Prevalence of anemia among pregnant women and adolescent girls in 16 districts of India

BACKGROUND

Nutritional anemia is one of India's major public health problems. The prevalence of anemia ranges from 33% to 89% among pregnant women and is more than 60% among adolescent girls. Under the anemia prevention and control program of the Government of India, iron and folic acid tablets are distributed to pregnant women, but no such program exists for adolescent girls.

OBJECTIVE

To assess the status of anemia among pregnant women and adolescent girls from 16 districts of 11 states of India.

METHODS

A two-stage random sampling method was used to select 30 clusters on the basis of probability proportional to size. Anemia was diagnosed by estimating the hemoglobin concentration in the blood with the use of the indirect cyanmethemoglobin method.

RESULTS

The survey data showed that 84.9% of pregnant women (n = 6,923) were anemic (hemoglobin < 110 g/L); 13.1% had severe anemia (hemoglobin < 70 g/L), and 60.1% had moderate anemia (hemoglobin > or = 70 to 100 g/L). Among adolescent girls (n = 4,337)from 16 districts, the overall prevalence of anemia (defined as hemoglobin < 120 g/L) was 90.1%, with 7.1% having severe anemia (hemoglobin < 70 g/L).

CONCLUSIONS

Any intervention strategy for this population must address not only the problem of iron deficiency, but also deficiencies of other micronutrients, such as B12 and folic acid and other possible causal factors.

Maternal mortality in seven districts of Uttar Pradesh--an ICMR task force study

Maternal mortality is a major health and development concern. The available information on maternal mortality in rural India is inadequate and scanty. This study presented maternal mortality data from the demographically and developmentally (including for health) poor performing state of Uttar Pradesh. A descriptive, cross-sectional survey was conducted utilizing a stratified cluster sampling design between 1989-90 in eight districts of Uttar Pradesh. Four good performing districts namely, Agra, Farrukhabad, Ghaziabad and Badaun from the western region and four poor performing districts from the eastern region namely, Gorakhpur, Basti, Varanasi and Pratapgarh were chosen. A door-to-door household interview survey was carried out in the selected villages covering a population of 11.67 lakhs in 889 villages. Maternal mortality rates during 1989 ranged between 533745 per 100,000 live births except in Ghaziabad district where the rate was as low as 101 per 100,000 live births. The rate in Eastern U.P. was higher (573 per 100,000 live births) as compared to that in Western U.P. (472 per 100,000 live births). A total of 286 maternal deaths were reported during the study period. The direct obstetric causes accounted for 55.7% of maternal deaths with haemorrhage (26.4%) being the most prevalent. Anaemia and jaundice (17.4%) were the most prevalent indirect causes of maternal deaths. Most of the maternal deaths could have been prevented if timely medical care was available.

Aflatoxin B1 contamination in wheat grain samples collected from different geographical regions of India: A multicenter study

In a multicenter study conducted by the Indian Council of Medical Research, 1,646 samples of wheat grain collected from rural and urban areas of 10 states representing different geographical regions of India were analyzed for aflatoxin B1 (AFB1). AFB1 concentrations of > or = 5 microg kg(-1) were recorded in 40.3% of the samples, and concentrations above the Indian permissible regulatory limit of 30 microg kg(-1) were found in 16% of the samples. The proportion of samples with AFB1 concentrations above the Indian regulatory limit ranged from 1.7 to 55.8% in different states, with the minimum in Haryana and the maximum in Orissa. The variation in wheat contamination among states seems to be mainly the result of unsatisfactory storage conditions. Median AFB1 concentrations of 11, 18, and 32 microg kg(-1) were observed in samples from Uttar Pradesh, Assam, and Orissa, respectively; concentrations in other states were <5 microg kg(-1). The maximum AFB1 concentration of 606 microg kg(-1) was observed in a sample from the state of Uttar Pradesh. The calculated probable daily intakes of AFB1 through consumption of contaminated wheat for the population in some states were much higher than the suggested provisional maximum tolerable daily intake. Human health hazards associated with such AFB1 exposure over time cannot be ruled out.

Aflatoxin B1contamination of parboiled rice samples collected from different states of India: A multi-centre study

Under a multi-centre study conducted by the Indian Council of Medical Research, 1,511 samples of parboiled rice were collected from rural and urban areas of 11 states representing different geographical regions of India. These samples were analysed for contamination with aflatoxin B(1.) The presence of aflatoxin B(1) at levels=5 microg g(-1) was found in 38.5% of the total number of samples of the parboiled rice. About 17% of the total samples showed the presence of aflatoxin B(1) above the Indian regulatory limit of 30 microg kg(-1). No statistically significant difference in percentage of samples contaminated with >30 microg kg(-1) was observed between pooled rural (19.4%) and urban (14.5%) data. A median value of 15 microg kg(-1) of aflatoxin B(1) was observed in samples from Assam, Bihar and Tripura. In all other states surveyed the median value was <5 microg?kg(-1).

Residues of DDT and HCH in wheat samples collected from different states of India and their dietary exposure: A multicentre study

Under a multicentre study conducted by the Indian Council of Medical Research, 1712 samples of wheat grain/flour were collected from urban and rural areas in 11 states representing different geographical regions of India. These samples were analysed for residues of DDT (2,2-bis (p-chlorophenyl)-1,1,1-trichloro ethane) and different isomers of HCH (1,2,3,4,5,6-hexachloro cyclohexane, a mixture of isomers) by gas-liquid chromatography. Residues of DDT were detected in 59.4% of 1080 samples of wheat grain and in 78.2% of 632 samples of wheat flour. Different isomers of HCH were present in about 45-80% of the samples of wheat grain/flour. Medians of DDT and total HCH, respectively, for pooled samples of wheat grain were 0.013 and 0.035 mg kg(-1), while those for wheat flour were 0.01 and 0.02 mg kg(-1). Estimated daily intakes of DDT and different isomers of HCH through the consumption of wheat contaminated at their median and 90th percentiles constituted a small proportion of their acceptable daily intakes. Amongst the pesticide residues analysed, statutory maximum residue limits have been fixed only for gamma-HCH in wheat in India, as 0.1 mg kg(-1) in wheat grain and zero in wheat flour. Residue levels of gamma-HCH exceeded these maximum residue limits in five of 1080 samples of wheat grain and in 340 of 632 samples of wheat flour. The failure to meet the requirement of the gamma-HCH maximum residue limit in large number of wheat flour samples was attributed to the fixation of practically unachievable zero limit. Comparing the previous studies and the present one, the levels of residues of DDT and HCH in wheat were significantly decreased.

Residues of DDT and HCH pesticides in rice samples from different geographical regions of India: a multicentre study

As part of a multicentre study conducted by the Indian Council of Medical Research, 2000 samples of rice were collected from rural and urban areas of 13 states representing different geographical regions of India. The samples were analyzed for residues of DDT [2,2-bis(p-chlorophenyl)-1,1,1-trichloroethane] and different isomers of HCH [1,2,3,4,5,6-hexachlorocyclohexane, a mixture of isomers] by gas-chromatography. Residues of DDT and HCH, respectively, were detected in about 58 and 73% of the samples analysed. Medians of both DDT and HCH in rice samples were around 0.01 mg kg (-1). Concentrations of alpha-, beta-, gamma- and delta-HCH exceeded a maximum residue limit of 0.05 mg kg (-1) for each isomer in rice fixed by the Ministry of Health and Family Welfare of the Indian Government in 4.3, 2.6, 1.7 and 1.2% of the samples, respectively. There is no statutory limit fixed in India for DDT residues in cereals. Its maximum residue limit of 0.1 mg kg (-1) in cereals recommended by Codex was exceeded by about 2% of the samples examined. Estimated intake of DDT and isomers of HCH through consumption of rice contaminated at their median and 90th percentiles constituted a small proportion of their acceptable daily intakes.

Iodine deficiency disorders in 15 districts of India

METHODS

A multicentre study to assess iodine deficiency disorders (goitre and deaf-mutism/cretinism) in 1, 45, 264 children (6 - <12 years old) from 15 districts of ten states was carried out during 1997-2000. Urinary iodine excretion was also determined in 27481 children, while iodine content was estimated in 5881 samples of edible salt. The sampling methodology followed was a "30 cluster survey".

RESULTS

The overall prevalence of goitre was 4.78% (4.66% of grade I and 0.12% of grade II) amongst the children examined. The highest prevalence of 31.02% goitre was observed in Dehradun district, while the lowest prevalence of 0.02% goitre was recorded in Bishnupur and Badaun districts. The overall prevalence of cretinism among children examined from seven districts was 0.072% whereas that of deaf-mutism was 0.27% among children examined from 8 districts. Median urinary iodine values was marginally less than the WHO cut-off values only in children of the 3 out of the 15 districts surveyed. Iodine content was found to be adequate in 55.45% of the salt samples.

CONCLUSION

The results suggested a significant decline in the prevalence of goitre in most parts of the country.

Resuscitation of asphyxiated newborns with room air or 100% oxygen at birth: a multicentric clinical trial

OBJECTIVE

To compare the short-term efficacy of room air versus 100% oxygen for resuscitation of asphyxic newborns at birth.

DESIGN

Multicentric quasi randomized controlled trial.

SETTING

Teaching hospitals.

INCLUSION CRITERIA

Asphyxiated babies weighing greater than 1000 grams, with heart rate less than 100 per min and/or apnea, unresponsive to nasopharyngeal suction and tactile stimuli and having no lethal abnormalities.

INTERVENTION

Asphyxiated neonates born on odd dates were given oxygen and those on even dates room air for resuscitation.

OUTCOME MEASURES

Primary: Apgar score at 5 minutes; Secondary: Mortality and Hypoxic ischaemic encephalopathy (HIE) during first 7 days of life.

RESULTS

A total of 431 asphyxiated babies, 210 in the room air and 221 in 100% oxygen group were enrolled for the study. Both the groups were comparable for maternal, intrapartum and neonatal characteristics. The heart rates in room air and 100% oxygen groups were comparable at 1 minute (94 bpm and 88 bpm), 5 minutes (131 bpm and 131 bpm) and 10 minutes (135 bpm and 136 bpm). Median apgar scores at 5 min [7 versus 7] and 10 minutes [8 versus 8 ], in the room air and oxygen groups respectively, were found to be comparable. Median time to first breath (1.5 versus 1.5 minutes) was similar in the room air and oxygen group. Median time to first cry (2.0 versus 3.0 minutes) and median duration of resuscitation (2.0 versus 3 minutes) were significantly shorter in the room air group. The number of babies with HIE during first seven days of life in the two treatment groups (35.7% babies in room air and 37.1% in the 100% oxygen group) were similar. There was also no statistically significant difference in the overall and asphyxia related mortality in the two treatment groups (12.4% and 10.0% in room air versus 18.1% and 13.6% in oxygen group).

CONCLUSION

Room air appears as good as 100% oxygen for resuscitation of asphyxic newborn babies at birth.

Vitamin A deficiency disorders in 16 districts of India

A multicentre study to assess vitamin A deficiency disorders (Bitot's spot and corneal scars) in 164,512 children (< 6 years) and night blindness among 113,202 children (24-71 months) from 16 districts of 11 states was carried out during 1997-2000. The prevalence of night blindness among 6,633 pregnant women from 15 districts was also assessed. The sampling methodology followed was a "30 cluster survey". The highest prevalence of Bitot's spot (4.71%), corneal scar (0.5%) and night blindness (5.17%) in children was found in Gaya district whereas the highest prevalence of night blindness (19.62%) among pregnant women was observed in Dibrugarh. No case of Bitot's spot was found in children screened from Mandi, Dehradun and Badaun districts. Similarly prevalance of night blindness was 'nil' among pregnant women of Badaun, Baramulla, Dehradun, Mainpuri, Srinagar, Bikaner and Raigarh.

Evaluating contraceptive choice through the method-mix approach. An Indian Council of Medical Research (ICMR) task force study

The method-mix approach was used to evaluate informed contraceptive choices in the present study. A total of 8,077 potential clients were given a balanced presentation of all available contraceptive methods in the national program, ie, the CuT 200 intrauterine device (IUD), low-dose combined oral pills (OC), condom, and sterilization (female/male) along with a new method, Norplant(R).(1) The majority of women opted for spacing methods; among them, the IUD was preferred by about 60% of clients, followed by condoms (9%), OC (6%), and Norplant (5%). Sterilization, mainly female, was accepted by about 17% of the women making an informed choice. The economic status of couples did not influence the contraceptive choices, as all the methods were offered free of cost in the present study, which is the current practice in the national program. Illiterate women more often accepted sterilization (about 25%) than did literate women (15%). This is because illiterate women had more children; about 30% of illiterate women had three or more children, as opposed to 16.2% of literate women. However, literacy status did not influence the choice of any specific spacing method. The study also revealed that, by encouraging potential clients to make an informed choice, they could override the provider's bias while accepting a particular type of spacing method. This is evident from the observation that Norplant was the first choice of the provider for 35% of the women, whereas only 5% of women preferred and accepted Norplant. The present study stresses an urgent need to promote the practice of informed choices in the national program with a variety of contraceptive options-especially, spacing methods for improving contraceptive prevalence and reproductive health in the country.

DDT and HCH residues in dairy milk samples collected from different geographical regions of India: a multicentre study

Under a multicentre study conducted by the Indian Council of Medical Research, 2205 samples of dairy milk were collected from rural and urban areas of 12 states representing different geographical regions of India. These samples were analysed for residues of DDT and different isomers of HCH by gas-liquid chromatography. Analytical quality assurance between various participating laboratories was ensured through analysis of check samples. The residues of DDT and HCH were detected in more than 80% of samples analysed. Concentrations of DDT residues, alpha-HCH, beta-HCH, gamma-HCH and delta-HCH exceeded their maximum residue limits prescribed by the Ministry of Health and Family Welfare of the Indian Government in 37, 21, 42, 28 and 4% of the samples, respectively. Median values of DDT and HCH found in dairy milk in India were more than the corresponding values reported from most other countries. The results showed significant variations in the incidence as well as level of these contaminants in dairy milk from different regions of the country.

Responsiveness of human male volunteers to immunization with ovine follicle stimulating hormone vaccine: results of a pilot study

A study of 140 days duration was performed to examine if human male volunteers (n = 5) respond to ovine follicle stimulating hormone (oFSH) immunization (administered adsorbed on Alugel on days 1, 20, 40 and 70) by producing antibodies capable of both binding and neutralizing bioactivity of human FSH. The kinetics of antibody production for both the immunogen (oFSH) and the cross-reactive antigen (hFSH) were essentially similar. The volunteers responded only to the first two immunizations. The boosters given on days 40 and 70 were ineffective, probably because of the presence of substantial amounts of circulating antibody to oFSH. Of the antibodies generated to oFSH, 25-45% bound hFSH with a mean binding affinity of 0.65 x 10(9) +/- 0.53 M(-1). The binding capacities at the time of high (30-80 days of immunization) and low (>110 days) titres were 346 +/- 185 and 10.5 +/- 5.8 ng hFSH/ml respectively. During the period of high titre, free serum FSH (value in normal males 1-5 ng/ml) was not monitorable. A 50 microl aliquot of the antiserum obtained from different volunteers between days 30 and 80 and on day 140 blocked binding of (125)I-labelled hFSH to its receptor by 82 +/- 9.7 and 53 +/- 12.2% respectively. The antibody produced was specific for FSH, and no significant change in the values of related glycoprotein hormones (luteinizing hormone/testosterone and thyroid stimulating hormone/thyroxine) were recorded. Seminal plasma transferrin, a marker of Sertoli cell as well as of seminiferous tubular function, showed marked reduction (30-90%) following immunization with oFSH. Considering that endogenous FSH remained neutralized for approximately one sperm cycle only (65 days), the reduction in sperm counts (30-74%) exhibited by some volunteers is encouraging. Immunization with oFSH did not result in any significant changes in haematology, serum biochemistry or hormonal profiles. There was no production of antibodies capable of interacting with non-specific tissues. It is concluded that it should be possible to obtain a sustained long-term blockade of endogenous FSH action in men by using oFSH as an immunogen. This is a prerequisite for obtaining significant reduction in the quality and quantity of spermatozoa produced, thus leading to infertility.

Aflatoxin B1 contamination in maize samples collected from different geographical regions of India--a multicentre study

Under a multicentre study conducted by the Indian Council of Medical Research, 2,074 samples of maize were collected from rural and urban areas of 11 states representing different geographical regions of the country. These samples were analysed for aflatoxin B1 using the AOAC method. Analytical quality assurance between various participating laboratories was ensured through analysis of check-samples. About 26% of maize samples collected from 11 states exceeded the permissible Indian regulatory limit of 30 micrograms kg-1. No statistically significant difference in percentage of samples contaminated (> 30 micrograms kg-1) was observed between pooled rural (27.8%) and urban (23.7%) data. The maximum level of contamination of 666 micrograms kg-1 was observed in the state of Haryana. The median level of < 5 micrograms kg-1 was observed in the states of Gujarat, Haryana, West Bengal, Andhra Pradesh and Karnataka. In all other states studied, the median level was found to vary between 10 and 35 micrograms kg-1.

Dynamics of contraceptive practice amongst urban Indian women

BACKGROUND

Most studies on knowledge, attitude and practice regarding contraceptives have been conducted in rural areas and urban slums. In this study, a mixed urban population was surveyed.

SUBJECTS

Two thousand parous women from different social and educational backgrounds residing in the metropolis of Mumbai (Bombay), Maharashtra were included in the study.

RESULTS

Fifty per cent of illiterates, semi-literates and highschool educated, and 80% of college-educated couples said that they had no gender preferences for their children, but actual practice belied this. Regardless of the level of education, 25%, 75% and 95% of all couples were sexually active by 6 weeks, 3 months and 6 months after childbirth. Awareness regarding the availability of various contraceptives increased with education; 20% of all graduate couples used condoms or the rhythm method immediately after marriage. After the birth of their first child, 80% of educated couples used spacing methods whereas even after the birth of their third child more than 50% of the uneducated did not. The major complaint of the intrauterine device users was menorrhagia and abdominal pain, while that of pill users was nausea, giddiness and headache. Spacing methods were popular among the educated, and terminal ones among the uneducated. Steroidal contraceptive pills were not popular with any group, regardless of the level of education.

CONCLUSION

Education was the main variable in the decisions regarding the family size, spacing interval, contraceptive awareness, its use immediately after marriage and during the postpartum period.

Aflatoxin B1 contamination in groundnut samples collected from different geographical regions of India: a multicentre study

Under a multicentre study conducted by the Indian Council of Medical Research, 2062 samples of groundnut were collected from rural and urban areas of 11 states representing different geographical regions of the country. These samples were analysed for aflatoxin B1 using the AOAC method. Analytical quality assurance between various participating laboratories was ensured through analysis of check-samples. Twenty-one per cent of groundnut samples collected from 11 states exceeded the permissible Indian regulatory limit of 30 micrograms/kg. No statistically significant difference in percentage of samples contaminated (> 30 micrograms/kg) were observed between pooled rural (22.9%) and urban (19.9%) data. Amongst the 11 states, the minimum and maximum per cent contamination respectively (> 30 micrograms/kg) was observed to be 15.2 in the state of Andhra Pradesh and 28.3 in the state of Haryana. The maximum level of contamination of 833 micrograms/kg was observed in the state of Gujarat. The median level of < 5 micrograms/kg was observed in the states of Gujarat, Haryana, Punjab, Andhra Pradesh and Karnataka. In all other states studied, the median level was found to vary between 10 and 20 micrograms/kg. The 90th percentile values were high in Andhra Pradesh (125 micrograms/kg), Gujarat (111 micrograms/kg) and Haryana (110 micrograms/kg). In the remaining states the 90th percentile value ranged from 60 to 93 micrograms/kg. Analysis of pooled data showed the percentages of samples exceeding the level of contamination of 5 micrograms/kg and 15 micrograms/kg, respectively were 44.9% and 37.4% which therefore, showed a marked increase when compared with the per cent of samples exceeding 30 micrograms/kg in the overall data.

Low-dose progestogen contraception and the nursing mother

Breast feeding, though an important and efficient contraceptive method, suffers from one major limitation: the contraceptive protection it offers the nursing mother ends abruptly without giving any physical indication of the return of fertility. Barrier methods and progesterone-only hormonal contraceptives, either in the oral, implant or injectable form, appear to be the primary contraceptive alternative for the nursing mother today. They neither adversely affect lactation, nor does the minute quantity of progesterone (NET or LNG) transferred to the infant affect its growth and physical well-being. Puerperal insertion of IUD carries an inherent risk of pelvic inflammatory disease, high expulsion rates and menorrhagia, once menses resume. Combination contraceptives affect both the quality and quantity of breastmilk; hence they are not recommended. Sterilization is a permanent method and therefore useful only when the family has been completed.

Can chronic maternal drug therapy alter the nursing infant's hepatic drug metabolizing enzyme pattern?

This study was carried out to investigate whether minute quantities of maternal drugs ingested over an extended period of time by a breast-feeding infant can alter the activity pattern of the infant's hepatic drug metabolizing enzyme (HDME). The HDME activity patterns of 12 breast-fed infants whose mothers were not on drug therapy were compared with those of 11 infants whose mothers had been taking 30 micrograms levo-norgesterel daily for 90 to 195 days (oral contraceptives group) and of 10 infants whose mothers had been taking ethambutol and isoniazid daily since pregnancy (tuberculosis group). As 6 beta hydroxycortisol in urine is considered to be a good and acceptable reflector of HDME activity, it was estimated from the infants' urine using enzyme-linked immunosorbent assay (ELISA) technique. A comparison of the patterns between 90 days of age and 195 days of age of the infants in the control group and the two study groups indicated an increase from 36.6 ng/mL to 58.4 ng/mL at 195 days in the control group. An initial decrease from 36.6 ng/mL to 26.2 ng/mL was noted with commencement of maternal levo-norgesterel therapy, followed by a slow and steady rise to 47.8 ng/mL at 195 days of age, with a shift in the peak from 120 to 135 days of infants age in the oral contraceptive group. A suppressed pattern with decreased levels of 6 beta hydroxycortisol ranging from 19.3 ng/mL to 26.5 ng/mL at 195 days was found in the tuberculosis group. The data were analyzed by two-way analysis of variance (ANOVA) coupled with Duncan's Multiple range test. Both treatment group showed significant differences from the control group at the 0.050 level. The HDME plays an important role in determining the final outcome of any drug in humans, as it controls the metabolism of drugs. Hence, alterations in its activity caused by the transfer of maternal drugs over a prolonged period of time could pose a serious problem to nurslings when they require drugs for their own benefit.

Vaginal bleeding patterns of women using different contraceptive methods (implants, injectables, IUDs, oral pills)--an Indian experience. An ICMR Task Force Study. Indian Council of Medical Research

Irregularity in vaginal bleeding patterns is the most common clinical side effect causing discontinuation of the method reported by the-users of the newer contraceptive methods, especially hormonal ones. An objective assessment of vaginal bleeding pattern is, therefore, critical in evaluation of a new contraceptive method for its acceptance and continued use. The menstrual diary records of women participating in clinical trials of several contraceptive methods undertaken by the Indian Council of Medical Research were analysed. It was observed that the long-acting progestogen-only hormonal contraceptives like levonorgestrel (LNG)-releasing subdermal implants Norplant or intrauterine devices (LNG-IUD) as well as injectable contraceptive NET-EN 200mg given 2 or 3 monthly produced disturbances in bleeding pattern in the majority of their users. Very heavy or prolonged bleeding, a potential health hazard was uncommon and a shift more towards infrequent bleeding was observed. In Norplant-II implants users, 75 to 80% of women had irregularities in bleeding pattern during the first year of use which improved with prolonged use. However, even at 4 years of use, about half of the users of Norplant-II implants continued to have irregular bleeding patterns. The bleeding disturbances occurred in 80% users of 200mg NET-EN injectable contraceptives also during first year of use, however unlike Norplant-II implants users, there was no improvement with prolonged use. Combined monthly injectable contraceptives containing 50mg NET-EN and 5mg estradiol valerate caused less bleeding problems with half of the users experiencing normal pattern during one year of its use. Combined low-dose oral pills, both triphasic and monophasic, produced much better cycle control as compared to any of the other hormonal contraceptive-treated groups; about 90% of combined oral pill users had normal bleeding patterns during one year of method use. The use of copper IUDs was associated with increased bleeding in 18 to 20% of women during the initial period of three months which improved with prolonged use. It was observed that the women having frequent or prolonged bleeding had discontinued the contraceptive method more often as compared to those having delayed bleeding episodes or oligomenorrhoea. However, discontinuation rates due to bleeding irregularities at one year were lower in Norplant-II implants users as compared to other long acting hormonal contraceptive methods such as injectables or IUDs in spite of similar or better bleeding patterns in women using these methods.(ABSTRACT TRUNCATED AT 400 WORDS)

Is time-interval between mini-pill ingestion and breastfeeding essential?

A study was conducted on four alternate days over an eight-day period in a group of 12 healthy, 20-35 year old exclusively breast feeding women who were interested in weaning their infants. On each study day the women ingested 150 micrograms levonorgestrel. Maternal blood and milk samples were collected at 2, 4, 6, and 8 hr intervals after LNG ingestion on the 1st, 3rd, 5th, and 8th day. A time-dependent decrease in maternal serum and increase in breast milk levels of LNG were observed. Maintaining a time interval between mini-pill intake and breastfeeding results in higher levels of LNG in breast milk, thereby exposing the infant to a bolus of LNG in a "single-delayed" feed.

At what 'infant-age' can levonorgestrel contraceptives be recommended to nursing mothers?

OBJECTIVE

Levonorgestrel (LNG), a low-dose progestin, does not affect lactation but like all drugs taken by breastfeeding mothers, it can be transferred to the infant via breast milk. How infants of various ages cope with this unwanted maternal drug would help in deciding when to recommend this method of contraception to breastfeeding mothers.

METHODS

The study was conducted in 30 exclusively breastfeeding mothers and their 4-, 12- and 24-week-old infants. The mothers daily received 30 micrograms LNG over a five-week period, thus exposing their infants to maternal LNG for that period.

RESULTS

Four-week-old infants could neither absorb nor metabolize LNG efficiently. Twelve-week-old infants could metabolize LNG more efficiently than absorb. Twenty-four-week-old infants could do both efficiently.

CONCLUSION

It is safe to introduce LNG to breastfeeding mothers at 12 weeks postpartum.

Handigodu disease: a radiological study. A new variety of spondyloepi(meta)physeal dysplasia of the autosomal dominant type

Handigodu disease is a new syndrome of familial spondyloepi(meta)physeal dysplasia. It is inherited as an autosomal dominant trait. The disease is prevalent in a localised area of South India. On the basis of detailed clinical, anthropometric and radiological investigations of 234 affected individuals, it has been observed that different clinical presentations reflect variation in the severity of the disease. All of them could be explained as being caused by defective development of bones as a result of monogenic disorder.

Use of traditional medical practitioners to delivery family planning services in Uttar Pradesh

This pilot study conducted in Muzaffarnagar district in the state of Uttar Pradesh, India, demonstrates the potential for using traditional medical practitioners in the delivery of family planning services after a brief training period. Practitioners participated continuously in the program for an intervention period of two years during which their services were accepted by the community. The impact of their involvement was reflected in increased knowledge of permanent as well as reversible contraceptive methods and in higher contraceptive use rates, especially of reversible methods adopted by women younger than 25 years (from 8 percent to 37 percent), in the intervention villages, as compared with increased knowledge and use (from 13 percent to 25 percent) of permanent methods alone in the control villages.

Indian experience of home based mothers card: ICMR task force study

To improve the quality of MCH services, a Home Based Mothers Card (HBMC) prepared and recommended by World Health Organization was adapted to Indian situation, and introduced in 1.5 lakh population of rural area covered by 6 participating centres under the aegis of Indian Council of Medical Research. Two thousand four hundred and forty six mothers were given this card and were followed up for a period of 2 years. Only 89.2 percent retrieval of the cards was possible after a period of 18 months. Screening of the population for "at risk" women monitoring and referral could be undertaken with the help of this card. Improved antenatal, and referral services were observed during the study period. The card (HBMC) was acceptable to the mothers as well as to the health workers, as a tool for improving the quality and coverage of MCH services being rendered at the Primary Health Centre.

Pregnancy outcome in women exposed to toxic gas at Bhopal

A study was undertaken to compare the effects of exposure to the toxic gas in pregnant women in Bhopal with pregnant women in a similar, unexposed area. A high incidence of spontaneous abortions (24.2%) in the pregnant women exposed to the toxic gas was observed as compared to those in the control area (5.6%). Other indices of adverse reproductive outcome, such as the rate of still birth and congenital malformation were not found to be different. The perinatal and neonatal mortalities were significantly higher in the affected area (6.9 and 6.1% respectively), as compared to the control area (5.0 and 4.5% respectively).

A focus of high degree chloroquine resistant P. falciparum in Mandla district (M.P.)

A study on the bioenvironmental control of malaria was launched in Bizadandi block (Mandla district, M.P.) in May 1986. Besides intervention, using environmental management methods and larvivorous fishes, weekly surveillance and chloroquine administration at 25 mg/kg body weight was practiced. Studies during 1987 revealed that a large number of P. falciparum cases did not respond to the standard anti-malarial treatment. Therefore, systematic 28 day in vivo studies were taken up on the follow-up of P. falciparum cases after administration of 3 day course of 25 mg/kg body weight as per the WHO procedure. Results revealed a high proportion of drug resistant cases belonging to RI (237), RII and RIII (182) category. In vivo studies on the sensitivity to metakelfin showed that some cases were resistant to this drug. There is an urgent need to eradicate this focus before it starts spreading to other areas.

ICMR Task Force Study on hormonal contraception. Transfer of norethisterone (NET) and levonorgestrel (LNG) from a single tablet into the infant's circulation through the mother's milk

A single tablet of either of the three different types of oral contraceptive preparations, viz. "Gynovlar" containing 3000 micrograms norethisterone (NET) and 50 micrograms ethinyl estradiol (EE2) or "Ovral" containing 250 micrograms levonorgestrel (LNG) and 50 micrograms EE2, or a daily progestogen only type--"Minipill" containing 30 micrograms of LNG only, were administered to 40 normal lactating women on a random basis. The sampling schedule in all the three body fluids, i.e. the maternal sera, breast milk and the infant's sera, was kept in such a manner that the peak levels of the contraceptive steroids would be expected to be present in these fluids. The results of this study indicate that the transfer ratio of LNG or NET from the maternal sera to her breast milk was approximately 10% (6-34%) for Gynovlar, 9% (5-18%) for Ovral and 6% (2-34%) for Minipill. However, it was interesting to observe that whereas the transfer ratio of NET or LNG from breast milk to infant's sera was similar for combination pills--8% (3-23%) for Gynovlar and 12% (3-42%) for Ovral, it was significantly higher for progestogen only Minipills--38% (13-92%) for LNG. The precise reason for the higher transfer ratio of LNG from breast milk to infant's serum in Minipill users cannot be explained.

ICMR task force study on hormonal contraception. Transfer of levonorgestrel (LNG) administered through different drug delivery systems from the maternal circulation into the newborn infant's circulation via breast milk

The transfer of levonorgestrel (LNG) from the maternal plasma via breast milk to the infant was studied in 38 fully lactating and breast-feeding women at 4-6 weeks postpartum, for a duration of 28 days. These volunteers were provided with LNG contraceptive treatment delivered through three, different routes of drug delivery system: (i) intrauterine devices impregnated with LNG (LNG-IUD); (ii) subdermal implant (Norplant (R)-2); and (iii) minipills (LNG 30 micrograms daily). On the first day after either the LNG-IUD (n = 14 women) or Norplant (R)-2 (n = 14 women) insertion, the maternal blood and breast milk samples were collected at 2, 4 and 8 hourly intervals. This was followed by daily collection of these samples as well as infant's blood from days 2 to 4 and thereafter on days 7, 14 and 28. For infant's blood samples from LNG minipill users (n = 10 women), only a single 4-hour sample was collected on the first day and no samples were collected on days 3 and 4. The rest of the schedule for collection of maternal blood and breast milk as well as infant's blood samples were the same in minipill users as for the other two treatment groups. The study revealed a lower LNG percentage transfer from maternal sera to breast milk--11.8 +/- 2, 7 +/- 2 and 8 +/- 1 and relatively higher percentage LNG transfer from breast milk to infant's sera--75 +/- 17, 68 +/- 20 and 32 +/- 3, in LNG-IUD, Norplant (R)-2 and minipill users, respectively. Therefore, LNG contraceptive steroid is transferred into the infant's circulation, the biological significance of which remains to be established.

Pharmacodynamic effects of levonorgestrel (LNG) administered either orally or subdermally to early postpartum lactating mothers on the urinary levels of follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) in their breast-fed male infants

Pharmacodynamic effect of levonorgestrel (LNG) present in small amounts in infant's circulation has not yet been studied adequately. In our present study, nine women were taking oral minipills (LNG 30 micrograms daily) and 10 were using subdermal implants, Norplant(R)-2, during early postpartum period from four weeks to 15 weeks. These were healthy lactating women in age group 20 to 35 yrs, who had full-term normal delivery of male infants. Daily 4-hour urine samples (from 8 AM to 12 noon) were collected from four weeks onwards to 15 weeks for estimations by radioimmunoassays of follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) levels. No significant differences (P greater than 0.05) were found between geometric means of the total area under curve at weekly intervals for FSH, LH and T hormones between the male infants from control group (n=10) when compared with oral minipill or Norplant(R)-2 users. These results are reassuring for future sexual growth and development of children who are exposed to contraceptive steroids during their infancy; however, they do require further confirmation by long-term epidemiological studies incorporating monitoring and surveillance of such children.

ICMR Task Force Study on hormonal contraception. Biological activity of ethinyl estradiol present in the breast milk

A study was conducted to compare the biological activity of the estrogenic component of the endogenous steroids in breast milk samples collected during various phases of lactation with those milk samples collected from women who were on estrogen therapy. The estrogenic biological activity in the milk sample was assessed by the immature mouse uterine weight gain assay. Milk samples collected during postpartum period from six different study groups, viz., control colostrum of 1-3 days and 4-6 days, transitional milk (10-20 days) and mature milk (1-3 months) were compared with colostrum and mature milk of women treated with Lynoral (ethinyl estradiol 0.1 mg) three times a day for three days. Estrogenic activity was observed only in animals injected with milk extracts of colostrum samples from both control and Lynoral-treated women; however, they were not significantly different from each other. Therefore it is not the exogenous estrogens, but the endogenous estrogen present in large quantities in the colostrum that is responsible for the biological activity.

Phase II randomized comparative clinical trial of Norplant (six capsules) with Norplant-2 (two covered rods) subdermal implants for long-term contraception: report of a 24-month study. National Programme of Research in Human Reproduction

In a randomized clinical study, contraceptive efficacy and bleeding patterns were studied in a group of healthy, regularly menstruating, non-lactating women (n = 84) using two 4.4 cm covered silastic rods containing levonorgestrel, Norplant(R)-2, and compared with another group of women (n = 88) using six 3.4 cm capsules also containing levonorgestrel, Norplant(R). The silastic rods or capsules were placed subdermally in the medial aspect of the upper arm. No method failure was reported up to 24 months of use in this study with either of the device. The bleeding pattern was also similar for both devices as indicated by average episode length, number of bleeding runs and number of spotting days. The continuation rates with both devices were over 80 per 100 users at the end of 12 months and over 65 per 100 users at the end of 24 months. Discontinuations due to expulsion of the device, bleeding problems or personal reasons were few and similar for both devices. The results suggest that silastic-covered rods, Norplant(R)-2, which are comparatively easier to insert and remove and have similar clinical effect, could replace capsules, Norplant(R), as a long-term reversible subdermal contraceptive.

Phase I comparative clinical trial with subdermal implants--bioabsorbable levonorgestrel or norethisterone pellet fused with cholesterol

The potential for antifertility effect of two bioabsorable pellets, one containing norethisterone (NET) and the other containing levonorgestrel (LNG) fused with cholesterol, was studied in a group of healthy, menstruating but sterilised women. The pellets weighed approximately 30 mg and contain 85% steroid and 15% cholesterol. A single NET pellet was inserted in 4 subjects, out of which 2 were also studied for steroid pattern in blood. After reaching peak levels within 48 hours, the plasma NET levels declined gradually within a fortnight's time, and thereafter, ranged between 200 to 700 mg/ml up to 90 days post-insertion. After this period, occassional spurts of NET release were seen. Bleeding pattern was studied in 37 cycles; mid-luteal progesterone (P) estimation was done in 16 cycles, mid-cycle cervical mucus was studied in 27 cycles and post-coital test (PCT) in 7 cycles. Cycle length with pellet insertion was of 25 to 37 days duration except one cycle of 55 days duration. All cycles studied during the treatment were ovulatory (P greater than 5 ng/ml) and no consistent effect was observed on cervical mucus as well as on PCT. Thus, a single NET pellet does not seem to have a reliable contraceptive potential. A single LNG pellet was inserted in 8 subjects, and steroid patterns were studied in 6 women. Peak levels of LNG were reached within 24 hours of pellet insertion and the levels fell gradually in a week's time. Thereafter, LNG levels ranged between 100-400 pg/ml up to 8 months. In contrast to the observation with NET pellets, only one subject showed frequent spurts of LNG release until the 4th month of treatment. Bleeding pattern was studied in 90 cycles, P was estimated in 52 cycles, mid-cycle cervical mucus studied in 55 cycles and PCT done in 26 cycles. Breakthrough bleeding (BTB) occurred on 15 occasions, 11 episodes being in 2 subjects. Cycle length varied between 21 to 42 days. The LNG pellet did not exert a consistent effect either on ovulation inhibition or cervical mucus or PCT. In their present form, therefore, a single LNG pellet also does not appear to have a reliable contraceptive effect.

Clinical performance and endocrine profiles with contraceptive vaginal rings containing a combination of estradiol and D-norgestrel

Contraceptive vaginal rings (CVRs) impregnated with a combination of estradiol and d-norgestrel were studied in 39 women. The rings were inserted as three weeks "in" and one week "out" schedule to allow withdrawal bleeding. Ovulation was inhibited in all cycles and promptly resumed on completion of the treatment cycles. Bleeding control was excellent. Incidence of breakthrough bleeding was 2.11 per cent in 273 cycles studied, with 89 per cent of the cycles within the acceptable range (25 - 35 days). Levels of estradiol after an initial rise were maintained between 50-100 pg/ml and, d-norgestrel levels were relatively constant between 1.8-3 ng/ml during the period while the ring remained in situ. Clinical acceptance was good. The main problem encountered was of spontaneous expulsion of the ring in the toilet, which might be due to the squatting toilet habits of Indian women and laxity of vaginal wall.

A study of interaction of low-dose combination oral contraceptive with Ampicillin and Metronidazole

Plasma levels of norethisterone (NET), ethinyl estradiol (EE), Ampicillin or Metronidazole were estimated in 16 women, who were taking low-dose oral combination contraceptive pills (containing norethisterone acetate 1 mg and ethinyl estradiol 30 microgram) and in whom concurrently, either Ampicillin (6 women) or Metronidazole therapy (10 women) was given. Neither Ampicillin nor Metronidazole therapy altered the 'peak' or 24-hour plasma levels and area under the curve, for NET and EE. Furthermore, oral contraceptive treatment did not alter the 'peak' levels of Ampicillin or Metronidazole. Progesterone (P) levels were in the anovulatory range in all Ampicillin treated cycles. However, in Metronidazole treated group, two out of 10 women showed a P rise of more than 4 ng/ml. The study was expanded to include another group of 15 women treated with Metronidazole, where only one women showed a P rise of more than 4 ng/ml. The occurrence of 'escape ovulation' as suggested by P rise of more than 4 ng/ml in three out of 25 Metronidazole treated women is either a chance incidence due to a different pharmacological response in them, or most probably due to the default in the regular intake of pills in these women. This is supported by the observation that one out of three women showing a P rise (greater than 4 ng/ml( during concurrent Metronidazole therapy, also showed ovulatory P values in oral contraceptive-only treated cycles. Furthermore, in the control group also, one out of 10 women had ovulatory P levels (greater than 4 ng/ml) in oral contraceptive-only treated cycles.

A study of interaction of a low-dose combination oral contraceptive with anti-tubercular drugs

Low-dose combination contraceptive (containing norethisterone acetate 1 mg and ethinyl estradiol 30 micrograms) was administered to women receiving concurrent therapy with either Rifampicin or "triple" antitubercular treatment consisting of paraaminosalicylic acid (PAS), isonicotinic acid hydrazide (INH) and streptomycin. Plasma levels of norethisterone (NET) and ethinyl estradiol (EE), PAS and INH were measured and the area under curve (AUC) was calculated for NET and EE. Rifampicin treatment (9 women) caused a statistically significant reduction of the plasma NET levels as well as the AUC of NET. In this group of women, though a trend for reduction in EE levels was observed in individual subjects, it was not statistically significant. Out of 7 regularly menstruating women on Rifampicin therapy, 2 showed a premenstrual rise of plasma progesterone (P) levels (> 4 ng/ml) suggesting an ovulatory cycle and 3 experienced menstrual irregularities. In contrast, plasma levels of NET and EE as well as their AUCs were not altered in 8 women receiving "triple" antitubercular therapy. Only one woman out of 8, had menstrual irregularity and all women had P levels in the anovulatory range. Furthermore, oral contraceptive treatment did not alter the plasma levels of PAS and INH.

Release of 19-nor-testosterone type of contraceptive steroids through different drug delivery systems into serum and breast milk of lactating women

The release of contraceptive steroids through different drug delivery systems into serum and breast milk was investigated in a group of lactating women. Four women in each group were taking either a low dosage progestogen compound like norethisterone (NET) 350 micrograms or d-norgestrel (d-Ng) 50 micrograms alone or low dosage combination pills containing NET 1 mg or d-Ng 150 micrograms with 30 micrograms ethinyl estradiol (EE2) or a biodegradable implant containing 25 mg NET or d-Ng. Peak levels in plasma and milk were seen in oral contraceptive users around 2 hours. Of the two low dosage progestogen compounds, d-Ng was below the detection limit in milk within 4 hours whereas NET was still detectable at the 24-hour interval. In contrast to this, because of the larger quantity of steroids in the combination pills, the NET/d-Ng levels in serum as well as in milk were high throughout the 24-hour period. With the subdermal route because of the sustained low release of the drug from the biodegradable implants, the levels in milk were below the detection limit within a day with d-Ng and within a week with NET.

Serum bile acids in women taking combination contraceptives

A longitudinal study in 60 women was undertaken to observe the changes, if any, in serum bile acids after taking oral combination pills containing either 50 or 30 microgram of ethinyl estradiol. The women were followed up to 12 months. Serum bile acids (cholyglycine conjugates) were estimated by radioimmunoassay. The combination contraceptives had no appreciable effect on serum bile acids.

A study of the use of intermittent serum luteinizing hormone, progesterone and oestradiol measurements for the detection of ovulation

The value of luteinizing hormone (LH), progesterone (P) and oestradiol (E2) in serum as an index of ovulation and corpus luteum function was studied in blood samples collected at infrequent intervals during the menstrual cycle from 19 healthy Thai women. A serum P level of more than 3 ng/ml was detectable in 70 to 80 per cent samples obtained between days 20 and 25 and a P peak and/or E2 peak (greater than 150 pg/ml) were found at this time in 85 to 94 per cent of the cycles. In not more than 26 per cent of the cycles was an LH peak (greater than 150 ng/ml-LER-907) detected when all results were considered. A significant P and/or E2 peak on day 22 or 23 occurred in more than 78 per cent of 25 to 33 day cycles, whereas, the P and/or E2 peak was detectable in only 50 per cent of the cycles lasting less than 25 or more than 33 days. The postovulatory serum P levels were the ones most consistently raised in patients studied over several consecutive cycles.