Predicting under- and overnutrition among women of reproductive age: a population-based study in central Java, Indonesia

OBJECTIVES

To evaluate changes over 1 year in weight and body mass index (BMI) among a population-based sample of non-pregnant women in Indonesia and to identify risk factors for developing under- and overnutrition.

DESIGN

Cross-sectional studies in 1996 and 1997 in the same population.

SETTING

Purworejo District, central Java, Indonesia.

SUBJECTS

Non-pregnant women (n = 4132) aged 15-49 years of age who participated in both 1996 and 1997. Based on BMI, women were classified as having chronic energy deficiency (CED), and as being either of normal weight or obese.

RESULTS

The mean height of the women was below the fifth percentile of international standards. In 1996, 16.2% had CED, 72.2% were normal and 11.6% were obese. In 1997, the corresponding figures were 14.4%, 71.2% and 14.3%, respectively, revealing a significant mean increase in weight and BMI. Among women classified as normal in 1996, 3.0% developed CED in 1997. Significant risk factors for developing CED were experiences of child deaths and non-use of contraceptives. Among women classified as normal in 1996, 5.3% developed obesity in 1997. Here, significant risk factors included most indicators of wealth as well as occupation.

CONCLUSIONS

The results should be important for future efforts to prevent CED and obesity in the general population; conditions which are both associated with health risks.

Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam

This study explores the perspectives of tuberculosis patients on which factors influenced their health seeking behaviour, with special reference to gender differentials in terms of delays in health seeking. In 1996, a multi-disciplinary research team carried out 16 focus group discussions. The study was done in four districts in Vietnam, both in the south and north of the country and in urban and rural areas. Qualitative analysis of data was performed following general principles of modified grounded theory technique. Participants in the focus groups described three main factors as contributing to delay in health seeking. These were fear of social isolation, economic constraints and inadequate staff attitudes and poor quality of health services. A model illustrating different factors influencing health seeking was elaborated and served as a basis for discussion of the findings. The main factor contributing to delay among women was described as fear of social isolation from the family or the community. Stigma was described as closely related to contextual factors such as gender-roles, socio-economic status and level of education and seemed to be mediated via denial and concealment of tuberculosis diagnosis and disease, thus causing delay. The main factor contributing to delay among men was described as fear of individual costs of diagnosis and treatment. Staff attitudes and quality of health service facilities were described as not always corresponding to people's expectations of appropriate health services. Women saw themselves and were seen by others as being more sensitive than men to poor service conditions and staff attitudes. A typical feature of the described health seeking behaviour of men was that they neglected symptoms until the disease reached a serious stage, by which time they tended to go directly to public health services without first visiting private health practitioners. Women, on the other hand, were described as having a tendency to seek out private services and practice self-medication before seeking care at public services. In conclusion, there is a need for better understanding of behavioural factors and for developing strategies, that take these into account. Health workers need to better understand gender and social aspects of tuberculosis control, particularly aspects that influence the likelihood for achieving equity in diagnosis and cure.

Stress from working conditions among home care personnel with musculoskeletal symptoms

A large proportion of the working population experiences musculoskeletal symptoms, which affect the individual's quality of life. Neck/shoulder and/or low back complaints are common among home care personnel. This occupational sector is characterized by high physical and psychosocial demands and the staff is typically female. The aim of this qualitative study was to gain a deeper understanding of those factors in the work environment of home care personnel that the individuals perceive as demanding and problematic. Eight employees in the home care service were interviewed in depth. Each interview was transcribed and Grounded Theory was applied. Stress, related to demanding physical and psychosocial working conditions, emerged as the core variable that probably contributed to the development and maintenance of musculoskeletal symptoms. Financial cut-backs at the municipality was seen as a cause of the demanding working conditions. In future studies it is important to evaluate prevention programmes focused upon coping strategies against stress.

Fatty-acid composition in serum phospholipids and risk of breast cancer: an incident case-control study in Sweden

The study of the relationship between dietary intake of fatty acids and the risk of breast cancer has not yielded definite conclusions with respect to causality, possibly because of methodological issues inherent to nutritional epidemiology. To evaluate the hypothesis of possible protection of n-3 polyunsaturated fatty acids (PUFA) against breast cancer in women, we examined the fatty-acid composition of phospholipids in pre-diagnostic sera of 196 women who developed breast cancer, and of 388 controls matched for age at recruitment and duration of follow-up, in a prospective cohort study in Umeâ, northern Sweden. Individual fatty acids were measured as a percentage of total fatty acids, using capillary gas chromatography. Conditional logistic-regression models showed no significant association between n-3 PUFA and breast-cancer risk. In contrast, women in the highest quartile of stearic acid had a relative risk of 0.49 (95% confidence interval, 0.22-1.08) compared with women in the lowest quartile (trend p = 0.047), suggesting a protective role of stearic acid in breast-cancer risk. Besides stearic acid, women in the highest quartile of the 18:0/18:1 n-9c ratio had a relative risk of 0.50 (95% confidence interval, 0.23-1.10) compared with women in the lowest quartile (trend p = 0.064), suggesting a decrease in breast-cancer risk in women with low activity of the enzyme delta 9-desaturase (stearoyl CoA desaturase), which may reflect an underlying metabolic profile characterized by insulin resistance and chronic hyper-insulinemia.

Attitudes to compliance with tuberculosis treatment among women and men in Vietnam

SETTING

A study carried out in 1996 in four districts representing south and north as well as urban and rural areas of Vietnam.

OBJECTIVE

To explore gender differences in knowledge, beliefs and attitudes towards tuberculosis and its treatment, and how these factors influence patients' compliance with treatment.

DESIGN

Sixteen focus group discussions were performed by a multi-disciplinary research team from Vietnam and Sweden. Analysis was performed using modified Grounded Theory technique, specifically evaluating gender differences.

RESULTS

Women were believed to be more compliant than men. Insufficient knowledge and individual cost during treatment were reported as main obstacles to compliance among men (poor patient compliance), while sensitivity to interaction with health staff and stigma in society (poor health staff and system compliance) were reported as the main obstacles among women.

CONCLUSIONS

It is time to adopt a more comprehensive and gender-sensitive approach to compliance, which incorporates patient compliance, doctor compliance and system compliance, in order to fully support individual patients in their efforts to comply with treatment.

Familial occurrence of preeclampsia

We conducted a cohort study on whether preeclampsia during the pregnancy of a mother is a risk factor for preeclampsia during the pregnancy of her daughter. Data from the Medical Birth Registry were combined with data from a local registry of births from 1955 to 1990. We could identify the births of 22,768 elder daughters and 2,959 younger daughters. These daughters had also experienced at least one delivery. If the mother had preeclampsia during her pregnancy with an elder daughter, then the elder daughter had an increased risk for preeclampsia in her first pregnancy (relative risk (RR) = 1.7; 95% confidence interval (CI) = 1.3-2.2). This increased risk persisted into the elder daughter's second pregnancy (RR = 1.7; 95% CI = 1.1-2.6). The risks for the daughters were also increased to a similar level if the mother had experienced preeclampsia in any other pregnancy. Furthermore, the risks were similarly elevated if only mothers with firstborn children were included in the analyses. Hence, preeclampsia during the pregnancy of a mother was a risk factor for development of preeclampsia during the pregnancy of her daughters; however, owing to a relatively small population attributable proportion, genetic predisposition explained only a minor part of the occurrence of preeclampsia in this population.

Different tuberculosis in men and women: beliefs from focus groups in Vietnam

After decades in decline, tuberculosis (TB) has been increasing worldwide. In 1993, the World Health Organisation declared TB a global emergency. Passive case-finding is an important part of TB control programmes, and this is strongly affected by people's perceptions and beliefs of TB and society's behaviour towards TB sufferers. The aim of this study was to describe the perceptions and beliefs of Vietnamese people regarding TB and its risk factors with special reference to differences between men and women. Sixteen focus group discussions (FGDs) were organised in four districts representing different regions in Vietnam and consisting of men and women, TB patients and non-TB participants. In general, participants had good knowledge of TB being a dangerous, contagious and infectious disease, caused by germs. However, traditional beliefs in different types of TB still exist, mainly among older people in rural areas, but also resorted to by other people once ill. Four main types of TB were reported: (1) 'Lao truyen' (hereditary TB), handed down from older generations to latter ones through 'family blood', regardless of sexes; (2) 'Lao luc' (physical TB), caused by hard work, more men affected; (3) 'Lao tam' (mental TB), caused by too much worrying-more women affected; and (4) 'Lao phoi' (lung TB), dangerous and caused by TB germs, transmitted through the respiratory system-more men affected. Other general risk factors were also mentioned. Men were perceived to get TB more often than women, as they were more exposed to risk factors during both work and leisure time. These traditional beliefs may contribute to long delays to TB diagnosis and increased social stigma and isolation of TB patients and their families due to erroneous beliefs in transmission routes. Our findings demonstrate areas where TB control programmes may be improved.

Impact of lactation on maternal body weight and body composition

Women worldwide generally lose weight and body fat during lactation. This loss, although increased by longer, more intensive breastfeeding, is modest and may be reduced by increased food intake and decreased activity. Higher parity and older age are associated with greater weight loss postpartum among poorly nourished women. Well-nourished women or those who breastfeed only for a limited time may not return to their prepregnant weight or body composition by the end of the lactation period. Those who are overweight or obese may have difficulty initiating or maintaining lactation. For the majority of women in the world, lactation is unlikely to represent a threat to their health. To advise women on how to optimize their health and lactational performance, one must consider all of the changes in maternal nutritional status that occur during a reproductive cycle, which may or may not compensate for the modest decreases in body weight associated with lactation.

Longer delays in tuberculosis diagnosis among women in Vietnam

SETTING

Study conducted in 23 randomly selected districts in four provinces of Vietnam.

OBJECTIVE

To describe and compare health seeking behaviour between men and women and to measure delays in tuberculosis (TB) diagnosis.

DESIGN

All patients (n = 1027) aged 15-49 years with new smear-positive pulmonary TB detected in the selected districts during 1996 were interviewed using a structured questionnaire.

RESULTS

Mean total delay to TB diagnosis was 13.3 weeks (95% confidence interval [CI] 11.5, 15.1) for women and 11.4 weeks (95% CI 10.6, 12.2) for men, including a patient's delay of 7.9 weeks (95% CI 6.5, 9.3) and 7.6 weeks (95% CI 6.9, 8.3) respectively. Doctor's delay was significantly longer among women (5.4 weeks, 95% CI 4.2, 6.6) than among men (3.8 weeks, 95% CI 3.3, 4.3). Women did not start seeking care later than men, nor did they have a different health seeking pattern. Women visited more health care providers than men (1.7 and 1.5 providers, respectively, P = 0.02).

CONCLUSION

Patient's delay is unacceptably long for both men and women. Women do not receive a diagnosis of TB by doctors or other health care providers as quickly as men once they seek health care. The reasons for this gender difference warrant further investigations.

Wife abuse among women of childbearing age in Nicaragua

OBJECTIVES

This study measured the prevalence, frequency, and severity of physical wife abuse and its risk factors in León, Nicaragua.

METHODS

A cross-sectional survey was conducted with a representative sample of 488 women 15 to 49 years of age.

RESULTS

The lifetime prevalence of spousal violence was 52% among ever-married women (n = 360). Spousal violence was significantly positively associated with poverty, parity, urban residence, and history of violence in the husband's family. No significant associations were found between spousal violence and women's age, education, marital dependency, or occupation.

CONCLUSIONS

Wife abuse constitutes a major public health problem in Nicaragua, requiring urgent measures for prevention and treatment for victims.

Concurrent Prevalence of Chronic Energy Deficiency and Obesity among Women in Purworejo, Central Java, Indonesia

There are few studies on the nutritional status of nonpregnant women. A population-based, cross-sectional study of nutritional status in 5,817 non-pregnant women 15 to 49 years of age was conducted in Purworejo District, Indonesia, in 1996. Weight, height, mid-upper-arm circumference (MUAC), and triceps skinfold thickness were measured, and information on socio-economic, demographic, and reproductive factors was collected. Seventeen percent of the women had chronic energy deficiency and 11% were obese. Mean weight, MUAC, and triceps skinfold thickness corresponded to the 25th percentile of standards and mean height to the 5th percentile. Obesity was more common among older women and chronic energy deficiency among both the oldest and the youngest women. Women working in agriculture, not using contraceptives, and not owning a television, radio, or refrigerator were more likely to have chronic energy deficiency. In summary, both chronic energy deficiency and obesity existed in Purworejo, and risk factors were identified. Interventions are needed to improve the nutritional status of girls and women before and after pregnancy.

Linking maternal and infant benefits of a nutritional supplement during pregnancy and lactation

To evaluate the effect of a nutritional supplement on change in women's weight during a reproductive cycle and on the difference in birth weight between one infant and the previous one, we analyzed data on 176 complete reproductive cycles from an experiment that was conducted in rural Guatemala. Women with an initial weight <50 kg were classified as marginally nourished or malnourished. Women whose intake of the supplement was in the top 2 tertiles were distinguished from those whose intake was in the lowest tertile. Linear regression modeling was used to estimate the effect of supplementation on these outcomes and to control for confounding factors. Malnourished women gained weight during the reproductive cycle, but their second (study) infant tended to weigh less at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative difference in birth weight. Marginally nourished women lost weight during the reproductive cycle and their second (study) infant tended to weigh more at birth than their prior-born infant. Higher intakes of supplement were associated with a less negative weight [corrected] trend for the women themselves. Well-nourished women and their infants did not show any of these benefits from supplementation. These findings help explain past contradictory findings on maternal depletion as well as on the benefits of nutritional supplementation for mothers and their infants.

Familial occurrence of dystocia

OBJECTIVE

A cohort study was conducted to determine the risk of dystocia for women whose mothers, sisters, or twin sisters had dystocia during childbirth.

STUDY DESIGN

A linked database was constructed between 2 separate Swedish birth registries. Obstetric data on mothers giving birth to daughters during the period 1955 to 1972 were studied. Among these daughters, sister-couples and twins were identified. The daughters subsequently became mothers during 1973 and 1990 and obstetric data on the first deliveries were also studied.

RESULTS

If a mother had dystocia when delivering her eldest daughter, this daughter had an increased risk of dystocia during her own first childbirth (odds ratio 1.7, 95% confidence interval 1.2 to 2.4). If the mother had an assisted instrumental delivery (vacuum extraction, forceps, or cesarean section) because of dystocia, there was a higher risk for her daughter to have an instrumental delivery because of dystocia (odds ratio 1.8, 95% confidence interval 1.0 to 3.1). Among primiparous sisters the risk of an instrumental delivery because of dystocia in a younger sister was more than tripled (odds ratio 3.5, 95% confidence interval 2.1 to 5.8) if her elder sister had a dystocic labor requiring instrumental intervention. The risk among twins increased more than 20-fold (odds ratio 24.0, 95% confidence interval 1.5 to 794.5) if 1 twin sister had dystocia during her first childbirth.

CONCLUSION

Dystocia has a familial occurrence, suggesting a possible genetic factor explaining inefficient uterine action.

Familial patterns in birth characteristics: impact on individual and population risks

BACKGROUND

Familial patterns in reproductive outcome have been suggested previously, but few studies have comprehensively evaluated both length of gestation and types of growth retardation.

METHODS

Information on intrauterine period and birth characteristics for a cohort of Swedish women born 1955-1972 was linked with information on these women's own reproductive experiences during 1973-1990. Familial trends in preterm deliveries, small-for-gestational age (SGA) births and two types of growth retardation were evaluated for mothers relative to their own birth characteristics (n = 4746), relative to their older sisters' deliveries (n = 2931) and among consecutive deliveries of the mothers (n = 14,209). Adjusted relative risks (RR) were calculated from logistic regression analyses.

RESULTS

Mothers who had themselves been preterm at birth were not at increased risk of any of the outcomes studied. Mothers who had themselves been SGA at birth had an almost 50% higher risk (NS) of giving birth to either a preterm or an SGA infant than had mothers who had not been SGA at birth. Mothers tended to repeat the same patterns in subsequent deliveries: RR was 3.7 for a second preterm delivery given a previous one and 7.8 for a second SGA delivery given a previous one. Among SGA siblings, chronic growth retardation was more often repeated than was acute growth retardation. Mothers with an older sister who had given birth to a preterm infant had an 80% higher risk of giving birth to a preterm infant.

CONCLUSIONS

Familial trends in gestational age and body proportions at birth were demonstrated; however, the relatively small population attributable risk per cents in Sweden are discussed.

Images of health and health care options among low income women in Punjab, Pakistan

We studied women's beliefs and experiences of health and health care among 42 women in an urban slum area in Lahore and a village 40 km outside of Lahore. Data were collected through repeated, in-depth interviews in Urdu or Punjabi totalling 200 hours. For triangulation purposes, four focus group discussions with additional women were performed, as well as in-depth interviews with eight mothers-in-law, three traditional practitioners and three medical practitioners. The women's images of health reflected expectations on the women in society. Women from the village and women from the lowest socioeconomic stratum (SES) spoke of health in terms of physical strength; women from the city and women from low SES spoke of health in terms of mental strength; and women from medium SES discussed it in terms of cultural competence. Overall, health had a very low priority in these women's lives. Two health problems were reported by all women: mental tension leading to headache and white vaginal discharge leading to body pains and fatigue. These health problems were seen as part of womanhood; if treatment was sought, it was often from traditional healers. Village women had a flexible, pragmatic attitude toward health care resources and used all types until treated. Their relation to the doctor was specific; they were mostly concerned with the medical treatment. In contrast, city women chose health care providers depending on type of illness, and being met with respect was for them of equal concern. Childbearing experiences influenced the perceptions of health and health care. Mothers of daughters were seen to both need and deserve less food, health care and attention. These mothers were less vocal about health complaints. Women without children spoke of health in terms of physical strength. These women may have less access to health care because children cannot be used as an "excuse", and because they are not worth spending resources on.

A new definition of maternal depletion syndrome

BACKGROUND

Although the term "maternal depletion syndrome" has been commonly used to explain poor maternal and infant health, whether such a syndrome actually exists remains unclear. This uncertainty may be due to the lack of a clear definition of the syndrome and the absence of theoretical frameworks that account for the many factors related to reproductive nutrition.

METHODS

We propose a new definition of maternal depletion syndrome within a framework that accounts for potential confounding factors.

RESULTS

Our conceptual framework distinguishes between childbearing pattern and inadequate diet as causes of poor maternal health; hence, our definition of maternal depletion syndrome has both biological and practical meaning. The new definition is based on overall change in maternal nutritional status over one reproductive cycle in relation to possible depletion and repletion phases and in relation to initial nutritional status.

CONCLUSIONS

The empirical application of this approach should permit the testing of the existence of maternal depletion syndrome in the developing world, and the distinction between populations where family planning will alleviate maternal depletion and those in which an improved diet is also necessary.