PIACT/PATH Washington, D.C. S t u d i e s i n I n d i a , T u r k e y , t h e P h i l i p p i n e s , and Lebanon have shown t h a t i n f a n t m o r t a l i t y . r a t e s f o r b a b i e s b o r n w i t h i n one y e a r o f a s i b l i n g ' s b i r t h a r e between two and f o u r t i m e s h i g h e r t h a n f o r b a b i e s b o r n a f t e r A s i m i l a r s u r v e y o f 6,000 women i n an i n t e r v a l o f t w o y e a r s o r more. I n d i a has shown i n f a n t m o r t a l i t y r a t e s o f a p p r o x i m a t e l y 8 0 p e r 1,000 when t h e i n t e r v a l between b i r t h s was t h r e e t o f o u r y e a r s , b u t 200 p e r 1,000 when t h e i n t e r v a l between b i r t h s was l e s s t h a n one y e a r . In f a c t , f i n d i n g s from 4 1 d e v e l o p i n g c o u n t r i e s i n c l u d e d i n t h e W o r l d F e r t i l i t y Survey program i n d i c a t e t h a t c h i l d r e n b o r n l e s s t h a n t w o y e a r s a p a r t a r e much more l i k e l y t o d i e i n i n f a n c y o r e a r l y c h i l d h o o d t h a n t h o s e whose b i r t h s a r e spaced t w o y e a r s o r more a p a r t . C u r r e n t l y , some t e n m i l l i o n i n f a n t s d i e each y e a r i n t h e T h i r d World. It i s e s t i m a t e d t h a t a major expansion o f f a m i l y p l a n n i n g s e r v i c e s l e a d i n g t o l e n g t h e n i n g t h e b i r t h i n t e r v a l c o u l d c u t t h e s e d e a t h s by h a l f o r more.1 S t u d i e s i n b o t h i n d u s t r i a l i z e d and devel o p i n g c o u n t r i e s , however, h a v e a l s o shown t h a t " t o o many" c a n be a l m o s t as dangerous as " t o o c l o s e . " Research i n China, E l Sal vador, C h i l e , a n d G r e a t B r i t a i n , f o r example, has shown t h a t t h e chances o f s u r v i v a l f o r t h e f i r s t and second c h i l d a r e s l i g h t l y h i g h e r t h a n f o r t h e t h i r d c h i l d and very s i g n i f i c a n t l y h i g h e r t h a n f o r t h e f o u r t h and f i f t h c h i l d i n a f a m i l y . I n f a n t m o r t a l i t y - r a t e s i n E l S a l v a d o r a r e a p p r o x i m a t e l y 6 0 p e r 1,000 f o r f i r s t - b o r n c h i 1 dren, and r i s e t o 160 p e r 1,000 among f i f t h and subsequent c h i l d r e n . 2 F i n a l l y , b i r t h s t o women who a r e y o u n g e r t h a n 20 o r o l d e r t h a n 35 a r e a l s o known t o i n c r e a s e t h e r i s k s t o b o t h m o t h e r and c h i l d . Studies i n A l g e r i a , Mexico, and t h e U n i t e d S t a t e s have a l l c o n c l u d e d t h a t a c h i l d b o r n t o a woman under t h e age o f 20 i s a p p r o x i m a t e l y t w i c e a s l i k e l y t o d i e i n i n f a n c y as a c h i l d b o r n t o a woman i n h e r mid-20s. After the age o f 30, t h e l e v e l o f r i s k a g a i n begins t o r i s e . These r i s k s t o l i f e and h e a l t h , summarized by " t o o c l o s e , t o o many, t o o 01 d, o r t o o young," hold t r u e f o r a l l income groups, thou$ i n each c a s e t h e i n c r e a s e i n r i s k i s e x a c e r b a t e d by p o v e r t y . Worldwide, a t l e a s t h a l f of t h e women who a r e now a t r i s k o f a n unwanted pregnancy a r e n o t u s i n g any e f f e c t i v e method o f f a m i l y p l a n n i n g . Increasing women's c o n t r o l o v e r t h e i r own f e r t i l i t y , t h e r e f o r e , c o u l d c l e a r l y h a v e a r e v o l u t i o n a r y i m p a c t on t h e h e a l t h o f m o t h e r s as we1 1 as t h e g r o w t h and s u r v i v a l o f t h e i r c h i l d r e n . I n p r a c t i c e , however, many women h a v e n e i t h e r t h e means n o r t h e freedom t o e x e r c i s e t h a t p r e f e r e n c e . B. METHODS Recent c o n t r a c e p t i v e prevalence surveys i n a v a r i e t y o f c o u n t r i e s d e m o n s t r a t e a heavy r e l i a n c e by most o f t h e w o r l d ' s p o p u l a t i o n on a v e r y s m a l l number o f c o n t r a c e p t i v e methods. Worldwide o u t o f n e a r l y 8 0 0 m i l l i o n m a r r i e d c o u p l e s o f r e p r o d u c t i v e age a b o u t 325 m i l l i o n , o r o n l y 4 1 p e r c e n t , a r e t h o u g h t t o u s e an e f f e c t i v e , modern f o r m o f c o n t r a c e p t i o n . Of t h e s e , a b o u t 136 m i l l i o n r e l y on v o l u n t a r y male o r f e m a l e s t e r i l i z a t i o n ; 70 m i l l i o n u s e t h e IUD ( 5 1 m i l l i o n i n C h i n a a l o n e ) ; 55 m i l l i o n u s e o r a l c o n t r a c e p t i v e s ; and 37 m i l l i o n u s e condoms. Use o f a l l o t h e r e f f e c t i v e modern methods ( s u c h as i n j e c t a b l e s and o t h e r b a r r i e r - m e t h o d s ) may t o t a l a n o t h e r 30 m i l l i o n . An a d d i t i o n a l 20 t o 40 m i l l i o n c o u p l e s may u s e methods such as p e r i o d i c abstinence, w i t h d r a w a l , o r o t h e r t r a d i t i o n a l forms of b i r t h c o n t r o l . The l i m i t e d d a t a a v a i l a b l e suggest t h a t each y e a r somewhere between 40 and 45 m i l l i o n womn undergo i n d u c e d a b o r t i o n s , about h a l f of them i l l e g a l procedures. One e s t i m a t e i s t h a t 20 m i 1 l i o n of t h e s e procedures f o l 1 ow c o n t r a c e p t i v e f a i l u r e - - a s t r o n g i n d i c a t i o n of t h e inadequacies of b o t h c u r r e n t c o n t r a c e p t i v e choices and c o u p l e s ' knowledge of h w t o p r o p e r l y use whatever method t h e y s e l e c t .3 The e f f e c t i v e n e s s of c o n t r a c e p t i v e methods can be viewed i n two ways: (1) t h e o r e t i c a l effectiveness, which d e s c r i b e s t h e 1 o w s t observed pregnancy ( o r f a i l u r e ) r a t e i n 100 users who s t a r t o u t t h e y e a r u s i n g a g i v e n method and who use i t c o r r e c t l y and c o n s i s t e n t l y under o p t i m a l c o n d i t i o n s ; and ( 2 ) t h e u s e - e f f e c t i v e n e s s r a t e , which d e s c r i b e s t h e f a i l u r e r a t e i n 100 " t y p i c a l " o r a c t u a l u s e r s who s t a r t out t h e y e a r u s i n g a g i v e n method. The a c t u a l r a t e s gauge e f f e c t i v e n e s s f o r a " t y p i c a l " group o f u s e r s , some a f whom may n o t be u s i n g t h e m t h o d c o r r Botn t y p e s o f pregnancy r a t e s a r e usual l y e c t l y o r consistently. r e p o r t e d f o r t h e f i r s t y e a r o f use. Longer-term u s e r s experience 1 ower pregnancy r a t e s , p a r t l y because they have found an e f f e c t i v e method t h a t is convenient f o r thern.4 - A1 1 o f t h e m a j o r c o n t r a c e p t i v e methods can be q u i t e e f f e c t i v e when used p r o p e r l y , as judged by t h e l o w e s t observed pregnancy r a t e s r e p o r t e d i n m a j o r s t u d i e s . A c t u a l o r " t y p i c a l " pregnancy r a t e s a r e low f o r volunt a r y s t e r i l i z a t i o n , o r a l c o n t r a c e p t i v e s , and IUDs. A c t u a l pregnancy r a t e s a r e somewhat h i g h e r f o r condoms, diaphragms, spermi cides, and p e r i o d i c abstinence. The d i f f e r e n c e s between t h e 1 owest observed pregnancy r a t e s and t h e a c t u a l pregnancy r a t e s f o r t h e s e methods i n d i c a t e t h a t t h e r e i s some d i f f i c u l t y i n u s i n g t h e method o r t h a t t h e method i s i n a p p r o p r i a t e f o r c e r t a i n people. I t i s p r e c i s e l y f o r t h e s e reasons t h a t t h e r o l e o f h e a l t h e d u c a t i o n and Speci f i c a l l y , approe f f e c t i v e communication cannot be overestimated. p r i a t e and e f f e c t i v e e d u c a t i o n a l s t r a t e g i e s and c o u n s e l i ng can he1 p b r i d g e t h e gap between t h e l o w e s t observed pregnancy r a t e s and a c t u a l r a t e s f o r any g i v e n p o p u l a t i o n . For example, t h e p i 1 1 has t o be t a k e n Likewise, i t i s each d a y - - t h u s a new b e h a v i o r has t o be learned. i m p o r t a n t t o t e a c h u s e r s t h a t condoms, diaphragms, and s p e r m i c i d e s r m s t be used d u r i n g each a c t o f sexual i n t e r c o u r s e . Methods which r e q u i r e p e r i o d i c a b s t i n e n c e need p a r t i c u l a r l y e f f e c t i v e c o u n s e l i n g and e d u c a t i o n programs t o h e l p c o u p l e s i d e n t i f y when o v u l a t i o n has t a k e n p l a c e and t o a v o i d i n t e r c o u r s e d u r i n g f e r t i l e days. The e f f e c t i v e n e s s o f a c o n t r a c e p t i v e method a l s o depends on why i t i s used. W i t h most methods, c o u p l e s who have a l l t h e c h i l d r e n t h e y want and so i n t e n d t o p r e v e n t f u r t h e r b i r t h s e x p e r i e n c e f e w e r unplanned pregnancies t h a n couples who want more c h i 1 d r e n eventual l y but i n t e n d t o delay b i r t h s . The d i f f e r e n c e p r o b a b l y occurs because couples who want n o more c h i l d r e n a r e more m o t i v a t e d t o u s e c o n t r a c e p t i v e s c o r r e c t l y and c o n s i s t e n t l y . Lack o f ' p e r s o n a l m o t i v a t i o n i s n o t always t h e cause o f 1ow c o n t r a c e p t i v e p r e v a l e n c e . Many o f t h e n o n u s e r s of c o n t r a c e p t i o n l i v e i n T h i r d W o r l d c o u n t r i e s where c o n t r a c e p t i v e u s e r a t e s a r e u s u a l l y u n d e r 1 0 p e r c e n t o f t h e r e p r o d u c t i v e - a g e p o p u l a t i o n (compared t o 65-75 p e r c e n t i n Western c o u n t r i e s ) .5 A c c o r d i ng t o l o n g i t u d i rial s t u d i e s , a s i g n i f i c a n t p r o p o r t i o n o f t h e s e c o u p l e s a r e h a v i n g more c h i l d r e n t h a n t h e y want. Most f i n d t h e i d e a o f p l a n n i n g d e s i r a b l e i n p r i n c i p l e. U n f o r t u n a t e l y , many e i t h e r l a c k r e a d y a c c e s s t o a f f o r d a b l e farni l y p l a n n i n g s e r v i c e s o r f a i l t o f i n d a n a c c e p t a b l e method -among t h e c h o i c e s a v a i l a b l e . F o r example, i n 29 low-income c o u n t r i e s i n A s i a and L a t i n America, h a l f o f t h e women i n t e r v i e w e d f o r t h e W o r l d F e r t i l i t y Survey s a i d t h e y wanted no more c h i l d r e n , b u t o n l y a b o u t a q u a r t e r o f them were u s i n g an e f f e c t i v e c o n t r a c e p t ive method. U n f o r t u n a t e l y , many c o n t r a c e p t i v e u s e r s i n t h e T h i r d W o r l d d i s c o n t i n u e use r a t h e r q u i c k l y . Much o f t h i s d i s c o n t i n u a t i o n c o u l d be p r e v e n t e d by s e n s i t i v e p r o v i s i o n o f fami l y p l a n n i n g s e r v i ces, a p p r o p r i a t e e d u c a t i o n a l m a t e r i a l s , p r o p e r c o u n s e l i n g as t o t h e s u i t a b i l i t y o f v a r i ous methods, and good g e n e r a l h e a l t h s e r v i c e s and f o l low-up. W o r l d F e r t i l i t y S u r v e y d a t a show t h a t fami l y p l a n n i n g methods can b e e f f e c t i v e l y used t o a v o i d pregnancy, and t h a t c o n t r a c e p t i v e u s e r s have l o n g e r b i r t h i n t e r v a l s t h a n nonusers. The d i f f e r e n c e s v a r y , dependi n g - o n t h e l e n g t h o f b r e a s t f e e d i ng and o t h e r f a c t o r s , f r o m l e s s t h a n one month i n Bangladesh a n d Turkey t o more t h a n t e n months i n Paraguay a n d S y r i a . S i m i l a r l y , t h e Danfa Comprehensive R u r a l H e a l t h and F a m i l y P l a n n i n g P r o j e c t i n Ghana f o u n d t h a t t h e mean b i r t h i n t e r v a l of c o n t r a c e p t i v e u s e r s was f i v e t o s i x months l o n g e r t h a n t h a t of nonusers. W h i l e t h e p e r f e c t method of c o n t r a c e p t i o n has n o t y e t been d i s c o v e r e d , c o u p l e s t o d a y who w a n t t o space t h e i r c h i 1 d r e n can choose among numerous r e v e r s i b l e methods. Each has c e r t a i n a d v a n t a g e s and d i s a d v a n t a g e s , w h i c h must be c a r e f u l l y weighed based on i n f o r m a t i o n p r o v i d e d t o t h e new o r p o t e n t i a l a c c e p t o r . I t s h o u l d be remembered t h a t w h i l e most methods o f c o n t r a c e p t i o n have c e r t a i n r i s k s , m u l t i p l e c l o s e l y spaced b i r t h s pose much g r e a t e r r i s k s t o t h e h e a l t h and l i f e o f t h e mother and h e r c h i 1 dren. 1 . O r a l Cont r a c e p t ives M o r e t h a n 55 m i l l i o n women a r o u n d t h e w o r l d a r e u s i n g o r a l c o n t r a Their popularity i s r e l a t e d t o t h e i r high l e v e l s c e p t i v e s (OCs). o f e f f e c t i v e n e s s , o v e r a l l s a f e t y , and a c c e s s i b i l i t y t h r o u g h comnerc i a 1 and p u b l i c l y s u b s i d i z e d c h a n n e l s as w e l l as t h r o u * p r i v a t e p h y s i c i a n s . Even i n c o u n t r i e s where laws o r i n a d e q u a t e p u b l i c h e a l t h s e r v i c e s 1 i m i t c o n t r a c e p t i v e a v a i l a b i lit y , OCs a r e u s u a l l y a v a i l a b l e i n pharmacies and o t h e r c o m n e r c i a l o u t l e t s t o women who can a f f o r d them. I n d e v e l o p e d c o u n t r i e s , where almost a1 1 u s e r s buy t h e i r OCs, s a l e s dropped d u r i n g t h e m i d t o l a t e 1970s, b u t r o s e a g a i n i n t h e 1980s. I n t h e T h i r d World, p u b l i c and p r i v a t e f a m i l y p l a n n i n g programs s u p p l y a1 1 b u t a m a 1 1 p e r c e n t a g e o f u s e r s . In d e v e l o p i n g c o u n t r i e s , t h e U.S. Agency f o r I n t e r n a t i o n a l Devel opment O t h e r donors p r o v i d e s a p p r o x i m a t e l y 100 m i 1 l i o n c y c l e s annual l y . and in t e r n a t i o n a l a g e n c i e s p r o v i d e a p p r o x i m a t e l y 20 m i l l i o n a d d i t i o n a l c y c l e s each y e a r . - K n w l e d g e o f t h e b e n e f i t s o f p i 1 1 u s e has grown c o n s i d e r a b l y i n r e c e n t years among t h o s e i n t h e medical community who a r e a b l e t o keep a b r e a s t o f c u r r e n t research. ( B u t t h e s e h e a l t h b e n e f i t s s t i l l need-to be w i d e l y communicated t o a1 1 l e v e l s o f t h e p o p u l a t i o n . ) I m p o r t a n t h e a l t h b e n e f i t s o f o r a l c o n t r a c e p t i v e s have been i d e n t i f i e d i n a d d i t i o n t o t h e p r e v e n t i o n of c l o s e l y spaced pregnancies. A t t h e same time, i t has become c l e a r t h a t t h e r i s k s a s s o c i a t e d w i t h o r a l c o n t r a c e p t i v e s a r e l a r g e l y c o n f i n e d t o women over age 35 and e s p e c i a l l y t o women over. 35 who smoke. The r i s k f o r younger women i s s l i g h t . Although more research i n t o t h e p o s s i b l e h e a l t h r i s k s o f c o n t r a c e p t i v e s t e r o i d use s p e c i f i c t o women i n developing count r i e s would be valuable, research so f a r i n d i c a t e s t h a t t h e i r o v e r a l l impact i s b e n e f i c i a l t o h e a l t h . For example, t h e p i l l causes decreased menstrual flow, a b e n e f i t t o women w i t h i r o n d e f i c i e n c y anemi a, a c o n d i t i o n p r e v a l e n t i n p o o r l y n o u r i s h e d popul at i o n s w i t h i n t e r n a l p a r a s i t e s , and m a l a r i a , as w e l l as among women who have borne many c h i 1 dren. W h i l e OCs a r e e x t e n s i v e l y used i n t h e 'Third World, c o n t i n u a t i o n and There a r e numerous v a r i a b l e s t h a t acceptance r a t e s va ry w i d e l y . can adversely a f f e c t successful OC use, such as t h e l o g i s t i c s o f r e s u p p l y and t h e l i k e l i h o o d t h a t p r o p e r p i l l use w i l l n o t be exp l a i n e d t o t h e user. Also, myths can p l a y a c e n t r a l r o l e i n d e t e r m i n i ng c o n t r a c e p t i v e e f f e c t i v e n e s s . For example, some common m i sconceptions a r e t h a t p i 1 1s should o n l y be t a k e n i f sexual i n t e r c o u r s e i s expected o r t h a t i t does n o t m a t t e r i f p i l l s a r e t a k e n i n t h e p r o p e r sequence. I n a 28-day packet, where seven p i l l s a r e Comnunications placebos, i t can o b v i o u s l y make a b i g d i f f e r e n c e . strategies t h a t provide c u l t u r a l l y appropriate information f o r f ami l y p l a n n i ng acceptors, emphas i z i ng p r o p e r use and addressi ng t h e f e a r s o f t h e c l i e n t , can g r e a t l y i n c r e a s e t h e c o n t i n u a t i o n r a t e s and a c t u a l e f f e c t i v e n e s s o f a1 1 f a m i l y p l a n n i n g methods. 2. IUDs I n t r a u t e r i n e devices a r e used by an e s t i m a t e d 70 m i l l i o n women worldwide. F o r t h e many women who can use them w i t h o u t d i f f i c u l t y , t h e y r e p r e s e n t a v e r y e f f e c t i v e , 1o n g - a c t i n g method of c o n t r a c e p t i o n which r e q u i r e s l i t t l e a t t e n t i o n on t h e p a r t o f t h e user. Although t h e l o w e s t observed pregnancy r a t e of most ILlDs i s n o t as g r e a t as t h a t o f combined o r a l c o n t r a c e p t i v e s , s t u d i e s conducted i n c o u n t r i e s w i t h low l e v e l s o f e d u c a t i o n general l y f i n d t h a t t h e u s e - e f f e c t i v e ness of t h e IUD i s much s u p e r i o r t o t h a t o f t h e p i 1 1. The usee f f e c t i v e n e s s o f t h e IUD can be g r e a t e r i n such circumstances because t h e r e a r e fewer v a r i a b l e s a s s o c i a t e d w i t h successful use. However, an e s t i m a t e d 10 t o 15 p e r c e n t o f IUD users d i s c o n t i n u e use because of p a i n and i r r e g u l a r o r heavy b l e e d i n g . Innovations i n IUDs have sought t o improve c o n t r a c e p t i v e e f f e c t i v e n e s s as we1 1 as c o n t r o l s i d e e f f e c t s such as these. Copper-beari ng and p r o g e s t e r o n e - r e l e a s i ng IUDs have been among t h e s e i n n o v a t i o n s . However, p r o p e r c o u n s e l i n g and c a r e f u l p a t i e n t s e l e c t i o n may a l s o have a b i g impact on o v e r a l l u s e r acceptabi 1it y and c o n t i n u a t i o n rates. Studi e s have shown t h a t i f a woman has been c a r e f u l l y i n s t r u c t e d i n what t o expect a f t e r t h e i n s e r t i o n , she i s l i k e l y t o be l e s s f r i g h t ened o r concerned s h o u l d any minor s i d e e f f e c t s occur and more l i k e l y t o manage t h e s e complaints h e r s e l f . I n a d d i t i o n , many of t h e problems- a s s o c i a t e d w i t h c u r r e n t l y a v a i l a b l e IUDs can be e l i m i nated by s k i 1 l f u l i n s e r t i o n techniques and f o l l o w - u p by w e l l - t r a i n e d health practitioners. I n j e c t a b l es and Imp1 a n t s An e s t i m a t e d two m i 1 l i o n women use t h e i n j e c t a b l e c o n t r a c e p t i v e Depo-Provera (depot-medroxyprogesterone a c e t a t e , o r DMPA) whi ch i s now approved f o r c o n t r a c e p t i v e use i n o v e r 80 c o u n t r i e s , and 200,000 u s e N o r i s t e r a t " ( n o r e t h i s t e r o n e enanthat e, o r NET-EN). B o t h Mexico and China manufacture t h e i r own i n j e c t a b l e s , and about 900,000 women use i n j e c t a b l e s i n those c o u n t r i e s . In j e c t ables have a number o f i m p o r t a n t advantages o v e r o t h e r c o n t r a c e p t i v e s . They c o n t a i n p r o g e s t i n o n l y ( i n i t s e l f an advantage f o r some groups of women, as many o f t h e s e r i o u s s i d e e f f e c t s a s s o c i a t e d w i t h s t e r o i d a l c o n t r a c e p t ives a r e li nked t o e s t r o g e n ) . I n j e c t a b l e s have a h i g h e r u s e - e f f e c t i v e n e s s t h a n OCs, which have t o be t a k e n every day. Furthermore, f o r women 1 i v i ng a t a d i s t a n c e from c o n t r a c e p t i v e o u t l e t s o r f o r women i n overcrowded l i v i n g q u a r t e r s who wish t o m a i n t a i n p r i v a c y r e g a r d i n g t h e i r c o n t r a c e p t i v e use, i n j e c t ables a r e t h e method o f choice, s i n c e they o f f e r l o n g - a c t i n g p r o t e c t i o n ( t y p i c a l l y , two t o t h r e e months) and r e q u i r e no a c t i o n on t h e p a r t o f t h e user. A new c o n t r a c e p t i v e method, NORPLANTQ i m p l a n t s , c o n s i s t s o f small hormone-releasi ng capsules wh- :h, when in s e r t e d under t h e s k i n, p r e v e n t pregnancy f o r up t o i i v e years. Unlike the injectable, t h i s method i s r e v e r s i b l e a t any t i m e and i s one o f t h e most e f f e c t i v e methods a v a i l a b l e today. The NORPLANT@ system i s c u r r e n t l y b e i n g i n t r o d u c e d i n s e v e r a l devel oping c o u n t r i e s : Chi1 e, Dominican R e p u b l i c , Ecuador, Egypt, Indonesia, Kenya, S r i Lanka, P h i l i p p i n e s , and Thailand, and i t i s expected t h a t t h e worldwide demand f o r NORPLANT@ i m p l a n t s w i l l be s t r o n g . The method w i 11 be e s p e c i a l l y v a l u a b l e i n devel oping c o u n t r i e s where use o f a l o n g - t e n c o n t r a c e p t i v e can overcome many o f t h e l o g i s t i c a l o b s t a c l e s t o t h e d e l i v Current i n t r o d u c t i o n s t r a t e g i e s e r y o f fami l y p l a n n i ng s e r v i c e s . f o r NORPLANT@ i m p l a n t s a r e emphasizing i n f o r m a t i o n a l and i n s t r u c t i o n a l m a t e r i a l s f o r p o t e n t i a l acceptors a s w e l l as f o r c l i n i c i a n s , f i e l d w o r k e r s , counselors, and d e c i s i o n makers. 4. Vaginal C o n t r a c e p t i o n New a t t e n t i o n i s a l s o f o c u s i n g on some o f t h e o l d e s t and more t r a d i t i o n a l forms o f c o n t r a c e p t i o n - - f e m a l e vagi n a l methods such as spenni cides, sponges, diaphragms, and c e r v i c a l caps. Spenni cides, e s p e c i a l l y foaming t a b l e t s , a r e i n c r e a s i n g l y a v a i l a b l e t h r o u g h o u t t h e w o r l d and r e q u i r e no p r e s c r i p t i o n . A new c o n t r a c e p t i v e sponge, Today@, approved by t h e U.S. Food and Drug A d m i n i s t r a t i o n i n 1983, i s a l s o s o l d w i t h o u t a p r e s c r i p t i o n and has a t t r a c t e d widespread a t t e n t i o n and in t e r e s t i n t h e U.S. The manufacturer began m a r k e t i n g i n t h e U.K. i n 1985. Mowever, t h e sponge i s r e l a t i v e l y e x p e n s i v e and cannot be reused; hence i t w i 11 p r o b a b l y never become v e r y p o p u l a r i n devel opi ng c o u n t r i e s ' n a t i o n a l fami l y p l a n n i n g programs. There i s a g r e a t need t o educate people about t h e e f f e c t i v e n e s s o f t h e two methods. When used p r o p e r l y , a female b a r r i e r method coupled w i t h a condom i s as e f f e c t i v e as t h e p i l l o r IUD i n p r e v e n t i n g an unwanted pregnancy, but a l l b a r r i e r methods c o n t i n u e t o have some m a j o r disadvantages.. A c t u a l f a i l u r e r a t e s of between 10 and 20 p e r c e n t p e r y e a r a r e much h i g h e r t h a n t h o s e f o r s t e r o i d a l methods o r IllDs, i n p a r t due t o t h e absence of good communication programs t h a t emphasize t h e importance of c o r r e c t use. A l t h o u g h b a r r i e r methods a r e g e n e r a l l y f r e e of m a j o r s i d e e f f e c t s , t h e i n c r e a s e d r i s k of pregnancy necessari l y a f f e c t s t h e r i s k - b e n e f i t c a l c u l a t i o n s f o r women who must d e f i n i t e l y a v o i d pregnancy. Moreo v e r , most b a r r i e r methods r e q u i r e t h e u s e r t o t a k e a c o n s c i o u s a c t i o n t o a v o i d pregnancy b e f o r e each sexual a c t . F o r many coup1 es, t h a t requirement i s e s t h e t i c a l ly unappeali ng o r d i f f i c u l t , e i t h e r p h y s i c a l l y o r p s y c h o l o g i c a l l y , t o f o l low c o n s i s t e n t l y . 7 5. Condoms Condoms a r e a safe, e f f e c t i v e , r e v e r s i b l e method o f c h i l d spacing. I n a d d i t i o n t o p r e v e n t i ng pregnancy, condoms p r o t e c t b o t h men and women from sexual ly t r a n s m i t t e d d i seases. They have no s i d e e f f e c t s , r e q u i r e no medical s u p e r v i s i o n and minimal i n t e r a c t i o n , and can be purchased w i t h o u t a p r e s c r i p t i o n . Yet condoms a r e underu t i 1 i z e d , b o t h i n d e v e l o p i n g c o u n t r i e s where f e r t i l i t y i s h i g h and in developed c o u n t r i e s , especi a1 l y among younger couples a t g r e a t e s t r i s k of sexual ly t r a n s m i t t e d disease. Also, condom a r e l e s s e f f e c t i v e i n many LDCs because men have n o t been i n s t r u c t e d i n p r o p e r use. Condom a r e o f t e n n o t p r o v i d e d w i t h a p p r o p r i a t e packa g i ng , e x p l a i n i n g u s e and/or a package i n s e r t . I n c o r r e c t use g r e a t l y i n c r e a s e s t h e r i s k of t e a r i n g . Another problem i s t h a t o f t e n condoms a r e reused f o r economic reasons and t h i s t o o i n c r e a s e s t h e r i s k of t e a r i n g . I n a d d i t i o n , improper o r l e n g t h y s t o r a g e of condoms i n hot, humid c l i m a t e s can cause t h e r u b b e r t o d e t e r i o r a t e . An e s t i m a t e d 37 m i l l i o n couples t h r o u g h o u t t h e w o r l d r e l y on condoms. Use i s h e a v i l y c o n c e n t r a t e d i n a few areas, however. Twot h i r d s of condom u s e r s a r e i n developed c o u n t r i e s . Japan a l o n e accounts f o r a p p r o x i m a t e l y 25 p e r c e n t o f t h e condom u s e r s i n t h e world. China accounts f o r a n o t h e r 20 p e r c e n t . Compared w i t h u s e o f o t h e r methods, condom use i s low i n L a t i n America, t h e Caribbean, A f r i c a , t h e M i d d l e East, and most o f Asia. I n t h e p a s t , condoms were o f t e n i g n o r e d by t h e medical c m u n i t y and frowned on by s o c i e t y because t h e y were l i n k e d i n p e o p l e ' s minds w i t h p r o s t i t u t i o n and venereal disease. Today, perhaps due t o t h e i n c r e a s e i n sexu a l l y t r a n s m i t t e d d i s e a s e and t o t h e g r o w i n g AIDS scare, condoms a r e r e c e i v i ng new a t t e n t i o n f r a n h e a l t h personnel and n a t i o n a l f a m i l y p l a n n i n g programs. Proper e d u c a t i o n and c o u n s e l i n g a r e p l a y i n g a c e n t r a l r o l e i n changing p e o p l e ' s p e r c e p t i o n s of t h e condom and t e a c h i n g them how t o use i t c o r r e c t l y . Research in A f r i c a n c o u n t r i e s i n c l u d i n g Botswana showed t h a t men wanted t o know mor'e about condom use, as w e l l as s u i t a b l e c o n t r a c e p t i v e methods f o r t h e i r spouses. The n a t i o n a l f a m i l y p l a n n i n g program i n B o t s w a n a has r e c e n t l y prepared a t t r a c t i v e p i c t o r i a1 m a t e r i a l t o k e t t h e need. 6. N a t u r a l F a m i l y P l a n n i n g Methods Two t o f o u r p e r c e n t of m a r r i e d couples w o r l d w i d e a r e e s t i m a t e d t o Abstinence f r o m be u s i n g some form of n a t u r a l f a m i l y p l a n n i n g . sexual i n t e r c o u r s e d u r i n g t h e woman's f e r t i l e p e r i o d t o a v o i d pregnancy, o f t e n r e f e r r e d t o as n a t u r a l f a m i l y p l a n n i n g (NFP) o r p e r i o d i c abstinence, r e l i e s on such t e c h n i q u e s as: ( 1 ) t h e c a l e n d a r ( o r rhythm) method which u t i l i z e s a h i s t o r y o f t h e woman's m e n s t r u a l c y c l e s t o c a l c u l a t e t h e f e r t i l e time; ( 2 ) t h e basal body t e m p e r a t u r e (BBT) method which i s based on d e t e c t i n g a c y c l i c a l r i s e i n d a i l y BBT t o i n d i c a t e t h e p r o b a b l e end of t h e f e r t i l e p e r i o d ; ( 3 ) t h e c e r v i c a l mucus method (CMM o r B i l l i n g s method) which i n v o l ves d a i l y o b s e r v a t i o n o f t h e amount and c o n s i s t e n c y o f a woman's c e r v i c a l mucus t o i d e n t i f y t h e o n s e t o f t h e f e r t i l e t i m e ; and ( 4 ) t h e symptot h e n n a l method which i s a c o m b i n a t i o n of t h e CMM and BBT. A v a i l a b l e e s t i m a t e s o f NFP prevalence r a t e s a r e very l w f o r L a t i n America and Asia, and t h e r e a r e almost no p r e v a l e n c e d a t a f o r Africa. Some o f t h e h i g h e s t prevalence r a t e s a r e t h o u @ t t o be i n t h e P h i l i p p i n e s , Sri Lanka, Peru, and M a u r i t i u s . However, s i g n i f i c a n t numbers o f women worldwide a r e u n a b l e t o use any of t h e c u r r e n t l y a v a i l a b l e t e c h n i q u e s r e l i a b l y because they have i r r e g u l a r m e n s t r u a l c y c l e s o r no c l e a r l y d e t e c t a b l e p a t t e r n of change i n body temperature, c e r v i c a l mucus, o r o t h e r i n d i c a t o r s . Although among small groups o f d e d i c a t e d , e x p e r i e n c e d u s e r s , p e r i o d i c a b s t i n e n c e has proved s u c c e s s f u l , i n widespread general u s e t h e methods show f a i l u r e r a t e s o f 10 t o 30 p e r c e n t p e r y e a r . The i m p o r t a n c e o f e f f e c t i v e c o u n s e l i ng and e d u c a t i o n f o r i s e v i d e n t . T r a i n i n g a c o u p l e i n t h e u s e o f NFP should i n c l u d e how t o d e t e c t t h e f e r t i l e days, b u t a l s o how t o a b s t i n e n c e . With p r o p e r t r a i n i n g , t h e NFP methods can be t o couples who cannot, o r w i l l n o t ( p e r h a p s f o r r e l i g i o u s use o t h e r methods o f c h i l d spacing. NFP u s e r s not only cope w i t h important reasons), Breastfeeding B i r t h i n t e r v a l s a r e l o n g e r , and f e r t i l i t y reduced, i n many populat i ons where women p r a c t i c e intens ive and l e n g t h y b r e a s t f e e d i ng. I t i s p a r t l y f o r t h i s reason t h a t r e c e n t d e c l i n e s i n b r e a s t f e e d i ng i n c i t i e s and some r u r a l areas o f many l e s s developed c o u n t r i e s have caused concern among p o p u l a t i o n e x p e r t s . Unless compensatory i n c r e a s e s i n t h e use o f modern c o n t r a c e p t i v e s occur, women who breastfeed f o r s h o r t e r periods w i l l experience s h o r t e r b i r t h i n t e r v a l s and h i g h e r f e r t i l i t y , w i t h p o t e n t i a l l y adverse consequences f o r t h e i r own h e a l t h and t h a t o f t h e i r c h i l d r e n . 8 C. FEWER DEATHS/FEWER BIRTHS I t would seem p a r a d o x i c a l t h a t t h e r a t e of p o p u l a t i o n g r w t A h should fa1 1 when t h e r a t e of c h i l d s u r v i v a l c o n t i nues t o improve d r a m t i c a l l y . 'The e x p l a n a t i o n of t h a t paradox, however, s h o u l d a l l a y t h e fears o f those who b e l i e v e t h a t a c h i l d h e a l t h r e v o l u t i o n w i l l l e a d t o another populat i o n explosion. For, i n p r a c t i c e , r e d u c i n g t h e r a t e s o f i n f a n t m o r t a l i t y i s l i k e l y t o h e l p s t a b i l i z e w o r l d p o p u l a t i o n growth a t a l o w e r l e v e l and a t an e a r l i e r time, I n t h e case o f young T h i r d World women, t h e death o f a c h i l d d u r i n g t h e f i r s t month of l i f e reduces t h e average i n t e r v a l between b i r t h s f r o m A c h i l d d y i n g even i n t h e second t h r e e y e a r s t o l e s s t h a n two years. y e a r of l i f e reduces t h e average b i r t h i n t e r v a l by almost s i x months. S i m i l a r l y , s t u d i e s i n t h e Gambia have s h w n t h a t i f a baby d i e s i n t h e f i r s t month o f l i f e , t h e n t h e average t i m e b e f o r e t h e next b i r t h i s o n l y 16 months; if a Gambian c h i l d s ~ ~ r v i v ef os r t h e f i r s t two years, on t h e o t h e r hand, then t h e average gap between one b i r t h and t h e n e x t i n c r e a s e s t o approximately t h r e e years. I n Bangladesh, t h e average i n t e r v a l between one b i r t h and t h e next i s a l s o increased by more t h a n a y e a r i f t h e f i r s t c h i l d survives i t s infancy. C h i l d s u r v i v a l tends t o reduce b i r t h r a t e s i n t h r e e separate ways. - F i r s t , c h i l d s u r v i v a l usual l y means t h a t t h e mother c o n t i n u e s b r e a s t feedi ng. As discussed, prolonged and unsuppl emented b r e a s t f e e d i ng i s a n a t u r a l c o n t r a c e p t i v e , which d e l a y s t h e r e t u r n o f o v u l a t i o n . Second, improved c h i l d s u r v i v a l means t h a t parents can more c o n f i d e n t l y g i v e b i rt h t o o n l y t h e number o f c h i l d r e n they a c t u a l l y w a n t - r a t h e r t h a n h a v i n g a d d i t i o n a l c h i l d r e n t o compensate f o r t h e f a c t t h a t one o r more o f t h e i r c h i l d r e n m i g h t die. Thus a decrease i n deaths would l i k e l y i n c r e a s e t h e use o f e f f e c t i v e methods o f f ami l y p l a n n i ng--even among couples w i t h t h e same number o f s u r v i v i ng c h i 1dren. A t h i r d mechanism by which an i n c r e a s e i n s u r v i v a l may l e a d t o a decrease i n b i r t h s i s b o t h more profound and perhaps more powerful. Whether o r n o t a husband and w i f e w i l l decide t o p l a n t h e number and spacing o f t h e i r c h i l d r e n i s c l o s e l y r e l a t e d t o t h e i r personal sense o f c o n t r o l over t h e i r own 1 i v e s and circumstances. Ma1 n u t r i t i o n , il l i t e r a c y , ill h e a l t h , and oppression can leave people w i t h so l i t t l e sense o f c o n t r o l over t h e i r own l i v e s and circumstances t h a t t h e y a r e a l i e n a t e d from t h e I f p r o g r e s s i n h e a l t h and education, i n very i d e a o f "planning." p o l i t i c a l p a r t i c i p a t i o n , and economic a c t i v i t y has helped t o c r e a t e a g r e a t e r sense o f mastery o v e r one's own d e s t i n y - t h e n t h e i d e a o f f a m i l y s p a c i n g is l i k e l y t o be welcomed as another o p p o r t u n i t y t o t a k e more c o n t r o l o v e r one's m n l i f e , t h e r e b y b e i n g a b l e t o a f f e c t and improve o n e ' s own and one's c h i l d r e n ' s l i v e s . Programs t o encourage b i r t h spaci ng can work t o g e t h e r w i t h o t h e r c h i l d s u r v i v a l a c t i v i t i e s , such as p r o g r a m o f immunization o r of o r a l r e h y d r a t i o n f o r d i a r r h e a l diseases. When h e a l t h workers a r e t a l k i n g t o m t h e r s about t h e b e n e f i t s o f immunization, o r a l r e h y d r a t i on, and b r e a s t f e e d i ng, t h e y can e a s i l y d i s c u s s t h e b e n e f i t s o f good b i r t h spaci ng. 8 D. CONSTRAI NTS TO CHILD SPACI NG O " O C o u p k s cannot u s e r e l i a b l e methods of c o n t r a c e p t i o n u n l e s s t h e y have access t o in f o r m a t i on and c o n t r a c e p t i v e s u p p l ies. I n some s o c i e t i e s , c o u p l e s may choose n o t t o space b i r t h s f o r v a r i ous reasons, such as f e a r t h a t t h e i r e x i s t i n g c h i l d r e n w i l l d i e , r e 1 ig i ous be1 iefs, f e a r o f s i d e - e f f e c t s , and s t a t u s a s s o c i a t e d w i t h large families. Lack o f encouragement by program p l a n n e r s , d e c i s i o n makers, medical c o m u n i t y . and t h e O Low p r i o r i t y w i t h i n e x i s t i n g MCH programs i n many h e a l t h m i n i s t r i e s . O F a i l u r e t o reach men w i t h a c c u r a t e i n f o r m a t i o n on f a m i l y p l a n n i n g / c h i 1 d s g a c i ng. " Myths t h a t becane p e o p l e ' s " r e a l i t y . " " Noncompliance and misuse o f t h e v a r i a r s methods o f f a m i l y p l a n n i n g . D i s c o n t i n u a t i o n : I n some d e v e l o p i q g c o u n t r i e s , f o r e v e r y 100 women who b e g i n u s i ng t h e p i 1 1 , 70-80 d i scont i nue b e f o r e t h e end of one year. I n each o f t h e above c o n s t r a i n t s , t h e key t o overcoming i t i s communic a t i o n o f one s o r t o r a n o t h e r and t h u s a n o t h e r f a c t o r i n c h i 1 d s u r v i v a l becomes one o f d e v e l o p i n g a n a p p r o p r i a t e communication s t r a t e g y . REFERENCES . 7, No. 9, September 1985, P. 3 . 1. pop1 i n e , Vol 2. S t a t e o f t h e w o r l d ' s C h i l d r e n , 1984, and P o p u l a t i o n R e p o r t s , No. 6, 1 / 2 7 , H/6, H/7, A/6, D/4. 3. " I s s u e s i n C o n t r a c e p t i v e Development," P o p u l a t i o n , P o p u l a t i o n C r i s i s Committee, May 1985, p. 2, 4. S t a t e of t h e W o r l d ' s C h i l d r e n , 1984, P o p u l a t i o n Re o r t s , No. 6, 1/27, H/6, ,H/7, A/6, D/4, and H a t c h e r , R-racepti ve Techno1 ogy 1984-1985, Ir v i n g t o n P u b l i s h e r s , Inc., 5 5 1 F i f t h Avenue, New York, NY, 1 0 0 1 i . 5. World Development R e p o r t 1984, P r e s s , New York, NY, p. 196. 6. " I s s u e s i n C o n t r a c e p t i v e Development," p. 2. 7. " I s s u e s i n C o n t r a c e p t i v e Development," pp. 8-10. 8. Habicht, J.P. - ing." . The W o r l d Bank, Oxford U n i v e r s i t y e t a1 , "The C o n t r a c e p t i v e R o l e o f B r e a s t f e e d - P o p u l a t i o n S t u d i e s , 39 (1985), pp. 213-232.
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