Howard I. Goldberg

Trends and differentials in mortality from cancers of the oral cavity and pharynx in the United States, 1973–1987

Background. This analysis consisted of an examination of trends and differentials in mortality from cancers of the oral cavity and pharynx in the United States for a recent 15‐year period.

Contraceptive Use and Fertility Decline in Chogoria, Kenya

This article describes the results pertaining to fertility and family planning from a 1985 survey conducted in the catchment area of Chogoria Hospital in central Kenya. Current contraceptive prevalence was found to be quite high, 43 percent as opposed to 17 percent for Kenya as a whole. The total fertility rate of 5.2 births per woman was 2.5 births lower than the national rate. Very few women reported wanting to have large numbers of children or thinking that fate or God should determine family size. Although these data cannot conclusively demonstrate that the family planning program operating in the area has been responsible for reduced fertility there, they do provide some support for this hypothesis.

Infant mortality and breast-feeding in North-Eastern Brazil.

Summary The effects of breast-feeding on infant health have been a topic of considerable discussion in recent years. In this paper multivariate techniques are used to examine the relationship between the failure to breast-feed and mortality among infants in four states of north east Brazil. It was found that breast-fed children were significantly more likely to survive infancy than children who were never breast-fed, even when other socio-economic, demographic and health variables were taken into account. This relationship was much more marked in rural than in urban settings. Other variables significantly associated with mortality were parity, mothers age at childs birth, mothers employment status and use of maternal/child health services. These findings are important for the particular population studied as well as for much of Latin America where incidence and duration of breast-feeding tend to be low but infant mortality is quite high

Rationale, Design and Methodology for the Navajo Health and Nutrition Survey

As recently as 1990, there was no reservation-wide, population-based health status information about Navajo Indians. To remedy this shortcoming, the Navajo Health and Nutrition Survey was conducted from 1991 to 1992 to assess the health and nutritional status of Navajo Reservation residents using a population-based sample. Using a three-stage design, a representative sample of reservation households was selected for inclusion. All members of selected households 12 y of age and older were invited to participate. A total of 985 people in 459 households participated in the study. Survey protocols were modeled on those of previous national surveys and included a standard blood chemistry profile, complete blood count, oral glucose tolerance test, blood pressure, anthropometric measurements, a single 24-h dietary recall and a questionnaire on health behaviors. The findings from this survey, reported in the accompanying papers, inform efforts to prevent and control chronic disease among the Navajo. Lessons learned from this survey may be of interest to those conducting similar surveys in other American Indian and Alaska Native populations.

Contraceptive use during lactation in developing countries.

Contraceptive use by breastfeeding women in developing countries has led to concern about potentially harmful effects of steroid contraceptives on the health of breastfed children. In this paper, breastfeeding womens use of the pill and hormonal injections is investigated using survey data from 17 Latin American, Asian, and African countries. The results indicate that while the proportions of breastfeeding women who use these methods were small in most countries at the time of the surveys, the proportion using the pill was not inconsequential. In general, younger lactating women with higher education and more live births who live in urban areas are more likely to use the pill than other breastfeeding women.

Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012

Objectives. In 1996, the U.S. Congress passed legislation making female genital mutilation/cutting (FGM/C) illegal in the United States. CDC published the first estimates of the number of women and girls at risk for FGM/C in 1997. Since 2012, various constituencies have again raised concerns about the practice in the United States. We updated an earlier estimate of the number of women and girls in the United States who were at risk for FGM/C or its consequences. Methods. We estimated the number of women and girls who were at risk for undergoing FGM/C or its consequences in 2012 by applying country-specific prevalence of FGM/C to the estimated number of women and girls living in the United States who were born in that country or who lived with a parent born in that country. Results. Approximately 513,000 women and girls in the United States were at risk for FGM/C or its consequences in 2012, which was more than three times higher than the earlier estimate, based on 1990 data. The increase in the number of women and girls younger than 18 years of age at risk for FGM/C was more than four times that of previous estimates. Conclusion. The estimated increase was wholly a result of rapid growth in the number of immigrants from FGM/C-practicing countries living in the United States and not from increases in FGM/C prevalence in those countries. Scientifically valid information regarding whether women or their daughters have actually undergone FGM/C and related information that can contribute to efforts to prevent the practice in the United States and provide needed health services to women who have undergone FGM/C are needed.

The Impact of an Integrated Family Planning Program in Russia

In 1995, the U.S. Agency for International Development implemented an integrated program of family planning education and services in six Russian cities to increase physicians’and women’s contraceptive knowledge and change current contraceptive use. Large population-based surveys of women ages 15-44 were carried out at the beginning of project implementation (in 1996) and 3 years later in two project sites and a comparison site. Results from these surveys indicate that project activities affected women’s knowledge of family planning methods, and caused women to have more favorable attitudes toward modern contraception. In addition, abortion rates decreased in project sites while remaining virtually unchanged in the comparison site. Because of uneven implementation of project interventions in the demonstration sites, however, the intervention’s actual impact on abortion rates remains unclear.

Cross-sectional survey methods to assess retrospectively mortality in humanitarian emergencies

Since the rates and causes of mortality are critical indicators of the overall health of a population, it is important to evaluate mortality even where no complete vital statistics reporting exists. Such settings include humanitarian emergencies. Experience in cross-sectional survey methods to assess retrospectively crude, age-specific, and maternal mortality in stable settings has been gained over the past 40 years, and methods appropriate to humanitarian emergencies have been developed. In humanitarian emergencies, crude and age-specific mortality can be gauged using methods based on the enumeration of individuals resident in randomly selected households-frequently referred to as a household census. Under-five mortality can also be assessed through a modified prior birth history method in which a representative sample of reproductive-aged women are questioned about dates of child births and deaths. Maternal mortality can be appraised via the initial identification of maternal deaths in the study population and a subsequent investigation to determine the cause of each death.

Rapid reduction of maternal mortality in Uganda and Zambia through the saving mothers, giving life initiative: results of year 1 evaluation

BackgroundAchieving maternal mortality reduction as a development goal remains a major challenge in most low-resource countries. Saving Mothers, Giving Life (SMGL) is a multi-partner initiative designed to reduce maternal mortality rapidly in high mortality settings through community and facility evidence-based interventions and district-wide health systems strengthening that could reduce delays to appropriate obstetric care.MethodsAn evaluation employing multiple studies and data collection methods was used to compare baseline maternal outcomes to those during Year 1 in SMGL pilot districts in Uganda and Zambia. Studies include health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and population-based investigation of community maternal deaths. Population-based evaluation used standard approaches and comparable indicators to measure outcome and impact, and to allow comparison of the SMGL implementation in unique country contexts.ResultsThe evaluation found a 30% reduction in the population-based maternal mortality ratio (MMR) in Uganda during Year 1, from 452 to 316 per 100,000 live births. The MMR in health facilities declined by 35% in each country (from 534 to 345 in Uganda and from 310 to 202 in Zambia). The institutional delivery rate increased by 62% in Uganda and 35% in Zambia. The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 25 in Uganda and from 7 to 11 in Zambia. Partial EmONC care became available in many more low and mid-level facilities. Cesarean section rates for all births increased by 23% in Uganda and 15% in Zambia. The proportion of women with childbirth complications delivered in EmONC facilities rose by 25% in Uganda and 23% in Zambia. Facility case fatality rates fell from 2.6 to 2.0% in Uganda and 3.1 to 2.0% in Zambia.ConclusionsMaternal mortality ratios fell significantly in one year in Uganda and Zambia following the introduction of the SMGL model. This model employed a comprehensive district system strengthening approach. The lessons learned from SMGL can inform policymakers and program managers in other low and middle income settings where similar approaches could be utilized to rapidly reduce preventable maternal deaths.

Pregnant Women's Intentions and Subsequent Behaviors Regarding Maternal and Neonatal Service Utilization: Results from a Cohort Study in Nyanza Province, Kenya.

Higher use of maternal and neonatal health (MNH) services may reduce maternal and neonatal mortality in Kenya. This study aims to: 1) prospectively explore women’s intentions to use MNH services (antenatal care, delivery in a facility, postnatal care, neonatal care) at <20 and 30–35 weeks’ gestation and their actual use of these services; 2) identify predictors of intention-behavior discordance among women with positive service use intentions; 3) examine associations between place of delivery, women’s reasons for choosing it, and birthing experiences. We used data from a 2012–2013 population-based cohort of pregnant women in the Demographic Surveillance Site in Nyanza province, Kenya. Of 1,056 women completing the study (89.1% response rate), 948 had live-births and 22 stillbirths, and they represent our analytic sample. Logistic regression analysis identified predictors of intention-behavior discordance regarding delivery in a facility and use of postnatal and neonatal care. At <20 and 30–35 weeks’ gestation, most women intended to seek MNH services (≥93.9% and ≥87.5%, respectively, for all services assessed). Actual service use was high for antenatal (98.1%) and neonatal (88.5%) care, but lower for delivery in a facility (76.9%) and postnatal care (51.8%). Woman’s age >35 and high-school education were significant predictors of intention-behavior discordance regarding delivery in a facility; several delivery-related factors were significantly associated with intention-behavior discordance regarding use of postnatal and neonatal care. Delivery facilities were chosen based on proximity to women’s residence, affordability, and service quality; among women who delivered outside a health facility, 16.3% could not afford going to a facility. Good/very good birth experiences were reported by 93.6% of women who delivered in a facility and 32.6% of women who did not. We found higher MNH service utilization than previously documented in Nyanza province. Further increasing the number of facility deliveries and use of postnatal care may improve MNH in Kenya.