 L. Lewis Wall, Associate Professor, Department of Obstetrics and Gynecology, Louisiana State University Medical Center, 1542 Tulane Avenue, New Orleans, LA 70112. Northern Nigeria has a maternal mortality ratio greater than 1,000 maternal deaths per 100,000 live births. Serious maternal morbidity (for example, vesico-vaginal fistula) is also common. Among the most important factors contributing to this tragic situation are: an Islamic culture that undervalues women; a perceived social need for women's reproductive capacities to be under strict male control; the practice of purdah (wife seclusion), which restricts women's access to medical care; almost universal female illiteracy; marriage at an early age and pregnancy often occurring before maternal pelvic growth is complete; a high rate of obstructed labor; directly harmful traditional medical beliefs and practices; inadequate facilities to deal with obstetric emergencies; a deteriorating economy; and a political culture marked by rampant corruption and inefficiency. The convergence of all of these factors has resulted in one of the worst records of female reproductive health existing anywhere in the world. (Studies in Family Planning 1998; 29[4]: 341–359)
Ann E. Biddlecom, Research Investigator, Institute for Social Research, University of Michigan, and Consultant for the Population Council, New York. Bolaji M. Fapohunda, Research Fellow, African Population Policy Research Center, Nairobi, Kenya. This article examines women's covert use of contraceptives, that is, their use of a method without their husbands' knowledge. Three questions are addressed: (1) How is covert use measured? (2) How prevalent is it? and (3) What are the factors underlying covert use? Existing studies are used together with survey and qualitative data collected in 1997 in an urban setting in Zambia from married women and their husbands. Women's covert use of contraceptives is estimated to account for 6 to 20 percent of all current contraceptive use, and it is more widespread when contraceptive prevalence is low. The multivariate analysis indicates that difficult spousal communication about contraception is the strongest determinant of covert use. Husbands' disapproval of contraception works through spousal communication rather than as a direct influence on covert use. Husbands' pronatalism had no significant effect. The article concludes with implications of covert use for reproductive health and family planning programs, especially women's (and men's) needs for confidential services. (Studies in Family Planning 1998; 29[4]: 360–372)
Susan E. Short,
Assistant Professor, Department of Sociology, Brown University, Maxcy Hall, Box 1916, Providence, RI 02912. Zhai Fengying, Professor and Head of the Institute of Nutrition and Food Hygiene, Chinese Academy of Preventive Medicine, Beijing. Of all the reforms and policies set in motion in the early 1980s in China, the one-child policy has been called the most far-reaching in its implications for China's population and economic development. Almost two decades later, little is known about what the policy looks like across local neighborhoods and villages. To sketch a more general picture of the one-child policy, this article presents panel data from three waves of the China Health and Nutrition Survey (1989, 1991, and 1993) collected in 167 communities in eight provinces. Local policy, including policy strength and policy incentives and disincentives, is detailed separately for urban and rural areas. These data confirm that no single one-child policy exists; policy varied considerably from place to place and within individual communities during the 198993 period. (Studies in Family Planning 1998; 29[4]: 373–387) ReportsKaushalendra K. Singh was Visiting Scholar, Carolina Population Center, at the time this report was written, and is currently Associate Professor of Statistics, Banaras Hindu University, Varanasi, Uttar Pradesh, India. Shelah S. Bloom, Postdoctoral Scholar and Amy Ong Tsui, Professor of Maternal and Child Health and Director, Carolina Population Center, University of North Carolina, Room 302B, CB #8120, 123 West Franklin Street, Chapel Hill, NC 275163997. To enhance the reproductive health status of couples in developing countries, the knowledge, attitudes, and behavior of both women and men must be investigated, especially where women depend on men for the decision to seek care. This study analyzes data from a survey of 6,727 husbands from five districts in the northern state of Uttar Pradesh, India. Data are presented on men's knowledge of women's health and on their own sexual behavior outside the context of marriage, on their perceptions of sexual morbidity and their attempts at treatment for specific conditions, and on their opinions concerning the social role of wives. Findings indicate that men know little about maternal morbidity or sexual morbidity conditions. Few husbands reported that they had had sexual experience outside of marriage and the majority of these few said they had had such a relationship with more than one partner. Of men who said they had had reproductive morbidity symptoms, many said they had not sought treatment. Men's views concerning the role of wives indicate a low level of women's autonomy in this region of India. Results indicate a pressing need for reproductive health education that targets both women and men in Uttar Pradesh. (Studies in Family Planning 1998; 29[4]: 388–399).
Annika Johansson, Social Researcher at the Unit for International Health Care Research, IHCAR, Division of Public Health Sciences, Karolinska Institutet, 17176 Stockholm, Sweden. Nguyen Thu Nga and Doan Du Dat Medical Doctors, and Tran Quang Huy, Nurse, Uong Bi General Hospital, Uong Bi, Vietnam. Kristina Holmgren, Gynecologist, Karolinska Hospital, Department of Obstetrics and Gynecology, Stockholm, Sweden. This study analyzes the involvement of men in abortion in Vietnam, where induced abortion is legal and abortion rates are among the highest in the world. Twenty men were interviewed in 1996 about the role they played in their wives' abortions and about their feelings and ethical views concerning the procedure. The results showed that both husbands and wives considered the husband to be the main decisionmaker regarding family size, which included the decision to have an abortion, but that, in fact, some women had undergone an abortion without consulting their husbands in advance. Parents and in-laws were usually not consulted; the couples thought they might object to the decision on moral grounds. Respondents' ethical perspectives on abortion are discussed. When faced with an unwanted pregnancy, the husbands adopted an ethics of care and responsibility toward family and children, although some felt that abortion was immoral. The study highlights the importance of understanding husbands' perspectives on their responsibilities and rights in reproductive decisionmaking and their ethical and other concerns related to abortion. (Studies in Family Planning 1998; 29[4]: 400–413)
Daniel Chandramohan, Clinical Lecturer; Laura C. Rodrigues, Senior Lecturer in Epidemiology; Gillian H. Maude, Senior Lecturer in Medical Statistics; and Richard J. Hayes Professor of Epidemiology, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT. This report presents data from a study carried out in three African countries to assess the validity of verbal autopsies based on information about symptoms and signs observed antemortem by relatives or associates of deceased individuals for determining the causes of institutional maternal death. The validity of the verbal autopsy was assessed for each cause of death, and for groups of "direct" and "indirect" maternal causes, by comparing the verbal autopsy diagnoses with the reference diagnoses and calculating their sensitivity, specificity, and positive predictive value. Verbal autopsies were found to be highly specific (98 percent specificity for all causes of maternal death) but not very sensitive (60 percent sensitivity for all causes except ante/postpartum hemorrhage). Verbal autopsy estimates of cause-specific mortality were comparable to expected values for most of the causes. The study shows that certain direct causes of hospital-based maternal mortality can be determined by means of verbal autopsies with a reasonable level of confidence. (Studies in Family Planning 1998; 29[4]: 414–422)
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