BIBLIOGRAPHIC DATA SEET 1. CONTROL NUMBER 2. SUBJECT CLASSIIICATION (695) BIB-~r7LOGRAP -AD DATA SPN AAH-605 PCOO-0000-G570 3. TITLE AND SUPTrtLE (240) Joint IGCC/IFRP East and South East Asia Seminar on Regional Fertility Research, Bangkok, Thailand, 1979 4. PERSONAL AUTHORS (100)
5. CORPORATE AUTHORS (101)
Int. Fertility Research Program
6. DOCUMENT DATE (110) 7. NUMBER OF PAGES (120) 8. ARC NUMBER (170) 1979 219p. FA301.32.161 9. REFERENCE ORGANIZATION (130) I FRP 10. SUPPLEMENTARY NOTES (500)
11. ABSTRACT (950)
12. DESCRIPTORS (920) Contraceptives 13. PROJECT NUMBER (150) Fertility Maternal/child health 932053700 Meetings Southeast Asia East AsiaHealth 14. CONTRACT NO.(140 ) 15.CONTRAC TYPEh(G40) Family planning Dealie systems Nutrition Delivery systems AID/pha-C-1172 16. TYPE OF DOCUMENT (160)
AID 590-7 (10-79)
CONTENTS Page
1. ACKNOWLEDGEMENT ...... 1 II. INTRODUCTION ...... 2 III. FOREW ORD ...... 3 IV. ADDRESSES ...... 4 Paper 1 (ii) Welcome Address By Dr. Somboon Vachrotai ...... 4 Paper 2 (ii) Opening Address By His Excellency, Dr. Krasae Chanawongse, Deputy Minister of Public Health ...... 5 Paper 3 (iii) Introductory Statement By Dr. Malcolm Potts ...... 6 Paper 4 (iv) Introductory Statement By Dr. L.S. Sodhy ...... 8 Paper5 (v) Closing Remarks By Dr. Somboon Vachrotai ...... 9 V. Paper6 AIDE MEMOIRE ...... 10 VI. Paper7 AGENDA FOR THE WORKSHOP ...... 12 VII. SUMMARY OF PROCEEDINGS ...... 14 VIII. GROUP SESSIONS ...... 27 IX. COUNTRY PAPERS ...... 36 Paper 8 (i) Indonesia ...... 36 Paper 9 (ii) Malaysia ...... 45 Paper 10 (iii) Nepal ...... 54 Paper 11 (iv) Philippines ...... 59 Paper 12 (v) Singapore ...... 32 Paper 13 (vi) Horg Kong ...... 63 Paper 14 (vii) Japan ...... 64 Paper 15 (viii) Korea ...... 67 Paper 16 (ix) Taiwan ...... 80 X. DOCUMENTS ...... 83 Paper 17 (i) Primary Health Care with Special Reference to Nutrition, MCH and Family Planning by Dr. Somboon Vachrotai ...... 83 Paper 18 (ii) Primary Health Care with Special Reference to Nutrition, MCH and Family Planning by Dr. Jae-Mo Yang ...... 85 Paper 19 (iii) Prospective Studies on the Risks and Benefits of Contraception by Dr. David A. Edloman ...... 98 Paper 20 (vi) Retrospective Studies Specially on Depo Provera by Dr. Malcolm Potts ...... 100 Paper 21 (v) Questions and Answers about Depo Provera, The Chiang Mai Experience and
AEenw for Irernational Development RL;c1c i1_0! S/-i3
Washington, D.C. 20523 the Recent U.S. FDA Action by Dr. Edwin B. McDaniel ...... 102 Paper 22 (vi) Camps - An Alternative Delivery System for Family Planning Servi'.es by Di. Dibya Shree Malla ...... 106 Paper 23 (vii) Organizations of Clinics/Training/ Effective Referral Systems on Outreach by Mr. Benjamin de Leon ...... 108 Paper 24 (viii) Organizations of Clinics - Training/Effective Referral Systems on Outreach by Dr. Debhanom Muangman ...... 115 Paper 25 (ix) Organization of Clinics - Training/ ,-ffective Referral Systems - Clinic Management by Dr. Johan A. Milek Thambu, Dr. Hamid Arshat and Datin Dr. Nor Laily Aziz ...... 120 Paper 26 (x) Family Planning Services by Traditional Birth Attendants by Dr. J.Y. Peng ...... 130 Paper 27 (xi) Report of the Panel on the Effects of Steroidal Contraceptives on Asians by Dr. Jose B. Catindig ...... 136 Paper 28 (xii) IPPF-ESEAOR Panel on the Effects of Steroidal Contraceptives on Asian by Prof. Ho-Kei Ma ...... 143 Paper 29 (xiii) Maternity Care Monitoring - Where Next? by Dr. Tina Agoestina ...... 145 Paper 30 (xiv) Maternity Care Monitoring (MCM) - Where Next? by Dr. Roger P. Bernard, Ms. Ellen Kendall, Dr. J.Y. Peng and Dr. Elton Kessel ...... 154 Paper 31 (xv) IsWhat we are offering Acceptable? The Case of Family Planning Acceptance in Indonesia by Dr. Haryono Suyono ...... 179 Paper 32 (xvi) Acceptability of Family Planning in Malaysia by Dr. Azizan Ghazali, Dat*n Dr. Nor Laily Aziz and Ms. Rita Raj Hashim ...... 183 Paper33 (xvii) Incidence and Follow up of Trophoblastic Diseases by Associate Professor Mark C.E. Cheng 189 Paper34 (xviii) Incidence and Follow-up of Trophoblastic Diseases by Prof. Ho-Kei Ma ...... 195 Paper 35 (xix) Incidence and Follow-up of Trophoblastic Diseases by Dr. Takashi Wagatsuma ...... 196 Paper36 (xx) Incidence and Follow-up of Trophoblastic Diseases in Taiwan by Prof. Pei-Chuan Ouyang ...... 202 XI. ROSTER OF THE SEMINAR ...... 210 ACKNOWLEDGEMENT
The IGCC/iFRP wishes to acknowledge with thaniks the and assisted the Secretariat from the early start of the prepara time taken off by H.E. The Deputy Minister of Public Health, tion of the Seminar and also for the preparation of the pro Thai;and, Dr. Krasae Chanawongse, from his busy schedule to ceedings. give his welcome address and to perform the Opening Cere mony for this Joint Workshop. Thanks are also due to Dr. Johan A.M. Thambu, our Rapporteur-General, and to all members of the Steering Com Thanks are due to the enormous assistance rendered by mittee, Resource Persons, especially those who contributed Dr. Somboon Vachrotai, Director General of Public Health, personal papers together with their dedicated roles as speakers Thailand, and his staff for assisting the IGCC Secretariat with aid session-coordinators. the overall details of all the administrative arrangements (in cluding the utilization of this office equipment, typing, pur- Last but not least we also like to acknowledge the active chase of sationery, ctc. etc.). Though he haslust come out of participation, valuable cooperation, assistance and contri hospital, ha was able to take up the chairmanship, and was bution of the Participants from the six IGCC member coun also active as Resource Person and member of the Steering tries, namely, Indonesia, Malaysia, Nepal, Philippines, Singa Committee. pore, Thailand, and participants from Japan, Korea, Hong Kong, Taiwan and from IPPF-ESEAOR, Kuala Lumpur. Our grateful thanks are also extended to the USAID, Identification No. AID/PHA-C-1172, for providing funds for Not to be forgotten to be acknowledged are the Observers the meeting, without which the seminar would not have taken from the Population Council Bangkok, PIACT Asia, UNFPA place. Bangkok, UN-ESCAP Bangkok, IDRC Singapore, WHO Pro gramme Coordinator Bangkok, ICARP ASIA, 2 other Repre We are profoundly grateful to Dr. J.Y. Peng, Associate sentatives from Taiwan and the Chairman FFPAM FPA Kedah, Director for International Activities of IFRP, who supported Malaysia. INTRODUCTION
1. The Joint IGCC/IFRP East and South East Asia Seminar 3. The proceedings consisted of both Plenary and Group on Regional Fertility Research was held at the Ambassa- Sessions. A total of 9 (nine) country papers and 19 related dor Hotel, Bangkok, Thailand, from 18-20 July 1979. documents were presented at the Seminar proceedings.
The Seminar was sponsored by the International Fertility 4. The Seminar was officially opened by H.E. The Deputy Research Program, Triangle Park, North Carolina, U.S.A. Minister of Public Health, Thailand, Dr. Krasae Chana wongse, preceeding the introduction of Dr. Somboor 2. The meeting was attended by participants from ten (10) Vachrotai, the Director General of the Department of countries namely, Indonesia, Malaysia, Nepal, Philippines, Health, Thailand. Dr. L.S. Sodhy, Secretary General of Singapore, Thailand, Hong Kong, Japan, Korea, and the IGCC Secretariat and Dr. Malcolm Potts, Executive Taiwan.There were a total of 47 participants and Resource Director of the IFRP both delivered the Introductory State- Persons and 11 Observers. ments respectively.
2 FOREWORD
of disciplines: 1973 until now 5 workshops have been jointly ness to the participants (who came from avariety Since in Health on Family Plan between IGCC and IFRP. Much research has been health researches and administrators organized current projects, capabilities in the IGCC region with assistance from the IFRP. The ning) of IFRP's accomplishments, done and plans. IGCC has taken on the task to coordinate this comparative and future priorities programme in the field of Reproductive Systems research the Regional needs in contra contraceptives, sterilization, pregnancy termination) in the It has also assisted to define (on and the introduction of new techno- Region. ceptive safety research logy in maternity health research. We must now find ways and means of meeting these unmet needs. This 3-day Seminar on Regional Fertility Research has helped not only to provide and establish aforum for exchange Dr. L.S. Sodhy of experiences of studies and -esearches done or still on-going Secretary General, in the participating countries, but also to bring greater aware- IGCC Secretariat.
3 PAPER 1
WELCOME ADDRESS
Dr. Somboon Vachrotai
Distinguished Participants, Ladies and Gentlemen: We are honoured today to have with us His Excellency the Deputy Minister of Public Health, Thailand, Dr. Krasae Chana- It ismy great pleasure to participate in this East and South wongse, known worldwide for his dedication as a physician to East Asia Seminar on Regional Fertility Research which is the health of rural communities which has already earned him jointly sponsored by IFRP and IGCC. Those of us gathered the Magsaysay Award. His Excellency has always been active here include not only research professionals but also highly ly involved in, as well as astrong supporter of, family planning qualified health and family planning administrators, and we research activities. are prepared to discuss and explore family planning research activities and needs in Asia, as well as increase our awareness Now, at this time, I would like to present Dr. Krasae of IFRP activities and its assistance role in meeting the family Chanawongse, Deputy Minister of Public Health, who will planning research needs of this region. kindly presentthe opening address.
4 PAPER 2
OPENING ADDRESS
H.E. Dr. Krasae Chanawongse
Distinguished Participants and Guests, Ladies and Gentlemen: Regional Research activities deserve much praise and applause. Such regional cooperation can lead us to self-reliance and self It is indeed a great honour and privilege for me to join sufficiency which is one of the major objectives that we wish you for the first day of this important meeting. This meeting is to achieve through our collaboration. a result of the joint efforts of two very capable and efficient organizations, the International Fertility Research Program and During the course of this 3-day meeting, there will be the Inter-Governmental Coordinating Committee (the Regional optimal opportunity for all distinguished participants to utilize Organization for Inter-Governmental Cooperation and Co- their expertise in identifying unmet needs in the field of Fertility ordination in Population and Family Planning in South East Research as well as to share experiences, many of which Asia. We may note with satisfaction that there have already might be the products of the six former meetings. been 6 Expert Meetings jointly conducted by these two orga- Because we are from a group of daveloping countries nizations, the IFRP and IGCC, in the field of Fertility Research. working under the severe constraints of limited resources, our These deliberationsing arend n-gingfamiy cceeratngcf marked importancepannng for rseach strengthen- ro-tasktaskis is to helphe channel sel the limitedthe limitedresources resources available to thoseour ing and accelerating on-going family planning research pro- areas of highest priority in order to avoid wasteful duplication grammes within our Region. As we approach the advent of theconcept of new decade, we must lock for new orientations and guide- of elth care withspeciation to tegrated of lines conductive to the formulation of a new and more effec- primary health care with special reference to integrated Nu tive development strategy for the 1980's. We all know that this trition, Maternal and Child Health and Family Planning services can be accomplished best through relevant action-oriented will be taken into consideration in the meeting, because this research on the one hand, and close Regional cooperation and approach is the most efficient and effective approach. coordination on the other. We must, therefore, join our hearts and minds together as According to the policy of the Thai Ministry of Public peoples of one world, now assembled at this important meet Health and, I believe, the policies of all nations represented in ing. We should make this meeting an important landmark as this meeting, Fertility Research has been given a high priority we prepare ourselves to enter the new decade of the 1980's. in overall Family Planning activities. Efforts have been made to establish a workable mechanism for Inter-Government co- May I now have the honour to declare open the IGCC/ operation and Inter-Sectoral coordination and to organize IFRP East and South East Asia Seminar on Regional Fertility pooled activities for the development of appropriate techno- Research. And I wish you all success in your deliberations. logies and strategies to deal with global population problems. The steps that have been taken by IFRP and IGCC to foster Thank you.
5 PAPER 3
INTRODUCTORY STATEMENT
Dr. Malcolm Potts
paper by Smith of the East-West Cen- And what have these considerations to do with the Inter A recent academic also what the author calls "crisis mortality" in the national Fertility Research Program? The IFRP must ter has studied way through Philippines (1). In several years, such as in 1883, change and adapt.Currently, it is one third of the 19th-century family planning organiza the death rate greatly exceeded the birthrate, often as the a three-year contract.Like nearly all Today, the IFRP is an result of cholera epidemics. tions, it began in a developed country. amalgam of staff in North Carolina and contributors through The human race has always lived with crises. In many out the world. The purposes of this meeting are to review on research and to help plan new projects and new themes the period of calm and relative progress since the end of going ways, study so that the IFRP can change and adapt to new cir War II has been an unusual and aberrant episode in for World and especially cumstances. human affairs. The events of recent years, recent months, suggest that perhaps we are returning to to an end. When normality, having to face crises more frequentlyl The easy money of the 1960s has come inflation is considered, the actual money available for research is declining (2). The effectiveness of the is taking revenge on the economic progress of in fertility control Inflation use of its resources will be scrutinized even more than the 1950s and 1960s. Politically, countries are turning to the IFRP's previously by its response to current needs.To make that res right. Doors are closing between nations, and as Southeast ponse as adequate and appropriate as possible, the fulltime Asia knows all tstaffAtoo well, wars still occur. of the IFRP need all the help and insight that contributors them. slow can give crises? Rapid reaction, not What happens in times of change, is needed. Radical changes, rather than compromises, The IFRP must work within a framework, partly deter are likely to succeed. Crises are a time of weeding out; some mined by its principal donor, the US Agency for International groups and traditions that do not adapt and respond simply Development (AID). The IFRP has a contract to improve and get eliminated, adapt fertile, regulation methods to meet the needs of deve loping countries. The IFRP also has agrant to help train medi disseminate information and these grand, if rather dismal, prospects to do cal and non-medical personnel, What have planning professionals in these planning and population? Perhaps, the current transfer techoology to family with family should, of course, also follow the crisis in petroleum su. .,as reminds us how shortsighted and countries. Such activities emphasis set by the US Congress. self-centered our interpretations can be. In the United States, guidelines and expensive." In reality, it people are saying, "Gasoline is too resources on the long for a finite resource that is rapid- In 1973, it was decided to focus AID has been too cheap, too on the poor of the poorest by rampant consumption. world's poor, and most especially, ly being depleted nations. One way to define the purpose of the current meeting is to help design research projects that place a special em Population trends are often interpreted with asimilar lack phasis on extending family planning services to the poor. His of realism. Some people think the problem of population Excellency Dr. Krasi and Dr. Somboon, who opened the growth is disappearing simply because certain birthrates are meeting, have pioneered many aspects of taking health care dipping, without realizing that absolute increments in the and family planning to needy populations in rural areas. population may be the same or greater than they were before. of family planning pro Some people measure the success of chemi the number of acceptors and avoid looking at The IFRP has established further development grammes by IUDs modified for post change or seeking demonstrable alteration in cal sterilization and the final testing of demographic We sincerely believe that abortion rates. It is too easy to forget that today's birth- partum use as its current priorities. illegal on problems whose solution rate statistics will be tomorrow's unemployment statistics these priorities focus attention assistance to the poor. perhaps involving hostile, restless millions, will be of greatest
6 In many parts of the world, the demand for voluntary we are the rich. female sterilization exceeds the capacity of services to provide the operation. The development of a transcervical method of One thing the IFRP can do is to help express the latent tubal occlusion that an auxiliary is able to use would be the demand for family planning and try to understand how people single most important technical advance that could be made perceive the se.vices we offer. Maternity Care Monitoring is a in family planning. powerful tool that not only tells us about the clinical needs and progress of a pregnant woman, but also enables us to review Similarly, the use of IUDs is often limited by the avail- the acceptability and adequacy of existing family planning ability of trained personnel to insert the device. A device that services. could be modified for immediate postpartum use might even tually be proved a responsible method of fertility control to In conclusion, the IFRP regards this meeting as an im put in the hands of auxiliaries and even traditional midwives. portant one, rdpresenting a formal policy of setting goals not in North Carolina but, as in this case, in Asia. If the meeting move forward globally. There are many needs that this meeting may address. succeeds, then it will help the IFRP group or institution at a What is the best way to involve traditional birth attendants in If we do not succeed, then, like any family planning services as well as in motivation of women to time of crisis, we will simply not survive because we have analysis, I believe that we accept contraception? What are the costs of providing family failed to adapt. However, in the final and that respond planning through hospitals, institutes, clinics or community- are well placed to continue to move forward exciting and, hopefully, even based services? What are the costs of treating incomplete ing to challenges should be an process. abortions due to an illegal operation as opposed to the costs enjoyable of legal abortions? What are the costs of services not only to the providers but also to the consumers? REFERENCES
I see a need to improve the organizational aspects of ad- 1. Smith PC: Crisis mortality in the nineteenth century ministration as much as the clinical aspects of contraception. Philippines: data from past records. J of Asian Stud 38: 51 -76, 1978. Ialso see problems. For those of us who jet set around the world, it can be difficult to define services and methods for 2. Greep RO, Koblinsky MA, Jaffe FS: Reproduction and those who travel in bullock carts. All of us at this meeting are Human Welfare: A Challenge to Research. MIT Press, on the same side of the great divide between rich and poor - Cambridge, 1976.
7 PAPER 4
INTRODUCTORY STATEMENT
Dr. L.S. Sodhy
Your Excellency Deputy Minister for Health Dr. Krasae, Dr. and Dr. Aragon the member of the Board of Commissioners of Somboon, the Population Commission. I also wish to mention that we have two Deputy Chairmen of the BKKBN (National Family Ladies and Gentlemen: Planning Coordinating Board, Indonesia), Dr. Haryono Su yono and Dr Pardoko. We are indeed grateful to them for their I have much pleasure and honour to address such a dis- presence. tinguished gathering on the occasion of this Joint IGCC/IFRP workshop. I also wish to make special mention of Dr. Vitura Sang singkeo, Executive Director of the ICARP. He informs me that First I want to convey our heartfelt gratitude to His Ex- he would like to work closely with the IGCC, and it is possible cellency the Deputy Minister for Health for taking time off that we may inthe near future have ajoint IGCC/ICARP/IFRP from his busy schedule to give such a stimulating address and meeting. to perform the Opening Ceremony for this Joint Workshop. We are indeed sir, very grateful to you. The IGCC and the IFRP have been working together for the past seven years. We have had several joint meetings and I also wish to thank Dr. Somboon and his able and hard- also cooperated in research activities related patlicularly to the working staff for all the work involved in preparing for this Asian region. This joint meeting is a further manifestation of meeting. Dr. Somboon deserves special mention. He has just this close and fruitful relationship. We are also very pleased came out of hospital in order to join us, and will later return to that the Executive Director of IFRP, Dr. Malcolm Potts is here hospital for further treatment. in person to attend the meeting. With regard to this joint meet ing I wish to make special mention of Dr. J.Y. Peng. He has We are also grateful to Dr. Somboon and the Government been the man behind the scenes to make this meeting possible of Thailand for agreeing to host this workshop inBangkok. and he has been constantly assisting in all the preparations for the past several months. We are fortunate to have with us very distinguished per sons. I wish to make special mention of Datin Dr. Nor Laily We have in all a very good group of people and I have who has come to attend this meeting inspite of her very busy every confidence that we will have an excellent and fruitful schedule. She has to return early to attend a very important meeting. meeting in Kuala Lumpur and later to fly to Nairobi for an inter national meeting. Another SGO present with us is Mr. Benja- Thank you. min de Leon, Executive Director of the Population Commission
8 PAPER 5
CLOSING REMARKS
Dr. Somboon Vachrotai
Diqtinguished Participants, Ladies and Gentlemen: bring out many valuable ideas.
Three fruitful days are being passed away. Though the This meeting would never have been successful without time will pass us by, all t'.e benefits we earn from various those competent Chairman, Rapporteur as well as the co country papers, and p,;sentation of the most well-done works ordinators and the very important group behind the scenes, from distinguished resource persons and participants also namely, the secretariat gtoup. those benefits from all valuable discussions and small group meetings, will permanently stay with us. We certainly will Finally, I would like to reiterate that, to me, our meeting apply them in our programme to make our common goal of has been highly successful because all of us are eager to help health activities in our region to be highly successful. All this each other. We will work hand in hand to try and keep this for the better life of our people who are still living in low privi- great cooperation and collaboration together. Finally, in clos lege situations. As a representative of all participating coun- ing we wish all of you a pleasant and bright time travelling tries here I would like to express our high appreciation to IFRP back home. and IGCC steering committee for providing us the auspicious opportunity otherwise we will never get together like this to Thank you. PAPER 6
AIDE MEMOIRE
IGCC/ IFRP EAST AND SOUTH EAST ASIA SEMINAR d) IFRP's future priorities and plans. ON REGIONAL FERTILITY RESEARCH 3. To define the IFRP's role in meeting regional needs in the following areas: INTRODUCTION a) Contraceptive safety research InJanuary 1973, the first meeting was organized by IGCC b) Introduction and transfer of new technology and invclved aworking group of representatives from member c) Maternity Health Research countries of the IGCC. This meeting called the IGCC Expert Group Working Committee on Sterilization and Abortion was Mechanics of the seminar held in Penang, Malaysia, and was made possible by a grant from the Population Council. Participants will be called for from member countries and from other countries in East and South East Asia where IFRP's The meeting considered all relevant matters on the sub- contributors are. Invited countries will be: Indonesia, Malaysia, ject of pre and post contraceptive fertility regulation. One Nepal, Fhilippines, Singapore, Thailand, Hong Kong, Japan, amongst theurgent recommendation was that the IGCC should Korea and Taiwan. coordinate acomparative research programme on sterilization and pregnancy termination within the Region. The IGCC The participants are requested to prepare ajoint Country approached the IFRP for assistance establishing such a pro- Paper on "Inventory within the Country of Previous Ongoing ject and the response was very favourable. Research" which includes:
Since then the IGCC and the IFRP have been working a) which are appropriate for Asian Women on Oral Pills; together. Five expert meetings have been jointly organized by b) traditional methods on abortion and other methods; IGCC and IFRP in the past. Miich research has been done in c) studies in IUD; the IGCC region with assistance from the IFRP. d) Trophoblastic diseases; and e) bringing with them some traditional medicines for fertility control It is now proposed to conduct a seminar with broader scope and to involve not only gynaecologists but also pro- Besides that, some participants (contributors mostly) are gramme administrators in health and family planning and other individually asked to present papers; also resource persons programme leaders in East and South East Asia. The Seminar from in and outside the region will be requested to prepare that will be conducted is to be set up to have a broader scope, papers. not only in the variety of participants who will participate but also in the choice of subjects to be discussed. The tentative list of subjects are: The objectives of the Seminar will be as follows: 1. Primary Health Care with special reference to Nutrition, MCH and Family Planning. 1. To bring together individuals of leadership stntus in the East and South East Asian Research, Health and Family 2. Prospective studies on risk and benefit of Family Planning Planning community in order to discuss regional activities Contraceptives. and needs. 3. Retrospective studies specially on Depo Provera. 2. To enhance the awareness of these individuals with respect to: 4. Alternative Delivery System for Family Planning Services: a) IFRP's past accomplishments; a. Camps b) IFRP's current projects; c) IFRP's capabilities; and b. Organization of clinics: training/effective referral
10 system 10 minutes, but the paper can be prepared as long as they (1) Outreach wish. (2) Clinic management The Seminar will last from 18 to 20 July, 1979, and will be c. Traditional Birth Attendant held in Bangkok, Thailand, at the Ambassador Hotel. 5. IPPF - ESEAOR Medical Committee Findings. One and ahalf days will be dedicated for Plenary Sessions, where papers will be presented and the other one and a half 6. Maternity Care Monitoring - where next? days for group discussion sessions. 7. Iswhat we are offering acceptable? All papers will be distributed at the Meeting.
8. Incidence and follow-up of trophoblastic diseases. The total attendants (participants, resource persons and observers) will be around 50 persons. Of thdse papers, only highligts will be read out for about
11 PAPER 7
AGENDA
18th July1979(Wednesday) Coordinator: Dr. Henry Pardoko "Primary Health Care with special 09.00-10.001HRS. OPENING CEREMONY Reference to Nutrition, MCH and (i) Introduction of H.E. the Deputy Family Planning" By Dr. Somboon Minister of Public Health,Thailand, Vachrotai and Dr. Taek I I Kim By Dr. Somboon Vachrotai. 14.35 - 14.45 HRS. DISCUSSION (ii) Welcome Address, By the Deputy Minister of Public 1445- 15.15 HRS. COFFEE/TEA BREAK Health H.E. Dr. Krasae Chana wongse. 15.15- 15.50HRS. PLENARY PRESENTATION ON (iii) Introductory Statements: TOPIC II (a) IGCC - By Dr. L.S. Sodhy (b) IFRP - By Dr. Malcolm Potts. Coordinator: Datin Dr. Nor Laily Aziz (a) "Prospective Studies on Risk and 10.00 - 10.3G HRS. COFFEE BREAK / GROUP PHOTO- Benefit of Family Planning Contra- GRAPH ceptives". By Dr. David Edelman
10.30 - 10.40 HRS. Announcement of Chairman and Rap- (b) "Retrospective Studies Specially porteur General. on Depo Provera". By Dr. Mal- Chairman: Dr. Somboc; Vachrotai. colm Potts and Dr. Edwin B. Mc Co-Chairman: Daniel Rapporteur-General: Dr. Johan Tham bu. 15.50- 16.10HRS. DISCUSSION
10.40 - 12.30 HRS. COUNTRY PRESENTATIONS 16.10 - 17.00 HRS. PLENARv PRESENTATION ON TOPIC III "Inventory within the Country of Pre vious On-Going Research" Coordinator: Dr. Haryono Suyono - Display of Traditional Medicines "Alternative Delivery System for Family Planning Services" 1. Indonesia 6. Thailand (a) Camps 2. Malaysia 7. Hong Kong By Dr. Malla Dibya Shree 3. Nepal 8. Japan 4. Philippines 9. Korea (b) Organization of Clinics 5. Singapore 10. Taiwan - training / effectivo referral systems Clarification of Country Papers. (1) Outreach
12.30 - 14.00 HRS. LUNCH BREAK By (i) Dr. Gloria Aragon or Mr. Ben jamin de Leon 14.00 - 14.15 HRS. DISCUSSION (ii) Dr. Debhanom Muangman
14.15 - 14.35 HRS PLENARY PRESENTATION ON (2) Clinic Management TOPIC I By Dr. Johan A.M. Thambu
12 (c) Traditional Birth Attendant 11.00 - 11.40 HRS. PLENARY PRESENTATION ON By Dr. J.Y. Peng TOPIC (VII) 17.00 - 17.30 HRS. DISCUSSION Coordinator: Dr. Malla Debya Shree "Incidence and Follow-Up of Tropho 19.30 HRS. SEMINAR DINNER blastic Diseases" 19th July 1979 ( )By (i) Prof.Mark Cheng Chi Eng (Thursday) yii) Prof. Ho-Kei Ma (iii) Dr. Takashi Wagatsuma 09.00 - 09.20 HRS. PLENARY PRESENTATION ON (iv) Prof. Pei-Chuan Ouyang TOPIC IV 11.40 - 12.00 HRS. DISCUSSION Coordinator: Dr. Suporn Koetsawang "IPPF-ESEAOR Medical Committee 12.00 - 12.30 HRS. CLARIFICATION ON GROUP DIS Findings" CUSSIONS By (i) Dr. Jose B. Catindig ii) Prof. Ho-Kei Ma 12.30 - 14.00 HRS. LUNCH BREAK
09.00 - 09.45 HRS. PLENARY PRESENTATION ON 14,00 - 17.30 HRS. * GROUP DISCUSSION SESSIONS TOPIC V Split into 3 Discussion Groups
Coordinator: Prof. Mark Chen Chi Eng "Maternity Care Monitoring - Where 20th July 1979 (Friday) Next?" By Ci)Dr. TinaAgoestina 09.00 - 11.00 HRS. GROUP DISCUSSIONS CONTINUE By () D. Tna AoesinaCOFFEE/TEA (ii) Dr. Roger Bernard 11.00 - 12.00 HRS. Secretariat Works on Group Reports 09.45 10.15 HRS. COFFEE/TEA BREAK 12.00 - 14.00 HRS. LUNCH BREAK 10.15 - 10.30 HRS. DISCUSSION 14.00 - 16.00 HRS. Chairman: Dr. Somboon Vachrotai 10.30- 11.00 HRS. PLENARY PRESENTATION ON PLENARY SESSIONS ON GROUP TOPIC (VI) DISCUSSION REPORTS Coordinator: Mr. Benjamin De Leon 16.00 HRS. CLOSING "is What we are Offering A',ceptable?" By (i) Dr. Haryono Suyono * Please refer separate document on Group Session to be (ii) Dr. Azizan bt. Aiyub Ghazali distributed later.
13 SUMMARY OF PROCEEDINGS
Wednesday, 18th July 1979. Director of the Commission on Population, Dr. Gloria Aragon, Member of the Board of Commission on Population, and two OPENING CEREMONIES (2) Deputy Chairmen for the BKKBN, Indonesia, i.e. Dr. Har yono Suyono and Dr. H. Pardoko, for their presence. This Seminar on Regional Fertility Research was held jointly by IGCC and IFRP. There were six (6) previous seminars He also made special mention of Dr. Vitura Sangsingkeo, conducted by IGCC in the past years. The first was in 1973 Executive Director of ICARP, who in the near future would like with the aid from the Population Council, and the rest of them to work closely with IGCC to have a joint IGCC/ICARP/IFRP were sponsored by the IFRP (Research Triangle Park, North meeting. Carolina). All were technical in nature and labelled as "Expert Meetings". Dr. Sodhy then informed the audience about the several meetings and cooperation in research activities between IGCC This seminar was held at the Ambassador Hotel, Bang- and IFRP and was very pleased indeed to have the Executive kok, from 18-20 July, 1979. Ten (10) countries attended the Director of IFRP, Dr. M. Potts, in person to attend the meet meeting, with 48 participants and 11 observers. Twenty (20) ing. Last but not least he thanked Dr. J.Y. Peng, as the man of the participants who also acted as Resource Persons, pre- behind the scene, who worked very hard in all the preparations sented papers. There were 29 documents/papers presented and made the meeting possible. and discussed. The participants represented the countries of Indonesia, Malaysia, Nepal, Philippines Singapore, Thailand, Dr. Sodhy's message was then followed by Dr. M. Potts Hongkong, Japan, Korea and Taiwan. from IFRP. He stated that measuring the success of family planning programme by acceptor rate is not an accurate one; The Opening Address was delivered by H.E. the Deputy it is better to use the demographic methods, e.g. incidence of Minister of Public Health, Thailand, Dr. Krasae Chanawongse, illegal abortions. He then explained the objectives of IFRP and who had been introduced by Dr. Somboon Vachrotai. H.E. the that priority has been given to develop family planning techni Deputy Minister stressed the importance of strengthening and ques for developing countries with the emphasis on training, accelerating the on-going family planning research in the I.E.C. and Transfer of Technology to Developing Countries. region and that new orientations and guidelines conducive to One other field was the Research Studies to find the needs for the formulation of a new and a more effective development the poor of the world. The technique of methods used for strategy for the 1980's should be looked for. It isfor this reason studies must be simple to improve family planning where the that he appreciated very much the steps that have been taken infrastructure is poor. He stressed further the importance of by IFRP and IGCC to foster Regional Research Activities. This the study of TBAs for family planning delivery services, the regional cooperation he stressed further can lead to self-re- study of cost of methods and the maternity care monitoring liance and self-sufficiency. He then declared open the meeting system. and wished all, the success in th,3ir deliberations. Before the presentation of the Country Papers, Datin (Dr) Dr. L.S. Sodhy, Secretary General of the IGCC, in his Nor Laily Aziz, Chairman of the Steering Committee, clarified Introductory Message, conveyed his heartfelt gratitude to His the objectives of the seminar. Excellency the Deputy Minister of Public Health, for his sti mulative address and for performing the Open Ceremony for After the addresses, it was announced that Dr. Somboon the Joint Workshop. He thanked Dr. Somboon Vachrotai and Vachrotai would act as Chairman and Dr. Suporn Koetsawang his hard working staff for the preparation of the meeting and as Co-Chairman and Dr. Johan A.M. Thambu was designated was also grateful to Dr. Somboon and the Government of as Rapporteur General. Thailand for agreeing to host this workshop in Bangkok. He was pleased and fortunate, to have many distinguished per sons attended the seminar, for special mention were Datin (Dr) COUNTRY PRESENTATION Nor Laily Aziz, Director-General of NFPB, Malaysia, inspite of her busy schedule, Mr. Benjamin de Leon, Acting Excutive The first iu present their respective papers were the
14 countries of Indonesia, Malaysia, Nepal, Philippines, Singa- delivery programme is part of the overall health care. All pore, Thailand and followed by Hongkong, Japan, Korea and acceptable methods of contraception, except abortion, are Taiwan. available.
The topic was "Inventory within the Country of Pre- Ressarch: Research is a basic activity in the National vious on-going Research". Programme from the start.
INDONESIA: Although research, and studies conducted in 1. Research in Demographic Levels, Patterns and Trends. Indonesia are limited in scope and intensity, the National Family Planning Programme has gained important information 2. Research in Socio-economic and demographic inter on various aspects of contraceptive use. Important issues relationship. related to the use of contraceptives have been identified like the suppressive effects of oral pills on lactation, the most suit- 3. Programme Oriented Research. able IUDs for Indonesian women, the epidemiology of tropho blastic diseases and the effects of sterilization on the socio- Trophoblastic Disease: Studies in Trophoblastic cultural life in Indonesia. The need of having a large number Disease were started at the University of the Philippines - of continuing users of contracbptives in their programme at Philippine General Hospital (U.P. - PGH) as early as the 30s. the end of 1990, made them aware of the ned for more effec tive, safe and acceptable means of contraception. IUD: In the early years (late 60's and early 70's), the IUD was the second method of choice. Since 1972 its use MALAYSIA: Malavsia re-affirmed that contraceptive/re- started to decline, and has now dropped to the 4th place. productive/fertility research must be given high priority in Nurses and midwives after training are now licensed to insert programme development. During the past 13 years the em- IUD. phasis has been on the hormonal contraceptives. Hormonal research is needed to guide and back the national programme. Oral Contraceptives: From 19)70 to the present, the That is why Malaysia est,3blished the National Family Planning pills have remained on top. The study under process for imple Specialist and Research Centre under the NFPB. This centre mentation is the trial study on different dose combinations of was to act as stimulus for the scientists and academicians to oral contraceptives; to determine the formulation most suit participate in research, and with the availability of Research able to the Filippino women. Laboratory Facilities, Research Grants, Study Fellowships, Financial Support for Attendances in International Congresses Traditional Methods: Researches on folk methods of and Seminars, local expertise be available for research studies. fertility control and abortion have been undertaken primarily Besides studies undertaken so far on pl~ls, injectables, IUCD to identify traditional methods of abortion and contraception, and sterilizations, study must also be carried out to develop to test the pharmacological effectiveness of local plants, to local available and acceptable contraceptives, the future Asian assess the effects of training programmes of TBAs (hilots) pill. to determine the characteristics of mothers seeking abortions, Popula NEPAL: The basic philosophy is that Family Planning and tionand toGroups. determine abortion rates in certain Philippine by NFP/MCH Project. Family MCH are carried out together Planning methods offered are pills, IUD, injectable contra- Problems of research on population is less on adequacy ceptives, condoms, and sterilization procedures like: mi ilap,of but more on the utilization of findings and recommendations. services are provided free laparoscopy, vasectomy. The cost. The prescribed mode of service delivery has been SINGAPORE: Research and Studies conducted. through clinics, community-based workers, mobile clinics and camps. In order to encourage more people to practice family Oral Pills: planning, the Nepal Contraceptive Retail Sales (CRS) Project is developed by His Majesty's Government of Nepal's Family 1. Trials comparing various dose requirements of oral Planning & Maternal and Child Health Project. It distributed pills; also various synthetic oestrogens. contraceptives through commercial channels throughout the country, e.g. pills (Gulaf) for women and Condoms (Dhaal) for 2. Effect of pills on carbohydrate metabolism. men. 3. Effect of pills on Coagulation. IUD: IUD users that was very popular in the beginning IUD: of the programme declined in the later years by 50%. This may be due to the major side effects; to increase IUD acceptors, 1. Trial comparing various types of IUDs. staff nurses are trained for IUD insertions. 2. Ectopic pregnancies and IUD. Abortion: Illegal abortions are performed by trained medical personnel as well as by untrained indigenous mid- Menstrual Regulation: wives. In Nepal not only to perform abortion is regarded as a of flexible and rigid canulas for surgical crime against the existing law but also anybody seeking abor- 1. Comparison menstrual regulation. tions or practising it or willing to be an accomplice to such an act is punishable with long term imprisonment. 2. Medical MR with prostaglandins.
Trtuphoblastic Disease: Although Trophoblastic Abortion: Diseases are common but no research has been conducted. 1. Psychosocial aspect of abortion. Population Programme has PHILIPPINES: The Philippines compared with in developed four component programme activities namely, 2. Safety of out-patients abortion Service Delivery, Training, IEC and* Research. The service patients abortion.
15 3. Safety of local anaesthesia. world, 4 different varieties of combined oestrogen/gestogen preparation are available for physicians to be prescribed to 4. Prostaglandin for preparative cervical dilatation in women who wish to use. multiporous pregnancies and mid-trimester abortion. Traditional Methods of Abortion: Induced abortion Sterilization: was legalised since 1948 and the standard method at the first trimester has been dilatation and curettage. For the mid 1. Concurrent versus interval sterilization in relation to trimester abortion, the standard method was the dilatation of abortion - both medical and psychological aspects. the cervix with the laminaria tent and followed by an insertion 2. Sterilization failures. of a rubber ballon with a pitoxin drop. Now more and more physicians are using an extra-amniotic infusion of Prosta 3. Safety of various methods of sterilization. glandin F. Studies in IUD: Clinical effectiveness of the IUD has HONGKONG: Research and Surveys inHongkong are done been investigated from as early as teh 1930's. In 1974, the Ota by several agencies as follows: ring and the Yusei-ring were officially approved, followed by the Lippes Loop and the FP-1, another Japanese produced (i) Hongkong Family Planning Associations: IUD in 1977. The Ministry of Health and Welfare holds a some (a) KAP Survey of Hongkong what conservative attitude toward the clinical application of (b) Impact of Industrialization on Fertility in Hong- medicated IUDs. kong (c) The Family Planning Requirements for the KOREA Housing Estates in Hongkong. Oral Contraceptives: Various kinds of oral contra (ii) Department of Obstetrics & Gynaecology, University ceptives have been used over the past 10 years and many of Hongkong: clinical and experimental studies have been conducted with (a) Coagulation changes in females on oral pills. the steroidal contraceptives. (b) Hyperprolacternaemia (c) Hormonal profile and various maturation in The list of titles for the on-going projects are as follows: Hongkong adolescence. on metabolic processes. Traditional Methods on Abortion and Other 1. Effects of oral contraceptives Methods: 2. Comparative study of an oral combination contraceptive Department of Biology & Biochemistry Department, preparation intablet and "paper-pill" form. Chinese University of Hongkong. 3. Study of prevalence of signs of vitamin deficiency in Non-steroidal contraceptive compounds from Chinese association with oral contraceptives. herbal drugs. 4. Comparative study of the bio-chemical effects of com Studies in IUD: bined estrogen/progesterone oral contraceptives contain ing 50mg or less of estrogen. a) Hongkong Family Planning Association: A comparative study fo the performance of 4 IUDs Abortion Method: Several research findings have in Hongkong. been found on the procedure of practising induced abortion. In the first trimester technique used are 95%, D & C, 65% b) Departmont of Obstetrics & Gynaecology, University section and 42.8% MR. In mid-trimester abortion the major of Hongkong: procedure utilized are metreurynter (36.2%), oxytocics in The dosage and effectiveness of continuous infusion fusion (28.2%), Bougie (23.0%), laminario (6.0%), Prosta of prostaglandin in first trimester abortions. glandin (3.5%), Saline Solution (2%), and some of them are used combined. Trophoblastic Diseases: on-going research am: Department of Obstetrics & Gynaecology, University of Titles for the Hongkong. 1. A mid-trimester abortion study. Laboratory Research: 2. Controlled clinical trial of flexible vs rigid cannulas for the a) Department of Zoology and Physiology, University early termination of pregnancy by endometrial aspiration. of Hongkong: Study of spermatogenesis and sperma maturation. IUD: Various types of IUD are introduced in Korea, but Lippes Loop was only inserted in the government programme. b) Department of Anatomy, University of Hongkong: Other types such as CU-T, Cu-7, Alza-T were inserted only on Hormonal influence on tissue culture. clinical trials and self-supporting. JAPAN The list of tables for the on-going research project on IUD are: Oral Pills: The use of Steroidal preparations as contra ceptives has not been approved. The Central Drug Control 1. A comparative study on the effectiveness of immediate Agency approved the drug as therapeutic agent for functional post-abortion intra-uterine contraceptive device insertion. uterine blbeding, dysmenorrhea or ovarian dysfunction and no^ for use as contraceptives. However, in the commercial 2. Case-control study on the relative risk of ectopic preg
16 nancy and pelvic inflammatory disease associated with Dr. H. Pardoko (Indonesia) acted as Session's Coordina IUD use. tor. The first paper was presented by Dr. Somboon Vach rotal. He started with stating that the Thai Government Health 3. Multi-center Study of the microbiology and histology of Service like most countries in Asia is also searching for alter the fallopian tube in IUD users. native methods for extending basic health services to the majority of rural villagers, a concept of Primary Health Care. 4. Hormone releasing vaginal rings. The Pitsunaloke Project, the Saraphi Project and now the Lampang Project are vanguard efforts that helped to resolve 5. Long-term effect of the IUD on the human endometrium. the current PHC approach to MCH, Nutrition and Family Plan Histologic, histochemical and ultrastructural studies. ning in Thailand. The Health development strategy of the Lampang Project Trophoblastic Diseases: Trophoblastic disease is a ivle e etrs mostly involves 4 key features: common disease in Korean women. Studies were undertaken for the clinical analysis and evaluation on the a) Developing Primary Health Care Workers for every women with trophoblastic disease wiio had been admitted village. and treated at hospital. b) Developing wechakorn or community health para Traditional Medicine for Fertility Control: In Korea, physicians, for every hospital and rural health center. c) Developing private sector involvement and com numerous plants or animal preparations have been used for munity participation inprimary health care work. the purpose of fertility control. The descriptions are based d) Integrating medical care, health promotion and upon the experience of human trial for hundred years. A list disease prevention services and developing improved of these plants and animals covering most of the natural pro- management practices from the provincial level to ducts with reputed antifertility effects are to be found in the the health centre level. full text of the Country Paper.
TAIWAN: Family Planning Programme started by voluntary Some of these features that have been developed are end agencies or as study projects in 1959, and was expanded as a replicated and adapted by the National Health Plan. At the national programme in 1964. In 1968 the regulations governing Dr. Somboon explained "Although a 'grass-root' primary the implementation of family planning was promulgated by health care manpower force have been developed comprising the Executive Yuan (Cabinet) and the Population Policy of the traditional midwives, village health post volunteers, communi R.O.C. was announced in 1969. Delivery of family planning cators, the journey to 'health for all by the year 2000' is a long services has been integrated as part of overall health care. way and still remain aformidable task.
There are four methods of contraception: - Lippes Loop The second speaker, Dr. Jae Mo Yang, did not turn up and Ota Ring, Oral Contraceptives, Condom and Male and and the paper was read out by his country fellowman: DrTaek Female Sterilization available to all married couples desirous I I Kim. Some points that can be summarised from his 50 of spacing. Of the acceptors, 50% are IUD users, 15% oral pages presentation are as follows: pills, 20% condom and 15% undergone sterilization. - Although during the last 17 years the Republic of Contraceptive Research: Research is one of the basic Korea has made rapid progress in economic develop activities in the national programme from the start. Popula- ment, however, attention to health care development tion/Family Planning related research activities in Taiwan has been paid only recently. Area, R.O.C. can be categorised broadly into: - There were many problems to be solved, he explain 1. Research on demographic levels, patterns and trends. ed: utilization of health 2. Research on socio-economic and demographic inter- - maldistribution and insufficient relationship. care resources. of doctors does not 3. Programme oriented research. - that the increased production provide solution for health care problem in rural areas individual The research is further dealing with: (doctors are more oriented in biological and medicine and over-specialization).
- systematic analysis of contraceptive acceptors -there is some misconception on" "Primary Health - oral contraceptives Care", that it is a service bf poor quality and only applicable in very poor undeveloped countries where - sterilization medical doctor is scarcely available.
Sterilization as a method was adopted since 1974 and (The percapita income in Korea exceeded US$1,000 and several follow-up services has been conducted since then. has more than one (1)medical doctor for every 2000 popula About 80% of the sterilization was performed by the contract- tion). ed private physicians. In order to remedy and test the misconception, Yonsei programme and After lunch break the seminar resumed again with presen- University started a community teaching took 2 townships as pilot on TOPIC I: "PRIMARY HEALTH CARE WITH family planning programme and tation the project was evaluated SPECIAL REFERENCE TO NUTRITION, MCH AND projects. After 3years (1975-1978) FAMILY PLANNING" on 3 aspects:
17 1. The changes of health status and evaluation on achieve- IUD is by laparoscopy. ment on maternity care, child health care, family plan ning, tuberculosis control and medical programme com- 7. InIndonesia, Nulliparous women had ahigh risk of moles pared with that of non-project areas. pregnancy as shown by a rate of 1:60, pregnancies for hospital studies. 2. The performance of Health workers with particular em phasis on field health workers and multipurpose workers. 8. In Bangkok, a study on hydatidiform mole had shown that 30% were in nulliparous women and 70% in multi 3. Aspect of evaluation or the community participation and parous women. community's attitudes towards the project. The Plenary Session in the afternoon was coordinated by The result of evaluation were extremely encouraging and Datin (Dr) Nor Laily Aziz and heard the presentations of Dr successful. There are (2) other on-going projects on family David A. Edelman on "PROSPECTIVE STUDIES ON RISK planning programme integrated with Primary Health Care. AND BENEFIT OF FAMILY PLANNING CONTRACEP- Conclusions about tnese two are not yet available at this TIVES", and "RETROSPECTIVE STUDIES SPECIALLY moment. C1N DEPO PROVERA" by Dr Malcolm Potts and Dr Edwin B. McDaniel. (Topic II). Ten (10) recommendations have been drawn from the outcome from the studies, the most prominent one was: Dr D. Edelman:
that Primary Health Care should be accepted by the Prospective studies designed to assess some aspects of Government and leaders in Korea with highest priority, various contraceptive materials, particularly oral contracep as the key to achieving an acceptable level of health for tives (OCs) and Intra-uterine Devices (IUDs), have been con all countries, whatever their level of development, and ducted mostly in the developed world (US, UK, Europe). The does not regard Primary Health Care as a "Medical Care relevance of these studies to the developing world is not of poor quality for rural poor in developing countries known. only". Before tea/coffee break, the floor was opened for dis- Issues related cussion on the country presentations and on Topic i. be a deterrent to theto theexpenses safety of contraceptivecontraceptive methodsservices. canHe took example of the decision made by the Family Planning Association of Hongkong to discontinue use of Depo Provera, SUMMARY AND DISCUSSIONS ON COUNTRY PRE- following the decision of the FDA. The decision of the FDA SENTATIONS AND ON TOPIC I appeared to be based on political rather than scientific grounds. The need for large prospective studies of the risks of all contra 1. Studies from 4 countries showed that: ceptive methods including depo provera is obvious.
- high percentage of failures with Fimbrectomy Dr. Edelman further reviewed significant contraceptive - there were less percentage of abortions in patients safety studies that have been conducted during the past pregnant and who had their IUCD removed. decade:
- all translocated IUCD, open or closed, should be 1. The Walnut Crack Contraceptive drug studies conducted removed because of the risk of tissue reactions and by the Kaiser Permanent Medical Care Programme, which adhesions. is a prospective study to determine the side effects of OCs. - there was a great number of hydatidiform moles observed in nulliparous women. 2. The cooperative statistical programme (CSP) under the leadership of Dr. Christopher Tietze, evaluated the safety 2. A Singapore Study on vaginal sterilization by Fimbrec- and effectiveness of IUDs, including the Lippes Loop, tomy with linen sutures showed a pregnancy rate of 3% Saf-T-Coil, Birnberg Bow, Margulies Spiral and Steel as compared to a pregnancy rate of 0.3% for the modified Ring. Pomaroy with a minilap technique: Recorded evidence in other countries had shown 'hat Fimbrectomy carried All these represent alarge investment of time and efforts good results. -but it is doubtful if these studies will provide definite answers to the many issues regarding the risks and benefits of contra 3. There is a need to study in other centres a comparative ceptives. He found case control studies are better suited for study on Fimbrectomy versus Tubectomy. the evaluation of rare adverse side effects than are prospective studies. Case control studies permit an assessment of the 4. Pregnancy with IUD had shown that if the device is left in relative risks of particular side effects for one type of contra it carried a higher abortion rate than if the IUD was re- ceptive verses another but do not peritit ass3ssment of the moved, absolute risks of the side effects. 5. Study in Thailand had shown that pregnancy with IUD in IDRC, WHO, IFRP are currently planning or undertaking situ did not carry any risk of infection or septic abortion, studies to evaluate specific aspects of contraceptive safety. But there are still many questions related to the safety of 6. A study of extra-uterine IUDs had shown that copper IUD contraceptive methods that cannot be answered through the had very extensive adhesions. More than 50% of trans- analysis of the IFRP's data. He referred to the studies in IUD located IUD hod moderate to severe adhesions. All types use in the US and Sweden that indicate a three to five fold of IUD carried high risk of adhesion and so all extra- increase risk of pelvic inflamatory disease to those of non uterine IUDs must be removed. The best way to remove users.
18 Studies conducted by the IFRP have neither supported 1974 3 cases nor refuted this claim. The principle purpose of the IFRP's 1975 8 cases studies has been to locate IUD-related events, such as fre- 1976 6 cases quency expulsion and removal. Large multi-clinic studies 1977 7 cases might be necessary whereby thousands of women using the 1978 2 cases major methods of contraceptives will be studied. Aside that it will be costly; the feasibility may be questioned. Total 26 cases of Carcimoma Endometrium He expressed the hope that each of the IGCC countries should deliniate the pertinent issues concerning the safety and benefits of various contraceptive methods. Contraceptive The above data is reassuring because the incidence of Ca studies should be conducted by any country, that reflect the Endometrium is not rising. The occurrence of 2cases of Endo needs of the country and not necessarily those of the funding metrium cancer in Rhesus Monkeys can and should not be agency. IFRP can help to design and support such design. extrapulated to Human beings. DMPA should be continued to be used. Dr Malcolm Potts: WHO earlier concluded that DMPA has safety and that This isa Summary of Dr. Potts' presentation: the study of Rh monkey has many defects.
1. Important management decision can be taken, based on In the discussion that followed, Dr. Potts and Dr. Mc- the results of short term studies. Daniel responded to the questions as follows:
2. Retrospective study is a quick and dirty way to get im- 1. The use of DMPA is part of the National Programme in Thailand and there are 80,000 on DMPA users in the portant data. programme. 3. Work on monkeys in USA - asmall number of monkeys were given a very high dose of DMPA and some of them Dr. McDaniel has 32,000 and they are mainly in the developed endometrial cancer. From the above, one can Chiengmai and Lampang areas. summarise that if you gave normal dose on a large popu lation, would you get the same effect? 2. Regarding the IUD and Pill, two types of studies would be of use: 4. If a rare disease is to be picked up, then a larger group for a long period must be followed-up to see if the drug or i) For large numbers of IUD acceptors; device caused or did not cause the condition; controls are IUD with threads vs. IUD with no threads. well matched. lii) Small study of type of organizm found in IUD with 5. Data may not be reliable because people after a long thread vs. IUD with no thread. period may forget if they took the drug or device. 3. Ethical and legal implications of prospective studies 6. Prospective studies, can study the risk/benefit. It is easy to know who died rather than to know who will die. From - for IFRP, there is a crmmittee that goes through the retrospective studies-data, one can plan prospective ethnics and legality of the study. studies. - for WHO, the protocol for the study to be approved The second speaker for the same subject was Dr Edwin by B. McDaniel. a) committee in the institution b) government of the country where the study to This presentation went on Retrospective Studies of Con- be undertaken traceptives use of all cases of Ca Endometrium in the Hospital - for Universities: the study must be cleared by the area in Chiengmai. The DMPA study in Chiengmai is one of University and the Government. the largest study in the world he said, and one of the longest ever done; it has been conducted for 14 years. The average 4. Retrospective Study can be meaningful, for the study number of injection per day is 426 foxcept Sunday). All deaths needed for immediate reassurance for programme imple certified as Ca Endomentrium were taken for this study. The mentation. Once this is available, then long term prospec diagnosis was made on a) Histology, b) Pre-assumptive, tive studies can be done. on clinical examination, and in some cases the pathological diagnosis was not proven. The reason being that on admission adiagnosis of Ca Endometrium was made and a biopsy taken, The late afternoon session on Topic III was coordinated but the patient died or was discharged a few days later. The by Dr Haryono Suyono (Indonesia). The topic was on original diagnosis was not changed inspite of the fact that at a "ALTERNATIVE DELIVERY SYSTEM FOR FAMILY later date that the histology report was ready and showed that PLANNING SERVICES". It consisted of 3 sub-topics: it was not endometrial Ca. a) Camps by Dr. D.Mlla (Nepal) The distribution of the 26 cases of Carcinoma of Endo- b) Organizations of Clinic (training/Effective referral metrium according to the year: systems)
19 b.1 Outreach by Mr. Benjamin de Leon vational skills recording and monitoring system. Nurses and (Philippines) and midwives were trained on comprehensive family planning Dr. Debhanom Muangman technology (pill dispense and IUD insertion). Physicians were (Thailand) given special training as a back-up to the trained nurses and midwives and in sterilization procedures. The community b.2 Clinic Management by Dr. Johan A.M. based population field workers and the Barangay Supply Point Thambu (Malaysia) Officers motivate and refer clients to service centres. On the other hand the clinics refer clients who need medical follow-up c) Traditional Birth Attendant by Dr. J.Y. Peng or re-supply of pills or condoms to the Field Workers. At the (IFRP) end of his presentation, Mr. Benjamin de Leon made the remarks: "that the Outreach Projects has become a viable and Dr. D. Malla: meaningful course of bringing Population and Family Planning information and services within easy reach of married couples The experience in Nepal was, that delivery of Family Plan- even in the remotest areas. ning Services through Camps can obtain the maximum output or result in agiven period of time. It was very popular. In 1973, Dr. Debhanom Muangman: the first laparoscopic sterilization camp was organized. The reports or results were encouraging. Number of cases steadily Dr. Debhanom's presentation went on Organization of increased. In 1978-79, 10 camps had 11,629 cases for lapa- Clinics and how to give good family planning services to the roscopic sterilization. Total cases of vasectomy was about people, so that there are not too many drop-outs Essentials 55,000. These camps were organized by different agents as for these services are: MCH Et Family Planning Project, Family Planning Association, Integrated Health Project, Social organizations are helping 1. Necessity of services to every person. bringing clients to and from the camps. Nepal is now consider ing using the camps for other family planning services like IUD 2. Clinics should be able to give a comprehensive family insertion and delivery of injectables. Different aspects of camp planning service. organization: 3. There should be adequate number of clinics in the com 1. Planning of camp munity.
2. Implementation 4. A continuity of service with good referral, good follow-up and good re-supply of contraceptives should be maintain 3. Follow-up ed.
4. The aspect of organization. 5. Quality of Service be maintained, it should be reliable and be backed-up by professional competence, that is ade After going into detail on every aspect, she made the state- quate for the whole community. ment "that Camp is definitely an effective means of delivery of family planning service in the remote and difficult areas of the 6. Administration and performances of family planning country, where medical facility is limited, workers must be efficient.
Mr. Benjamin de Leon: He then discussed the situation of family planning ser vices as it istoday in Thailand. There are 3 stages: His presentation was about the "Outreach Project", and how it related to the clinic service component of the Philippine 1. Physicians play a dominant role. Population Programme, and also touched on the Training and referral system which supported the outreach project. The 2. Paramedical personnel play adominant role. outreach project was launched in 1976, to provide family plan ning information and services to the barangays in the rural 3. Community people play adominant role. areas. It is managed by the local governments. He then des cribed the criterion for recruitment of personnel and types of Each stage has its advantages and disadvantages. For workers and clinics. developing countries, where there is ashortage of physicians, Stage 2 will do better. But the best is then when it will come The delivery system which is comprehensive and cohesive to Stage 3. There should be 2 groups of providers e.g. the is moved into the institutionalization of it by adoption of a co- smaller medical group and the larger non-medical group. ordinating guideline for family planning service delivery pro- These 2 groups should work closely and do not come into motion and service delivery. Rules and f,rrctions of clinic per- conflict with each other. Everyone will have its own role in the sonnel and field-workers in each municipality are identified in service, adjust to his/her profession. And this system of work the guidelines, should be backed-up by the clinics. The training for the full-time Outreach Worker is a con- Dr. Johan A.M. Thambu from Malaysia spoke on Clinic tinuing process, with a basic pre-service training focussed on Management. He discussed the situation in Malaysia. He first Country organization, family planning technology, human explained the structure of the National Family Planning Board, relation and communication. After this training the workers Malaysia, which was set-up in 1966 under the Prime Minister's may be licensed to dispense pills. Department. He then discussed the National Family Planning Programme schedule, starling from the year 1966-1976 and The Barangay Supply Point Officers have been trained year 1976-1986. After giving a sketch of the National Family informally on a person to person basis, by the full-time out- Planning Service coverage he gave apicture of the clinic struc reach member. There is also a formal training for 3 days and ture and staffing, pattern of clinic by type in the action pro includes family planning technology, information and moti- gramme. A special clinic service will be provided by the Na
20 tional Spcialist and Medical Research Centre of the National JPP'is concerned just as other agencies are that in Family Planning Board. This will include activities like consul- creasing use of western contraceptive technology in develop tation, counselling, minor surgical procedures, clinical re- ing countries may be inappropriate or unsafe, given the health search, teaching and medical record keeping. This centre will and dietary condition of users in these countries. The initial also serve as a referral centre for all problems related to contra- meeting of this panel was held in Hong Kong in September ceptive usage (pills, IUD, injectables) and do surgical contra- 1978, and brought together 12 research contributors and 11 ception for male and female. Other activities are: consultation gucsts research scientists. There were 48 on-going projects and counselling in infertility and endocrine disfunction, cancer related to the study of the effects of steroidal contraceptives detection, ultra sound and low dose monography. Regional identified by the panel. Some of the following recommenda Specialist Centres will be set-up in Johore Bahru, Penang, tions could be used as guidelines for family planning workers lpoh and Kota Bahru and would provide the same services but (the proceedings of this workshop is not yet available because on a smaller scale. Speaking about training of family planning many of the projects are still on-going). personnel, he explained that various types of training courses have been conducted not only for menmbers of the Board but Statement of Recommendations also including personnel coming from the Ministry of Health, FFPAM, State FPAs and other non-governmental agencies. 1. Re-affirm the safety of Depo Provera (DMPA) The curriculum have been standardised by the Board. On the This has the advantage of increasing milk production. Clinic Management of acceptors he gave a description of the It causes less derangement of metabolism of carbohy procedures receiving new acceptors by the nurse and the pre- drates, liquids, aminoacids, vitamins and coagulations. scription of contraceptives. The cafetaria system is followed. When compared to the oral combined preparations of oestrogen and progestogen. The last speaker for the day was Dr J.Y. Peng (IFRP). Traditional Birth Attendants ITBAs) in Indonesia, Malaysia, 2. The existence of menstrual disturbance is confirmed. Thailand, and Philippines play an important role in the main- This has been identified as the main cause for non-accep tenance of Maternal Health. There is a sizeable and identifiable tance. group of these old women. Dr. J.Y. Peng shared Iris ex periences in the TBA project in Malaysia Istarting in 1969). He 3. For users of combined oestrogen-progestogen prepara described the training of these TBAs and the special project tions there are changes in coagulation functions carbohy to utilize TBAs for the National Family Planning Programme drate liquid aminoacids and vitamins metabolism but the in Malaysia. Simple illustrated delivery records are designed clinical significance of these changes in Asia is still not for TBAs to record the deliveries they attend. At the end of well established. his presentation Dr. Peng suggested the Organization of an Agency to promote the cooperation and coordination in one 4. Ideally combined oestrogen-prcgestogen preparation of the four countries mentioned before. The first step, he should be used for short-term spacing. said, would be to identify key people and organizations in each In the later part of the reproductive life, it should be pre country. Then to organize meetings with them to consider scribed with caution. objectives, activities and future plans. In CBD programmes, it is advisable that women above the age of 35 are fully assessed by a doctor before the Summary of the discussions that followed the presenta- combined O.C. is prescribed. tions: 5. There is a need to be aware of the psychosexual effects 1. In four Asian Countries, TBAs are being trained and uti- of steroidal contraceptives. lized ;n their national programme. Other Findings 2. A proposal was made to establish a coordinating orga nization for TBAs. 1. Excessive weight gain in DMPA users
3 A committee outreach survey is in process in Philippines 2. The oestrogen content of cycloprovera is viewed with despite the low salary, yet these outreach workers took caution the leadership. 3. Low dose progestogen pills (lynestrenol and d-Norgestrel) 4. IN the four points planning for outreach workers, effec- has low acceptance and continuation rate. tiveness must come before efficiency. 4. No ideal combined oestrogen-progestogen preparation. 5. TBAs can be used to improve rural health service by re ducing maternal mortality and infant morbidity. TBAs 5. No major advantage of paper pill noted. must be made aware of modern health service and to refer cases earlier. The next Plenary Session on Topic V, was chaired by Prof. Mark Cheng Chi Eng (Singapore), as the Session Co Thursday. 19 July 1979 ordinator. The topic was "Maternity Care Monitoring -- Where next". Speakers were Dr. T. Agoestina (Indonesia) The morning plenary session was chaired by Dr. Suporn and Dr. 'loger Bernard (IFRP). Koetsawang, Speakers on TOPIC IV, "IPPF-ESEAOR MEDICAL COMMITTEE FINDINGS" were Dr J.B. Catin- Dr. Tina Agoestina reported on the Maternity Care Moni dig and Prof. Ho-Kei Ma. Their presentations went on a toring Study conducted in Indonesia by the Coordinating report of the Panel on "EFFECTS OF STEROIDAL CONTRA- Board of Indonesia Fertility Research Study (BKS-- PENFIN). CEPTION ON ASIANS" held by the Regional Medical Com- A variety of problems came out from the preliminary result mittee IPPF-ESEAOR. of the Maternity Research Study. These should be tackled
21 in the near future. Some of the recommendations were as developing countries, because although it is desirable to base follows: standards or facts known facts are frequently largely irre levant. But obtaining relevant facts regarding maternity care 1. It is urgent that MCM for Indonesia be expanded to in- within developing countries, where variation in standard care clude representative samples, and that the Study design are extreme is even more difficult he explained further. He should reflect the actual condition that prevail in the suggested then ways to use data as standard in order to im country. prove maternity services.
2. The Government of Indonesia through the Ministry of Studies of maternity care using a standard maternity Health and the Family Planning Coordinating Board record with programmed computer feedback have been found should be actively involved in MCM. useful. Strategies for implementation of MCM must vary from country to country because of the liverse pattern of organiza 3. A continuous period of time (at least 5 years) for data tion of maternity services. He then gave some advices and collection is necessary in order to enable the researchers factors on using a computerised record system. to compare and evaluate the progress of different levels Services from year to year. As conclusions and recommendations he stressed the of Maternity following: read out the following facts: As background material she - The cost of poor maternity Care is large and incal The total population of Indonesia is 140 million. culable. The crude birth rate is40%. The deliveries are conducted at hospitals and at peripheral - MCM describes a tool, which can maximize know health centres but inthe remote areas births are helped by ledge for improved maternity care and family health. the TBAs, who had ro training. The accurate maternal mortality rate is still unknow,. - in its applications it should improve in quality and Only figures from teaching hospitals or top referral hos- cost effectiveness pitals are available, even then, figures often differ in meaning due to different definition and/or different re- Lastly he conveyed his message: cording systems. The IFFH with support from the UNFPA and the IFRPcan Dr. Roger Bernard: now offer consultation to Ministries of Health to design coun try projects for MCM, which may be eligible for UNFPA and In his introduction, Dr. Roger Bernard said: other financial support.
the term "Maternity Care Monitoring" was coined to The Discussions on Topic IV and V are summarised as stress the need and potential of routinely completing a record follows: that would lead to systematic feedback. As part of the clinical record, physicians and midwives routinely collect data that Dr. Tina Agoestina is returned to them in the form of pre-programme computer tables organized around four (4) major themes: Indonesia has experienced a fertility decline from 5.3to 3.8 in the last few years. Indonesia istrying to have this system a) Family formation and reproductive experience of MCM in the routine system of maternity monitoring but the b) Family health and lactation problem is how to make this work-tool simple. c) Clinical management and outcome of the current delivery including antenatal care an,' Dr. Roger Bernard d) Desired family size and contraceptive .;eition/prac tice. This system MCM picks up such changes as fertility.
This systematic analysis of information led to the recognition 1 It is a most delicate system to get answers. It is of tremen of a new data source of an inter-disciplinary nature that could dous national importance. To undertake a study there be provided rapidly and cost-effectively. The 1st (first) National must be a formal Government request - outline. Your experience with the National Maternity Record, was in Colom- system, and a proposal will be made on how to help a bia. The result was used by the Ministry of Health to identify formal grant proposal. areas needing improvement in the Colombia Maternity Care System. 2 The MCM is avery elaborate form. This form has under gone 3 changes at recommendations of FIGO and WHO. Soon the Health theme was linked with the MCM, be cause for monitoring the repo oductive histories of women who 3. At present there are 4ways to data collection system: deliver need the systematic identification and quantification of high risk pregnancies and of risk factors in a specific centre a) Census and in various maternity care. b) Vital statistics c) Social research Dr. Bernard reported on the analysis of data from 24 d) Health statistics maternity centres in Asia, each with records on 700 or more consecutive deliveries. Since a minimum time - span of re- But now we have anew data collection system - You are cording, one year was needed, the analysis was further res- presently discovering interdisciplinary data collection tool. tricted to four Asian centres for Trend Studies. MCM will be the future most effective routine collection of MCH work. Tables of studies can be found in the full text of the paper. He stressed the need for local standards of maternity care in The Plenary Sessions on Topic VI was coordinated by
22 Mr. Benjamin de Leon (Philippines). The topic was on "Is ment income generation and status of women. what we are Offering Acceptable?" The second Speaker on the same subject was Dr Azizan Dr. Haryono Suyono (Indonesia) as the first speaker, bt. Aiyub Ghazali "ACCEPTABILITY OF FAMILY PLAN- started with the history of the family planning movement in NING IN MALAYSIA". The family planning concept was Indonesia, the undersigning of the U.N. declaration on Popu- basically presented in macro-economic terms in Malaysia. lation by President Soeharto in 1967 that resulted in the Poli- The approach was contraceptive and clinic based. In order to tical Commitments of the Government e.g. the establishment reach a demographic goal of lowering the population growth of the BKKBN in 1970. rate from 3% to 2% between 1966 and 1985. The families readily accepted the family programme. It was discovered that Then he explained: in the rural areas, service delivery was found to be more effec tive if it was to be integrated into Maternal and Child HeLth 1. The functions of the BKKBN as the Coordinating Body Service delivery of the Ministry of Health. This was realized in infamily Planning matters and 1975 and family planning is part and parcel of MCH. with 2. The operational strategies and commitments. It showed a favourable acceptor rate in the areas integrated service. To make it more attractive and acceptable extend The growing number of acceptors through the years have and with visible benefits, the integrated programme is Another important con accumulated to 14 million only for Java and Bali (1974) and the ed to nutrition and parasite control. to be served (approximately 22,000), the tent is that people must see that some economic gain can be number of villages part of Provinces to be covered, soon it becam3 possible in the near future. They must see that they are growing number in it. The that the programme's administrative structure should of the programme because they are actively involved evident are officially be reviewed, and a new service delivery system to be devised, use of some modern methods of contraceptive supported by religious leaders. The acceptability of the various to Primary emphasis was to be placed on making family alternatives offered by the programme was related directly planning avillage rather than a clinic oriented activity, certain factors such as:
He further stressed that primary responsibility for manag- - availability, ing and implementing a programme of fertility limitation, in- - economic, cluding motivating, recruiting and maintaining family acceptor - socio-cultural, was to be transferred from the Government to the people and - religious, their community. The second objective was to gradually - educational, broaden the scope of family planning from its narrow Birth - age. prevention realm to more possitive objectives of promoting overall family planning welfare by linking family planning with Dr. Azizan then went on into alternative methods and general development programme of the Government. He then degree of acceptability and reasons for acceptability/rejec widened out on the village family planning approach in Bali tions of various methods, and she concluded that: It is im with the Banjar system. portant to any family planning activity or related activity to study not only the most acceptable contraceptives but also the A similar cor.;munity involvement was also developed in type of information and methods of their delivery to target Java. The first step is through the provision of contraceptive groups inthe context of socio-economic, cultural and religious resupplies to those already using the pi!l and the condoms in situation. the villages. Village contraceptive distribution centres (VCDC) have been created for these purposes in most of the villages in The last plenary presentation was on "INCIDENCE AND Java. The functions and systems of distribution of contra FOLLOW-UP OF TROPHOBLASTIC DISEASE" (Topic VII) ceptives of these Pos-KB (Family Planning - post) was then and Dr. D. Malla (Nepal) was the Session coordinator. explained. There were 4 speakers: acceptors are served, When in the beginning only old more and more the village volunteers in the Pos-KB actively - Prof. Mark Cheng Chi Eng (Singapore) worked to motivate and recruit others inthe community. They - Prof. Ho-Kei Ma (Hongkong) organized the so called, village acceptors group. Non-family - Dr. Takashi Wagatsuma (Japan) planning activities are undertaken lbeyond family activities) - Prof. Pei-Chuan Ouyang (Taiwan) such as various economic cooperation, rice and money saving programmes, home handicraft and other;s more. Prof. Mark Cheng Chi Eng The link between Pos-KB and the family planning Clinic He made the observation that there is no universal agree diseases. The care by the family planning field workers. The camat ment on the classsificaion of trophoblastic is taken which head) becomes the vocal point for ensuring that classification used in Singapore is Tow's classification, (sub-district in 1966. communities themselves become involved in. was adopted For the outer islands (outside Java and Bali) where the situations are somewhat different than Java and Bali, an alter- In his conclusion he stated: epidemiological studies have native approach for reaching the village is still to be sought. shown that several factors as age, parity, socio-economic For the whole National Programme, now abroader programme status, predispose to molar pregnancies. These risk factors commitment has been adopted, that is the acceptance of small may all be related. Large scale epidemiological studies are family norm. In order to broaden the appeal of fertility limita- necessary to elucidate the relative importance and the relation tion, the BKKBN in cooperation with other Ministeries of the ship of the risk factors. The finding of apparent occurence of Government will soon begin to employ the five (5) basic needs edpidemics of moles is important as it suggests an infective of all Indonesians; these include Health, Education, Employ- etiology. Again this requires confirmation, Great importance
23 should be put on follow-up of mole cases for 2 reasons: He ihen explained on the various methods of diagnosing 1. 83% of choriocarcinoma are preceded by a molar preg- the hydatideform mole. Or. the incidence of the trophoblastic nancy and disease in Japan he reported that incidence within different selected prefeatures is fairly constant at a rate of 5 to 6 per 2. the mortality rate of choriocarcinoma increases sharply 100,000 population and 3.5 per 1,000 live births. The incidence with increase in interval between the occurrence of nole of the invasive mole and that of choriocarcinoma vary con Japan and detection of choriocarcinoma. It is logical to iollow- siderably in different prefectures. It is estimated that cases for up to four years because 95% of our 11977) with a population of 113,499,000 and number of live up mole birth 1,755,032 have 5,000 to 7,000 cases of hydatideform choriocarcinoma are detected within four years. moles annually. Prof. Ho-Kei Ma Follow-up formula for the hydatideferm mole is then In her brief presentation Prof. Ho-Kei Ma discussed the explained. An intensive follow-up of individual cases after the objectives, the possible achievements and the problems cf : P,,acuation of the mole from the uterine cavity is the only way Regional-wise or National-wise follow-up programme for to prevent or to detect the development of the invasive mole patients with molar pregnancy. As an example she took the or choriocarcinoma in the early stages. Several different on-going Hongkong programme. She outlined the programme follow-up are recommended by various University Hospitals. as follows: - A patient with a molar pregnancy who wishes to have Objectives for the follow-up programme for mole patients: a child in the near future may proceed to plan the next preg nancy, provided that the followinj conditions are fulfilled: 1. To study the post-abortal MCG pattern, the urine HCG level must decrease after the evacuation to a level below normal R.H. (less than 20 lU/L) and must stay at 2. To correlate the MCG regression pattern with the course that level for at least three normal ovulatory cycles. of the disease. The standard therapy against choriocarcinoma today is 3. To make early diagnosis of residual or malignant tropho- hysterectomy combined with chemotherapy. blastic disease in mole patients. Prof. Pei-Chuan Ouyang Then she went on into the various steps of the protocol and continued on observing the problems of a multicentre Taiwan has an apparently high incidencu of gestational follow-up programme, like: trophoblastic disease. In the years 1951 - through 1978, 457 cases have been accumulated in the National Taiwan Uni 1. wrong diagnosi,3 versity Hospital. Fw.uf. Ouyang described the evaluation on the variations in incidence according to the changes of period 2. incomplete laboratory study: and a study comparison of the therapeutic results of destruc a) ,io sample tive moles and choriocarcinorw, cither with or without chemo b) no delivery samples therapy. Summary of the findings wL - as follows:
3. loss to follow-up 1. 457 patients with gestational trophoblastic diseases were treated and investigated between 1951 and 1978. 4. communicatio-i 2. The overall incidence relldve to deliveries was 1:124. The possible achievements are: This figure was consideiably higher than that of Western Countries. However the a-tual number of patients was 1. selection of hig[-risk mole patients for chemotherapy not decreased, though a remarkable improvement in socio-economic status hasi been achieved in Taiwan in 2. a survival rate of higher than 95% of patients with gesta- recent years. tional Trophoblastic disease. 3. The presence of gestational trophoblastic disease relative 3. reduction of cost of health care in the National pro- to total deliveries is substantially higher in thu group of gramme. over 40 and in grand multiparos.
Dr. Takashi Wagatsuma 4. A high incidence is also shown in this locality from a stand-point of surgical specimen submitted to patho The research of trophoblastic disease in Japan was orga- logical examination. nized in 1974 by the Ministry of Health and Welfare, with the establishment of a Task Force. Since then more than 30 5. The survival rate in hydatideform mole and destructive Japanese University Hospitals and Medical Institutions took mole, either with or without chemotherapy is generally part. Ther, are 2 possibilities in the development of hydatide- good. In contrast, choriocarcinoma is quite malignant. form mole: The survival rate prior to chemotherapy was only 17.2% clearly different with destructive mole. 1. that the hydatideform mole develops either from an ovum fertilised with diploid sperm or from the duplication of an 6. The histological diagnosis is completely acceptable how ovum fertilized with 23X sperm but detailed mechanism ever, its availability is limited because of thu improvement of this are yet to be clarified, in early detection and in early institution of chemotherapy in the occasion of malignant transformation. Accordingly, 2. Immune selection theory as a mechanism for the develop- a practical and clinically oriented classification system ment of the hydatidefo:m mole. should be adopted in this locality.
24 and into 7. After chemotherapeutic intervention, the survival rate of b) How can MCM be carried out of institution choriocarcinoma has a definite value on cure of chorio- village. carcinoma. c) Would a multicentre study of the epidemiology of Due to length of the presentations, no discussion was trophoblastic disease be useful. held, on Topic VI and VI1. )r How ran more data be obtained on natural deaths? Display of Traditional Herbs For the results of the Group Session, please refer to the A display of traditional herbs used as contraceptives was reports. shown in the waiting hall in front of the Conference Room by countries: Malaysia and Nepal. 20th July 1979, Friday at 1400 hours and breaking up for lunch, Dr. Sodhy gave clarifica- The last Plenary Session was opened Before Agenda was: on the group discussions that will commence right after chaired by Dr. Somboon Vachrotal. The tions many question were lunch and ended on the next day, 20th July 1979 at noon. Raports on Group Discussion. Not raised. One observation came from Nepal: The participants includii'ng Observers and Resource Per MCM Study. The old sons will be then split into 3 (three) groups. Each Group was - Nepal is interested to join the assigned the Task of Discussing Topics with the following form is too big, but if IFRP can design asmaller form, the Study. guidelines: Nepal has the capacity to undertake Vach Research into Service Delivery Before the chairman of the Seminar, Dr. Somboon Group 1: observersi 1. Primary Heaith Care with Special Reference to Nutrition, rotai, officially closed the seminar, participants and resource persons were given the time and opportunity to MCH, Family Planning, etc. express their views regarding the seminar. 2. Traditional Birth Attendants. Dr. Pardoko:
3. Alternative Delivery Systems for Family Planning On behalf of the participants thanked IGCC/IFRP for (Example: ways to expand family planning through private organizing the meeting. It was a stimulating and fruitful meet the participants, practitioners). ing. He also thanked the Thai Government, Dr. Sodhy and the Resource Persons. 4. Cost effectiveness of different delivery system. of ser- Dr. J. Catindig: 5. Ways to gain insight into consumer perception vices. On behalf of IPPF-ESEAOR 6. Are the services we are offering acceptable? - 3day workshop useful and important - the programme implication-action, safety effective Group II: Reproductive 9isks ness and acceptability of oral contraceptives. Contra- on Risks and Benefits of 1. Perspectives Studies -- IPPF/donor concern, because through the member ceptives. association, a huge numbe'r of contraceptives distri Studies specially on Depo Provera. buted. 2. Retrospective IPPF's concern with safety User perspective of contraceptives, we must be con IPPF-ESEAOR Medical Committee Findings. 3. cerned if the oral contraceptives we are offering is Some of the items that might be discussed are how to: acceptable to the consumers. the pro - It is essential that the dollars invested in gramme is worthwhile. bi What administrative infrastructure is necessary to; mount prospective or retrospective studies. - IGCC/IFRP/IPPF will meet to discuss the unmet Users would needs. c) What items of concern among Asian warrant case control retrospective studies. Mr. Lloyd Emeison - UNFPA!UNDP: for MCM Study should Group III: Maternity Care Monitoring and Trophoblastic - Those interested for funding Disease. put in their request.
1. Maternity Care Monitoring - Where Next? Dr. Jarrett Clinton - Population Council:
2. T-aditionaI Birth Attendants. - Share the concern expressed
3. Incidence and Follow-up of Truphoblastic Disease. - Too much talk and emphasis on technology Among topics that might be discussed are: - Need to think of user perspective. many deliveries need to be monitored - a a) How - ICARP Asia sample on all cFses. Dr. Vitura Sangsingkeo
25 - Extremely pleased with the Seminar and the quality sensible questions. of the scientific papers. - Questions that IFRP has not looked into in its re - Will use extracts in their publication, search activities.
Dr. Richard T. Mahoney - PIACT: Dr. L.S. Sodhy - IGCC
- Found Seminar extremely useful. - meeting of 65% success
- 4 years ago Ford Foundation - Greek Report. - the evaluation will come in 2 years from now if the decision made now - A series of recommendetions. - thanked Dr. Somboon and Staff - High priority - studies on contraceptive safety. IGCC and Staff - Funding Agents/Research, this is the direction in Dr. Potts and Staff which to move. Dr. J.Y. Peng Dr. Roger Bernard - IFRP: - Senior Government Officials - A new organization, the International Association for - Participants, Resource Persons and Active Observers Maternal and Neonatal Health (IAMANEH) being formed in Switzerland. - HoteliManagement
- Funding for Maternity Care Monitoring will increase Dr. Somboon Vachrotai in the 1980, as part of the activities for maternal and neonatal health. Inhis closing speech Dr. Somboon Vachrotai said among others: - Funding may come direct from above association or through WHO or UNFPA. - benefits we earn from Country Papers, presentation of Resource Persons, Participants and from dis Prof. Chong Chun Hian (Malaysia): cussions in the Group Meetings will permanently stay with us. - Agreed with sentiments expressed by Dr. Pardoko. - we will certainly apply them in our programme - to Dr. Malcolm Potts - IFRP: make our common goal of health activities highly successful. - Maternity Care Monitoring isthe success story. - high appreciation to IFRP/IGCC Steering Com - Trophoblastic Disease - must get funding because mittee, the Chairman/Session Coordinators and the there is adefinite need to study this problem. Secretariat Group.
- Safety of oral contraceptives - useful information Finally he expressed the hope: for management of programme and propaganda. - will work hand in hand to try and keep great coopera - Group discussion especially Group I has raised many tion and collaboration together.
26 GROUP SESSIONS
OBJECTIVES FOR GROUP DISCUSSIONS 5. Ways to gain insight into consumer perception of ser vices. I. Objectiyes 6. Are the Services we are offering acceptable? a) In-depth study and the exchange of experiences of the current programme. Group II: Reproductive Risks b) Assessment of the research needs in the following: 1. Prospective Studies on Risks and Benefits of Contra i) Contraception (include all forms of contra- ceptives. ceptive technology) e.g. pills, IUD, sterilization, 2. Retrospective Studies Specially on Depo Provera. abortion, etc. ii) MCH/Family Planning/Nutrition/Delivery Ser- 3. IPPF-ESEAQR Medical Committee Findings. vice System, etc. Some of the items that might be discussed are how to: c) Identification of Research Projects in accordance a) Define diagnostic criteria. with the country priorities. d) Formulation of the identified Research Projects. b) What administrative infrastructure is necessary to mount prosp, ctive or retrospective studies.
e) Assessment of the following: c) What items of concern among Asian users would i) Capability (resources, manpower, development, warrent case control retrospective studies. etc) Group II: Maternity Care Monitoring and Trophoblastic ii) Capacity for research nationally and inter- Disease nationally and to provide solutions. 1. Maternity Care Monitoring - Where Next? f) Evaluation of on-going research projects and making * recommendation for possible future activities. 2. Traditional Birth Attendants. GUIDELINES 3. Incidence and follow-up of Trophoblastic Disease.
Group 1: Research Into Service Delivery Among topics that might be discussed are:
1. Primary Health Care with Special Reference to Nutrition, a) How many deliveries need to be monitered - a MCH, Family Planning, etc. sample on all cases.
2. Traditional Birth Attendants. b) How can MCM be carried out of institutions and into villages. 3. Alternative Delivery Systams for Family Planning. (Exam p'd: ways to expand family planning through private c) Would a multicenter study of the epidermiology of practitioners). trophoblastic disease be useful? What might it cost? 4. Cost Effectiveness of Different Delivery System. d) How can more data be obtained on natural deaths?
27 THE DISCUSSION REPORT FROM vi) Studies are to be carried out on Traditional Medicine. GROUP I(A Et B) I1l. While delivery systems are considered, individual coun The group discussed the topics given as guidelines for tries should use the particular mode of delivery system suited discussion. to them. One may be more useful to one than other. I. The population who are to be covered by Primary Health Care varies from country to country, these are population in In this aspect coordination of the different activities and rural areas and urban poors, systems seems to be more important. There is need for re search in developing system for coordination at all level. The There is a disparity in the development of health care involvement of social organization like women's organization, services like nutrition, MCH & FP. In some countries FP ser- youth organization, specially in IEC should be studied. vices are better developed than MCH and in other it is the other way. These services should be integrated and provided Private Practitioner' participation in the delivery of health as part and parcel of total health care service. The base line care service can be very valuable. Not much has been done to study of basic needs of the communities have not been assess- mobilise it. So the Group feels that steps should be taken to ed in some countries. The demand for types of service are to use this resource in delivery of the health care service. come from the community for the fulfilment of their needs; the demands can be created using the educational and develop- The cost effectiveness of the system are to be evaluated ment approach. when the time calls for it after all the priority areas have been considered. When te above problems are identified the research should be directed into the following aspects of PHC, MCH IV Et V These both points are considered together as they and FP Services. are interrelated
i) In the organization of logistic supply the following The concept of FP should be understood as means to points are considered: improve quality of life by consumer as well as providers and not merely the use of contraceptive and fertility control. The 1.1. The assessment of existing manpower and their research isto be directed to. utilization to be carried out. There are other group of personnels involved in health care 1.1. In-depths analysis of existing datas are needed. They service delivery like nurse midwife, TBA, local should be analysed by using the appropriate method village worker - most of them are multi- to monitor the perception and attitude in term of purpose workers. As IEC is an integral part of MCH and FP Service. health care service, teachers, religious heads, village leaders and students can be the avail- 1.2. New research are to be done with the involvement able and useful manpower to deliver this ser- of social psychologists and behavioural scientist. vice. Research can be carried out to find out how best they could be utilised. 1.3. The studies are to be carried out to find out the acceptance and effectiveness of free against service 1.2. The constrain in the establishment of supply with payment. of logistic support specially to remote areas are well recognized and research should be 1.4. The assessment must be carried out at regular inter done on how the providers can overcome the val to make the datas more valuable. These informa constrains, tion should be disseminated to consumers and pro viders as soon as possible to have effective planning 1.3. We shculd study whether the community work- and service. worker. er could be trained as multipurpose GROUP 11 The analysis of the workload and performance of multipurpose worker should be made. Studies on reproductive risks and benefit could best be II. TBA conducted in situation where: We recognise that TBA are valuable aids in the delivery of health care service in countries of this region. They need some a) Comprehensive and systematic record systems of training and supervision. So the research are to be directed contraceptive use exist. to: b) A high prevalence of contraceptive use exists. c) And a mixture of fertility regulation methods exists. i) To evaluate criteria for selection of TBA for training. Although alarge data banks on the clinical experience of ii) To expand the function of TBA as post partum use of contraceptive use leg. IFRP) and many research studies have uteretonic drugs and p;lls. been conducted leg. IFRP, WHO) additional methodologies are needed to establish ageneral perspective on the risks and iii) Functions of the supervisory system to be evaluated, benefits of contraceptive use. iv) Comparative study of performance and result of different The Group reviewed the administrative opportunities pre health worker as Nurse midwife, Trained TBA and Un- sented by the careful mapping and recording of contraceptive trained TBA. users in Bali (Pop: 2.4 m, adequate prevalence of use of IUDs, Pills and sterilization) and the comprehensive organization of v) The maternal and infant mortrlity and morbidity of home the INC, Philippines (Pop: 4 m. adequate prevalence of use of delivery by TBA should be analysed. condoms, pills, IUDs and sterilization).
28 Among rural populations adequate standard diagnostic eqidemiological study. Prof. Wagatsuma can give criteria for illness would be difficult to establish, but in each of more details after investigating the matter. the two above cases it would be worth carrying out a pilot Nigata with Prof. Ishisika study to determine if a sample of all deaths among fertile Aichi Takeuci (?) women could be conducted and aplausable explanation of the cause of death established. - Indonesia: Such a study might not expose any specific mortal risks Bali is considered a likely place for such a study. 1 many of contraceptive use, but might demonstrate a difference in provincial hospital + 5 small hospitals. But as mortality between users and non-users of contraceptive traditional birth attendants exist, the study would methods and the documentation of such a difference would have to tap this paraprofessional corps as well. be valuable in establishing realistic perpectives on the safety of family planning when made available through systems of Philippines: delegated medical distribution. Greater Manila would be the best place to conduct such study. With around 6'500 deliveries, annually, A retrospective stud' on the long term consequences of Prof. Aragon picks up 80 TD, whereas with around ligation could be considered in Nepal, where several 30'000 deliveries Prof. Apelo picks up around 160 tubal in metro thousand women have now had voluntary sterilization through TD trt Jose Fabella Memorial Hospital. As camps in stable, traditional society with a good possibility of polian Manila virtually all deliveries are registered, adequate follow up.The children of sterilized couples might be both Prof. Aragon and Apelo may serve as resource compared to those of similar age whose parents were not for such project. sterilized and who continued to have children. - Thailand A long term follow-up of abortion, including subsequent 95% of deliveries occur at institution in Bangkok contraceptive use, should be considered. Metropolis. This mearis that a multicenter study could possibly be organized in downtown Bangkok, The Group saw a need to try and establish the broad signi- among the various universities/hospitals .. such ficance of the information which is accumulating from meta- "Ramathibodi, Chulalongkorn, Hospital for Women, bolic studies of small groups of pill users. and Siriraj.
The Group felt that the current studies and plans for - Hong Kong studies by IFRP and WHO on Depo Provera were adequate. Would be ideal but has now a problem of migration. Discussion Group Ill - Singapore This place is recognized as an ideal place of study, Maternity Care Monitoring and Trophoblastic Disease if Government agrees.
The group discussed the following three items in the - Korea that Korea following order: While not discussed, the group feels could be an ideal place, at least agiven region. 1. Trophoblastic Disease Traditional Birth Attendants, - Taiwan 2. of migra 3. Maternity Care Monitoring. Taipei City woL;d be ideal, but a problem tion.
I. Incidence and follow-up of Trophoblastic Disease 4. Preliminary Assessment could be made by travelling epidemiologist who would collect some information on The discussion may be summarized as follows: feasibility and appropriateness. 1. Is there a need for Trophoblastic studies? Unanimous answer by the group: Yes. 5. A small expert group should be nominated to review, among others, all protocols now existing and that expert 2. What kind of question should be answered? group may send its delegate to the Tokyo FIGO meeting INCIDENCE STUDIES are needed that really cover several in October, in order to learn from evolutions on that end. defined geographic areas. Based on Prof. Wagatsuma's report, such studies will ldve k include the question of II. Traditional Birth Attendants the husband's aga. The discussion may be summarized as follows 3. Identification of po!%ible places to conduct incidence studies. 1. because of the remarkable number of TBAs existing in four Asian countries: The participants discussed possibilities: Malaysia 3,000 - Malaysia: Thailand 33,000 Island of Penang with 1million population might be a Indonesia 60,000 possibility. However, Prof. Chong feels that Malay- Philippines 30,000 sia's contribution might rather lie with the Laboratory aspect in Kuala Lumpur around 125,000 - Japan: a coordinating body should be created to work out At least one prefecture might be identified for a neat more common knowledge on this corps of birth attend
29 ance for these four countries, of service statistics should always be reviewed for secur ing the main features that elevate service statistics to 2. Both IFRP and IFFI- might be helpful in helping to deve- functional monitoring of maternity cvre. Not using new lop simplified MCM systems adopted to birth attendants. data collection systems for monitoring is considered a great waste of resources both human and technical. The 3. This instantly available woman power should be fully new data collection systems should be utilized by both utilized for improving pregnancy outcome in rural areas. health administrators and the service providers, i.e. the obstetrician and midwife. This is the only practical way to 4. The first meeting of coordination of TBA activities for improve pregnancy outcome in a programmed manner these four countries could be held during the World with full involvement of the profession. Congress of FIGO in Tokyo if key people on TBAs from these four countries attend the congress. It is hoped that 7. The discussion group then pushed for concrete steps IFFH, IFRP or WHO could support the coordinating to be taken to secure optimal development of maternity activities, care monitoring in Asian countries. The following steps were suggested for IGCC countries to take action for the Ill. Maternity Care Monitoring - Where Next? national development of maternity care monitoring systems: The discussion may be summarized as follow: 7.1. Countries who have not yet tested the system are 1. The entire group felt that there is great need for each encouraged to conduct afew studies at the Univer country not only to study but above all to monitor ma- sity Teaching Hospital and possibly some selected temity care. referral hospitals. IFRP/IFFH/FIGO may provide initial help to secure the implementation of such 2. The countries that had acquired experience with the studies. Early feedback should be used towards IFRP/FIGO maternity record also recognized thp the developing a monitoring system in cooperation Monitoring would have to be developed from within the with the Ministry of Health. country by the obstetrical profession and in intimate cooperation with and support from the Ministry of Health. 7.2. The development of national matornity care moni- The entire group rallied to this view. toring systems is bound to the development of simple maternity records. Hence a national task 3. Reliability of recording and data collection coordina- force will have to be formed to make in-country tion would have to be major concerns of the group en- decisions on the number and content of items to trusted with the execution and supervisior of Maternity enter maternity records at the teaching/referral Care Monitoring. hospital level, the intermediate health center level and the most peripheral level. The group agreed 4. The group also felt that the mid-term aim isto push moni- that the nucleus of such: toring from University centers into regional teaching and referral hospitals in a first step, and from there National Task forces on MCM Core questions further into the health centers. Increasing simplifiation of the data collection tool along this centrifugal imple- should be instituted without delay and that the mentation path would be essential. However, each persons indicated below should call a meeting for country would have to decide for itself on the scope of establishing such task forces that would recommend items to be monitored at each level of maternity care the content of future MCM forms at the various services, levels of MCH service delivery.
5. The present 903 form was considered (by all participants 7.3. In order to secure an orderly process of work that in this group who had experience with it) too long for would be productive within a short time, the IFRP/ routine monitoring. However, its value for initial studies FIGO short maternity record (910) should be the of maternity care was recognized and actually lauded as starting point for discussion. Certain university and a demonstration tool of the potential of future national* other centers may want to adhere to the longer maternity care monitoring, whose major aim would be to IFRP/FIGO 903 form (in use since October 1977) to provide a mechanism of poer review towards im- do maternity care studies in addition to monitor proving pregnancy outcome in aprogrammed manner. ing. But ingeneral, the summary record (910) might provide a basis for use across ALL institutions (Uni 6. The fundamental question as to whether new data versity/Provincial Referral hospitals and even certain collection systems of maternal and child health Health Centers). In essence, the entire "institu services, including obstetrical services (now being tional;; management pyramid should be uniformly developed incertain countries with considerable expense) monitored, at least experimentally, in order to identi could be used for monitoring as well, was asked by the fy the key problems that are to emerge from the Philippine Delegation. The group felt that maternity care analysis of the monitored centers. The following monitoring is az much an attitude and spirit as a tech- delegates have agreed to call the founding meeting nological feature and that new data collection systems of the task force described above:
30 Country Delegates and suggesttd persons 7.5. The recommendations will be forwarded to Dr. Roger P. Bernard for an analysis of the three lists Indonesia Prof. S. Suleiman from the various countries and in order to design a Prof. M.J. Hanaflah draft form for the IFFH Executive Committee to meet during the Tokyo FIGO meeting in October Malaysia Datin (Dr.) Nor Laily Aziz 1979. The main aim of this Intermediate exercise Prof. Chong Chun Hian is to secure a broad comparability of the future national questionnaires across both Asian countries Philippines Prof. G. Aragon and indeed on a truly international scale. The re Dr. F. Bayan commendations of the task forces should be sent not later than 15th September to Research Triangle Singapore Prof. Mark Cheng Park, in order to be able to do this analysis. The Dr. Ng Kwok Choy analysis will start on October 1st and no late comers can be considered for technical reasons. Taiwan Prof. Pei-Chuan Ouyang 7.6. The draft torm will then be submitted to all countries Dr. Fu-Min Chent concerned for final decision by each country. The an international Vachrotai major emphasis will lie on securing Thailand ThailandDr.Dr. SomoonSomboon V acha common data core and to organize country speci Dr. Kamheang Chaturachinda fic requirements in such a way that computer pro Nl (Mrs.)Dr. Maa Dibya Shree gramming remains constantly effective Country Dspecific items may be entered in country specific Nepal boxes. be en Other countries in the IGCC region should couraged to adhere to the same procedure. 7.7. All this work is preparatory for countries to develop a proposal for instituting "institutional MCM" that 7.4. These task torces should come up with recommen- may require international funding. IFFH will help in dations for a MCM-form giving precise information developing such proposals if solicited. on which questions of the 910 form should be used 7.8. It was agreed that steps 7.2 to 7.6 are to be consi in-country 'or thein-cunty montorngrnonitoring'o th ofo MaerniyMaternity CCaredered are as a high priority action to secure further ctoer 979. "institutional pyramid" (List A: decis aki ioin across the entire g y retained questions). A second list should give the questions that are to be eliminated (List B: dropped It was also agreed that the Task Force will concen questions). A third list should give the questions that trate after the Tokyo meeting on the number and should be added to the national MCM-form (List C: substance of questions that will have to be used in country-specific questions). the "Primary Health Care Pyramid".
31 Objectives Research Methodology
1. Primary Health Care, To develop a creditable 1.1 Assessment of the Sample Household Sur Nutrition MCH, FP. PHC System as a pilot basic need of the vey project community
1.2 Planning and orga- Field Trials nisation PHC to meet the needs of the Community
1.2.1 Type of PHC worker 1.2.2 Roles and func tion 1.2.3 Training 1.2.4 Logistics: support 1.2.5 Supervision and link up with health delivery system
To identify and recruit 1.3 Study existing parti- Field Trials suitable country deve- cipation and organi lopment workers. sation
To review, improve and 1.4 Assessment of utili- Sample screening expand the PHC system sation and accept ability of serice provided
2. TBA To develop criteria for 2.1 Review of existing Inventory of TBA selection of TBA recruit- criteria for selection mint and training. and training of TBA
To identify future roles 2.2 Review of present Sample interview and and training of TBA. roles and practices participating observation of TBA
To identify and isolate 2.3 Study of chemicdi Chemical laboratory beneficial effects of control of traditional analysis Traditional medicine, medicines
To review, improve ex- 2.4 Assessment of per- Sample survey Study & pand TBA programme. formance of TBA re interview
3. Alternative delivery To improve existing and 3.1 Study the different Field study system including identify new system ways and means of Cost-effectiveness providing FP ser vices.
To develop a system 3.2 To study involve including training for FP, ment of GPs and other physicians parti- other Physicians de cipating in the delivery of livering FP service. FP service
4. Perception and 1) To develop/improve 4.1 Assessment of KAP acceptability comprehensive pro- acceptability con gramme which re- cept of programme flects the need of as well as delivery the people and system including therefore emphasis- service fees ing a humanistic 4.1.1 providers approach to deve- 4.1.2 consumers lop.
2) To reorientate and retain providers.
To improve and develop 4.2 Evaluation of exist- Field study innovative IEC pro, ing IEC with its gramme to effectively various components ,ommunicate the con cept of the programme.
32 Name of Country Oral Contraceptive IUD Injectables Sterilization Abortion Services Delivery Reproductive Anatomy
Completed Longitudinal, time mo- Indonesia tion study to evaluate Prospective study are acceptability and safety on hospital cases, integrated FP/MCH acti- Findings: - vities & personnel utiliza- Provision of creditable back up support services increases ecceptability/ tion. Findings show that safety. there is under utilization O I O of personnel due to On Going On Going On Going training therefore need On Going Prospective Study on Prospective epidermio- to review curriculum & Prospective sociological Feasibility Study Prostaglandin multicentre study in 1000 hospital cases, safety/failures/effects in logical study of the In- develop multi-purpose study on the couple as 1000 hospital cases. cidence of abortion family health nurses. a biological unit and using Randomized Res- etiological factors. ponse Technique.
Malaysia Completed Completed Completed Completed Completed Completed Completed
I Clinical trials to test I Several case studes 1 Prospective study on 1) Study of psyho- I) Case studies of hos- 1) Various follow-up 1 Case studies show efficacy of various on efficacy/side efficacy. Findings sexual effects of pital records on sep- studies on effective- ed that H. Mole types of OC. Find- effects / complica- common with other vasectomy. Find- tic abortion. ness of services have varied diverse ing show that low tion. Preliminary re- studies that men- ings show that an- 2) Prospective and re- offered. clinical presenta dose containing go- suits show favour- strual irregularities xiety coordinates trospective study tious and minics ing ethynyl oesgra- able result for cop- were main reasons with parity, concluded that ma- 21 Evaluation of inte- systems ofthreaten dial is suitable with per T. for termination. jority of those seek- gration with MCH ed abortion making minimal side effects. 2) Clinical studies on ing induced &bor- showed that MCH early diagnosis diffi On Going On Going various types/me- tion were utilizing services were not cult. On Going 1) Use of paramedics 1) Comparative pro- thodology. western medical affected neocovively in IUCD insertion. spective study on service, by additional work 2) Case studies slowed of H. 1 Metabolic studies 2) Study effectiveness Depo and Norigest load. that 6-10% would pro among pill users, of sutured IUCD in terms of accep- On Going Mole Preliminary results (Lippee and Copper tion. tolerance, side 1) Epidemiological stu- 3) Various KAP stu- gress to choriocarci showed favourable T) immediately after effects. dy do determine ex- dies. noma and the risk picture of low dose postpartum or de- tent of morbidity as increases with parity pill in relation to livery, a result of abortion, and age. carbohydrate and lipid metabolisms and coagulation factors Name of Country Oral Contraceptive IUD Injectables Sterilization Abortion Services Delivery
Completed On-Going On-Going Completed Completed On-going
Thailand a. Prospective on com- 1. Epidermiological stu- 1. Epidermiological stu- Prospective to compare Epidermiological study 1. Pilot Project to find bined. Finding showed dy on relation of IUD dy on relation of methods of sterilization on incidence of illegal feasibility of utiliza that the combined pill with PID/Ectopic DMPA usage on inci- laparo-electro, laparo- abortion. Study recom- tion of non-phy with the lowest dose so Pregnancy. dence of Cacervix, ring. Finding shows least mends liberalization of sician health per as to produce the least corpus, ovary, complication using non- existing laws to prevent sonnel (midwives) in side effects is 6-levo- breast, liver, electrical method but the attendant complica- IUCD insertion. norgestril 0.15 mg. + past operation pains. tion of criminal abortion. Finding shows that EE 30 mg. and therefore, there was no statis should be offered in Na- tical difference in tional orogrammes. efficacy between physicians and mid On-Going Research wives and therefore more midwives Prospective clinic cases should be trained in on safety of low dose on IUCD insertion. lactating women. Preli minary finding shows 2. K A P Survey I.d. does not suppress amongst trained lactation, and untrained TBA on Family Planning activities. FP Pro gramme should train TBAs.
On-going 1. Pilot Project to i,'.e grate FP with immu nization component of MCH pro gramme. Abortion Service Delivery Name of Country Oral Contraceptive IUD Injectables Sterilization
Taiwan On-going Case Study (IFRP) Completed CompletedCoped Japan Case study on efficacy/ Case study to study side effects. Findings in effer't of new PG Ana paper. logue. Findings show that this is relatively effective.
On-Going Korea Evaluation of various management and orga nizational aspects of Primary Health Care at the village level.
Ut Completed Nepal Case studies to analyse Pilot study to determine efficacy/side-effects of acceptability / continua various methods. Find- tive rate of acceptors in ings higher continuation clinic based and com with IUCDs & Depo. munity based delivery system
Finding:- Community based more favourable. Nepal service delivery community now.
Philippines On-Going Prospective studies to analyze efficacy/side effects of various methods. PAPER 8
INDONESIA
Country Paper
INTRODUCTION the overall national development programme we expect the country to progress along the road to modernization The Indonesian National Family Planning programme in such a way as to support the ultimate population objec recorded a substantial achievement in terms of number of tive of asmall family. new acceptors in the last eight years since its initiation in 1971. The ultimate goal of Indonesia's family planning programme To implement the three-phased strategy, the following is the wide spread adoption of a small family norm. In quanti- activities become the essential parts of the programme: tative terms it is striving to reduce fertility as measured by CBR by fifty percent by the year 1990 (instead of the year 2000 (1) Continued efforts to expand new family planning accep as it was planned.) from 1971 level of approximately 44 per tors as possible. The record shows that up to date accu thousand. mulatively more than twelve million couples have accept ed family planning since the initiation of the programme To reach the goal the programme is planned to be exe- in 1971. In the noxt five years another twelve to fourteen cuted through three broad phases. The phasing of the pro- million couples of acceptors are expected to be recruited. gramme implementation goes in line with the other sectorial development plans, which again are intogral parts of the (2) Increased efforts directed at better maintenance of accep- National Development Plan in Indonesia. Those three phases tors. Up to date more than five and ahalf million couples are: in Indonesia are practising family planning, of which around 64 percent using oral contraceptives and 27 per (1) A short-term phase of 5 to 10 years of intensifying in- cent using the intra-uterine-device. At the end of the next formational and educational activities to introduce the five-year period it is expected to have twelve million family planning concept and establish contraceptive couples practising family planning. services at the grassroot level. At the same time the pro gramme is laying the foundations with and private groups (3) Incooperate the efforts of accepting small family norm to integrate the introduction of the idea of small family through governmental apparatus and through existing norm into their development programmes. social and cultural institutions.
(2) A medium-term phase of 10 to 25 years which seeks to In the context of expansion of programme coverage the completely integrate most of the population with existing traditional clinic-base family planning programme has general government developmental programmes. In this context ly been shown to be poorly suited to our needs since the ma each ministry is expected to devote part of its resources jority of our people live in rural areas where clinics, no matter and manpower to combatting the population problem the number, are not readily accessible to couples with need for through its own funded and directed programmes. The services. To cope that problem various efforts have been ex role of the BKKBN (National Family Planning Coordinat- perimented. One form of delivery system is to have one villagei ing Board) would be primarily that of coordinating and designated as aperson to whom pill and condom users should orchestrating the various programmes to ensure that the turn periodically to obtain contraceptive supplies. To date this overall population policy is implemented. scheme isfound in countless villages throughout Java. Yet no two resupply schemes are alike. Infact the programme has not (3) A long-term phase which creates social, economic and tried to adopt or promote a single model. Instead, it has en psychological conditions wherein the small family norm couraged the villagers to develop a system that suits the needs can feasibly become an integral part of the Indonesian and interests of the communities themselves. Another form way of life. It has actually been initiated as an operational emerged as a modification of the above one, and that is tie programme component sirnce the last few years, but it existence of the "acceptor-groups", each of which designate requires many more years to accomplish. As an output of one person who represents the group as a voluntary family
36 planning worker. Although these persons are not paid, the role those accepting the intra uterine device since the initiation of provide them with increased prestige in the eyes of the corn- the programme. The percentage level was 54-7% in 1970 and munity. They gain an important social status in their commu- uecreasing gradually to the level of 18.3% in 1979, while the nity. In fact they have considerable responsibilities for seeing percentage level of oral pill showed an 'increasing trend from that everyone's supply of pills or condom isobtained from the 27.5% to 68.8% for the same period. Our record of current using clinic or village-depot and is distributed properly to the women users shows that 26.96% of the eligible couples are still in their group. They also play an important role in keeping the IUD and 64.42% the oral pill in 1979. In absolute numbers track of current users, on their use of contraceptives and in it could be stated that about 1.1 million couples of the accu reporting dropouts and suspected pregnancies to the field- mulated 2.6 million recruited for IUD have dropped out, while worker or nurse midwive. To keep these acceptor-groups alive for oral pill the figure was 5.3 million couples out of 8.9 million, a number of social activities are conducted by the group, like which shows ahigher continuation of use of IUD over oral pill. lottery, money saving etc. which attrack new members and These figures refer only to the use of pills distributed through encourage old members to continue using contraceptives, the programme which are limited in types and composition. The use of other pills available inthe free market has yet to be The programme in Bali has adopted another type of re- studied. supply system, which is incorporated in the traditional acti vities in the hamlet or banjar. A monthly meeting of the banjar Quarterly independent samply surveys showed cumu attended mostly by men, includes population problem in the lative drop-outs rates for respectively 12, 24 and 36 ordinal discussions and this meeting is used for resupply of contra- months of 10.2%, 20.4% and 25.8% for IUD and 35.8%, ceptives through the husbands. 52.9% and 67.7% for oral pill.
The government seeks to encourage those various kinds The reasons for drop-out from IUD after the 36th ordinal of approach and is trying to replicate their success elsewhere month were psychological (11.2%) followed by expulsion of in the country. As of this year the programme is expanded the device (7.1%), accidental pregnancy (2.4%) and want to geographically as to cover all the 27 provinces in Indonesia. It have another child (4.2%). The reasons of drop out from pill requires strengthening of the management of the national pro- were psychological (15.3%), health 12.3%),accidental preg gramme which brought about consequences of inflating the nency (5.9%) and want to have another child (17.4%). organization both at the central as well as at the provincial level. In addition the national programme has widened its From the above statistics we could conclude that although scope of function by initiating "beyond family planning" pro- a large number of new acceptors have been recruited the per grammes, that support the family planning programme. These formance of use of the pill as well as the IUD still has to be are and will be dealing among others with the legal aspects of improved. the population programme, nutrition family pldnning pro gramme. The involvement of women in the effort for increas ing the village family income, etc. Research and studies for the improvement of the per formance have already been initiated in recent years by various In the light of the experience gained by the programme to universities in Indonesia. Inthe following chapters the findings date an increasing attention has been devoted to the use and of some studies are presented. Research and studies on the side-effects of use of contraceptives used in the pro- contraceptives are being conducted by various universities in gramme. Data on side-effects are compiled for careful evalua- Indonesia to back-up the national family planning programme. tion and assessment. This paper contains some reports on the Some of the results are presented here, dealing with the intra use and side-effects of various contraceptives in Indonesia. uterine device, the oral pill, sterilization and the incidence of trophoblastic diseases. The Programme Achievement a. The Intra Uterine Devices The acceptance records show that the national family which plaiing programme has gained an increasing number of new IUD isone of the effective contraceptive methods acceptors, but they show agradual decreasing proportions of has both advantages and disadvantages.
TABLE I
Advantages Disadvantages with IUD insitu. 1. High Effectiveness. 1. Possibilityof Pregnancy concerned with menses. 2. Long-term duration. 2. Unsuitable to medesty and culture or religious back 3. Reversible. 3. Unsuitable to a certain ground. 4. Suitable during lactation. 4. Pain or Discomfort and Insertion. 5. Preconceptive. 5. Non-self Administration. 6. Coitally independent. 6. Presence of Contra Indication. hypermenorrhea, uterine 7. No sexual effect. 7. Side effects: bleeding, cramps, infection, anemia, perforation, etc. 8. No serious effect on General Health. 8. Possible Effect on fetus (medicated IUD). 9. No Continuous Supply required. 10. Relatively Low Cost. 9. Medical Personnel, Clinics and Instruments are required for providing and Follow Up. (6)
37 After nearly two decades of use, the IUD remains "a later post partum period, and immediately after abortion. generally safe, effective and useful form of birth control". Research is now underway to develop postpartum IUDs The number of women using IUDs isgrowing slowly but minimizethat will resistperforation expulsion and misplacement.and post partum inserters that will research steadily. Despite extensive experience and continuing originalin both problemsdeveloped of andIUD developinguse remain unresolvedcountries, someand some of theof ThereTeeae~vosavnae are obvious advantages innpoiiga providing an IUD U im m the promising new solutions remain unproven. (5 s mediately after c alivery for the woman who wants this protec tion rather than insisting that she make a return visit which Several attempts have been made to improve the effec- may be difficult for her. (5) tiveness and acceptability of the inert intra uterine device. The RESULTS findings suggest that the performance of inert IUDs may not be improved (2) and further progress can be expected only in During the first year of the official government supported development of bioactive and medicated devices, effort in family planning in Indonesia (1969), the majority of new acceptors (55%) selected the IUD. Pill acceptors con Experience with the IUD throughout the world has sisted some 27% of the total compared to 18% for the con demonstrated that within certain limits clinical and individual dom and other methods. factors may have more impact on continuing IUD use than the design of the device itself. By 1977-1978, the situation had reversed itself. New pill acceptors were by and large the majority (72%) followed by The skill of the health personnel, whether physician, mid- the IUD (19%) and condom and others (9%). wife, or other auxiliary, and the care and follow-up provided may produce more satisfied users *han does the latest per- The programme has been recruiting each year younger mutation of device. women with lower parity. At the start of the programme, the average new acceptor was about 30 yearr of age with 3,5 to To ensure best results, proper insertion iscrucial. The IUD 4,2 living children. must be inserted gently and high into the uterine fundus. By 1977 the average age of acceptance had declined to The geometric factors which adversely affect IUD per- 26.5andaverageparityhaddeclinedto2,4-2,8living children. formance are predominately those resulting from an unfavor able relation between the geometric parameters of the IUD Throughout, IUD acceptors have tended to be slightly and those of the endometrial cavity. (3) older with higher parity. The attractiveness of the IUD of this group of women is due to the relative finality of the method, compared to the pill, in preventing unwanted or further preg The most appropriate time for IUD insertion, first pro- nancies. vided by Gravenberg in 1931, is that IUDs should only be in serted immediately after menses. Interms of continuation rates, aJava-Bali wide survey in 1976-1977 revealed that after 12 months of exposure, some As Gravenberg pointed out, this assures that the woman 64% of programme pill acceptors continued using that method is not pregnant. Insertion during or immediately after men- whereas 90% of all IUD acceptors did. After 36 months of struation has other advantages: the cervical is dilated, the exposure all but 32% of all pill acceptors had terminated use of endocervical canal is soft, and any bleeding produced by in- the first method of acceptance, for the IUD only25% had. sertion ismasked by normal menstrual bleeding. In order to strengthen the contribution of the IUD in The World Health Organization has noted that limiting assisting the Indonesian National Family Planning Programme IUD insertion to the menstrual period may not be a practical achieve its objective of a 50 percent decline infertility between approach in large-scale family planning programmes. (7) the years 1970 and 2000, several decisions have been made which will be implemented over the coming years. Inthe interval period of a woman, the best time to insert an IUD is probably the time she appears in the clinic or health A devics more superior to the present Lippes Loop should center to request it, regardless of timing of her menstrual cycle be introduced into the programme (4). except if there iscontra indication. Research on various new IUDs in some teaching centers Inthe last decade investigators have found that IUDs can had been done, plain latex leaf, Cu T 200 E Cu 7 200, Multi be successfully inserted after delivery, both in the early and load Cu 250 IUD and Progestasert.
38 TARLE II
INERT IUDa (PLAIN LATEX LEAF VERSUS LIPPES LOOP)(DOUBLE BLIND STUDY) 1976 - 1978
Plain Latex Lippes Loop D
Mean Age 26.5 26.2 Mean Parity - 2.6 2.5 Side effects: Intermenstrual bleeding: - spotting 10.3 19.4 - moderate 6.0 6.5 - severe 0.0 0.5
Dysmenorrhoe: - mild 7.1 7.5 - moderate 1.1 0.5 - severe 0.5 0.5 Intermenstrual pain: - mild 4.9 8.6 moderate 0.0 1.1 - severe 0.0 0.0 Leucorrhea 10.3 5.3 Infection 0.5 0.0
This study showed that the new inert Plain Latex Leaf IUD has higher pregnancy rate but lower percentage of bleeding and pain than the Lippes Loop D. TABLE III REASONS OF DISCONTINUATION, CU 7 200 AND CU T 200 1975 - 1978
a.
Reasons of discontinuation Cu 7 200 I year 2 years 3 years
Pregnancy 1.0 1.9 1.9 Expulsion 2.9 3.8 3.8 Reasons of Removal: - bleeding and pain 1.7 2.9 2.9 - medical indication 1.0 0 0 - planned pregnancy 3.9 11.5 17.3 - personal 2.9 6.7 6.7
b. Reasons of dlscontlnuatlon Cu T 200
I year 2 years 3 years
Pregnancy 2.0 3.0 3.0 Expulsion 2.0 2.0 2.0 Reasons of Removal: - bleeding and pain 2.0 2.0 2.0 - medical indication 0 2.0 2.0 - planned pregnancy 1.0 11.9 13.9 - personal 5.9 7.9 7.9
39 The effectiveness of IUDs Cu 7 200 an-J Cu T 200 is the who are predominantly Moslems, in relation with observing same in the period of 2 years and 3 years et use.(1) the daily prayers. On the other hand amenorrhae due to oral contraceptives pills occured very rare. In the last few years the Medicated Progestin IUD (Progestasert) are ongoing method of oral contraceptive pills without taking the last 7 studies in some teaching hospitals in Indonesia. tablets of the 28 pills prescribed have been used to avoid men struation during the fasting month and during the pilgrims visit Multi Load IUD has been distributed by the National to Mecca. A University of Indonesia Medical School study Family Planning Coordinating Board as the National Pro- indicated that slight elevation of blood pressure in normoten gramme IUD to the hospitals and health cenzers. sive women during oral contraceptive use apparently has no ill effect on health. Blood pressure usually incieases from the Continued international donor assistance will permit the 2nd to 12th month of use and returns to pretreatment levels programme to offer a wide selection of more readily accept- within 3-6 months after discontinuing the pill. However, the able IUD devices than before, hypertensive women taking oral contraceptive has caused more ulevaticn in blood pressure. It is in this context that ad AdirectivehasgoneoutfromthechairmanoftheNational ministration of combined oral contraceptive pills should be Family Planning Coordinating Board to all implementing units carefully considered relative to patients who develop hyper at all levels of the government that acceptance of the IUD is to tension by such pills. be conciously and more explicitly encouraged than in the past. Special information and motivational campaigns are to be The metabolic effects of the combined oral contraceptive undertaken in the belief that better and more relevant informa- pills has been studied by the University of North Sumatra tion concerning the IUD will greatly enhance its overall popu- Medical School. It was found that there was impaired glucose larity. tolerance of the study group compared with the controls. The triglycardies and cholesterol also showed significant increase b. The Oral Contraceptive in tne study group. The investigators are in te opinion which is in line with other investigators that the administration of During the past 20 years, oral contraceptives have been combined oral contraceptive pills should be carefully relative to used by millions of women throughout the world. In Indo- women with particular risks, e.g. latent diabetes or potential nesia about 70% of new acceptors are pill users and it is esti- diabetics. mated that about 3 million women are current pill users. The low dose combined pill (containing no more that 0.5 mg of The effect of oral contraceptives on the liver has been estrogen) is being used. studied by a group from the University of Airlangga Medical School, Surabaya. They reported that although oral contra Besides their many advantages, various undersirable side ceptives modify excretory function of the liver and are statis effects of oral contraceptives have been reported. Certain side tically significant, the data still showed within normal limit effects of the pill known in the western world, thromboem- values. These changes appear to be reversible when drugs are bolism, myocardial infarction, and other cardiovascular com- discontinued. The effect of the O.C. on the cytology of vagina plications may not apply to our women. The women of Indo- and cervix have been investigated by University of Pajajaran, nesia as all women of Asia differ from the women of indus- Bandung. They reported that there was an increase of Monilial trialized nations in diet, life style, genetic heritage, smoking vaginitis in the pill users and the cervical cytology and showed habits, exposure to diseasesvectors ard environmental conta- changes as in folic acid deficiency. minants and myriad other ways that seem to effect cardio vascular diseases. It is in this context that safety research in Effect of oral contraceptives on lactation has been studied oral contraceptives is badly needed in this country. Unfor- by investigators frum the University of Pajajaran, Bandung. tunately, not enough research has been done to justify any Studies have shown that combined oral contraceptives may conclusion. The side effects of oral contraceptives usage cause a reduction in milk volume. The ongoing project will in which showed symptoms of "pseudopregnancy" such as vestigate whether or not low dose combined pills will have a nausea, dizziness, headaches, enlarged and tender breasts, supressive effect on lactation. weignt gain, breathlessness and depression have been studied by i:w'i,.gators from the University of Indonesia, Jakarta, the Regarding toumorigenic effects of oral contraceptives, Univei ty of Pajajaran, Bandung and the University of North there are no report ye, in Indonesia although there are a num Sumatera, Medan. Although reliable measurement of those ber of reports in the literature on the relation of genital tumors, side effects is difficult and many of them could occur with or breast tumors and liver tumors to the use of oral contracep without oral contraceptives it was concluded that the most tive. frequent side effect reported was nausea and occured only in the first 3 cycles. However headaches and dizziness were still From the above reports it is clear that additional research reported although the administration of the oral pills was dis- on oral contraceptives is needed in Indonesia and a multicenter continued. With regard to the menstrual side effects for a study shouldbe supported and encouraged. majority of normal women, they produce more regular cycles, shorter in duration with less heavy bleeding, less abdominal c. The Voluntary Sterilization discomfort, and partial or total relief from premenstrual ten sions. Infact, reduced menstrual bleeding is an important In Indonesia sterilization was started in teaching hospitals health benefit for our women who are undernourished and in the big cities such as Medan, Jakarta, Bandung, Yogyakarta suffering from anemia. Extremely irreguiar bleeding, such as and Surabaya. Indication for sterilization in general has been a spotting and constant or intermittent bleeding usually occured mishap experienced by a mother as a consequence of a repro due to forgetfulness in taking the pill or failure to understand ductive process (e.g. postpartum hemorrhage), hence almost very well the instructions involved as we deal with less edu- all the patients are older women who have many children cated peop!e. already. In case there are male patients, it is only because they are of a very advanced age so as to facititate prostate hyper This side effect is very important for Indonesian women trophy operation in the future.
40 which was established in March 1974, for the purpose PUSSI Jakarta, of initiating ano assisting the development of a family planning by undertaking activities, particular!y Planning Programme, however, programme in Indonesia The Indonesian Family reproduction and family planning, which sterilization component, and in in the field of human does not include a voluntary carried out by others in the field of Society for Voluntary Steriliza- had not been adequately February 1974, the Indnesian a Sub-Division of Human Repro voluntary sterilization family planning. The clinic is tion (PUSSI) was established to promote Department of Obstetrics and Gynecology, on a national basis. duction in the School of Medicine, University of Indonesia and the Dr. Cipto Hospital. The clinic is located at a distance of Support of VSC by the National Family Planning Pro- Mangunkusumo approximately two kilometers from the hospital. IP-AVS gr3mme is a fairly recent development, the emphasis in this a subgrant to the Klinik Raden Saleh providing funds, field being on research and education rather than service to awarded establish, equip, and staff a voluntary sterilization training the public. Funds to cover the cost of procedures still must to center in Jakarta. This training programme is conducted under come from the patients. It is evident that, with few exceptions, the auspices of the Department of Obstetrics and Gynecology, VSC is still a relatively costly procedure performed by gyne- School of Medicine, University of Indonesia and Dr. Cipto cologists for middle and upper class women of relatively high Mangunkusumo Hospital, at the family planning facility: the age and parity. A limited number of male procedures are per- Klinik Rader, Saleh. formed. Most procedures are performed by surgeons Iuro- logistsl. To date, under the first year subgrant which became 1, 1977, 1.934 female voluntary steri- Given the limited number of gynecologists and urologists effective on November have been performed. Training started at in Indonesia, while expanding availaoility of specialist con- lization procedures May 1, 1978, with 18 general practitioners and trolled methods (e.g. culdoscopy and laparoscopy), additional the center on having completed training at consideration has been given to those methods (e.g. mini- 21 Obstetrician/Gynecologists laparoscopy and vasectomy) that can eventually be performed the present time. that by non-specialist physicians. Therefore, it was decided will be required to submit to the training training centers be established to develop a manpower re- All traineeF statistical reports for a period of one year, source upon which voluntary sterilization services could be center quarterly age and parity of their VSC acceptors as well as built under the auspices of the Departments of Obsterics and describing the encountered. The training faculty will Gynecology and Surgery in prominent medical schools all over any complication each trainee within six months after the com the country. attempt to visit in order to assess the trainees' ability as wide an area as pleton of the training PUSSI has initiated steps to cover VSC services. branches through- and success in establishing possible through the establishment of ten been out the country. A number of these branches have Voluntary Sterilization Acceptors in 1978/1979 entrusted with activities in the fields of education and training through the establishment of voluntary sterilization training Sterilization services acceptors in the period 1978/1979 in Medan, Jakarta, Bandung, Yogyakarta, Surabaya centers 39.869, consisting of 7.444 male acceptors (vasec One of PUSSI's main activities is the coordina- number and Manado. female acceptors (tubectomy). With the Voluntary Sterilization Training Pro- tomy) and 32,425 tion of the National results obtained in 1978/1979 family planning participants who sterilization as a method of contrareption gramme. have selected Indonesia since 1974/1975 have been registereu to KLINIK RADEN SALEH throughout number 122.312, consisting of 24,561 male sterilization acceptors. One of the training centers is the Klinik Raden Saleh ir
DEVELOPMENT OF NUMBER OF STERILIZATION ACCEPTORS IN 16 PROVINCES IN INDONESIA
1977/1978 1978/1979 Total Sterilization in 1974/1975 1975/1976 1976/1977
9.556 7.444 24.561 Male 1.959 2.115 3.487 26.063 32.425 97.751 Female 7.724 12.519 19.020 39.869 122.312 Total 9.683 14.634 22.407 35.619
sterilization participants has where a voluntary and Bali, the greatest number of In 16 Provinces throughout Indonesia (7.9%), followed by the largest num- been found in North Sumatra Province sterilization programme has been in operation Sumatra Province 1978/1979 has West Sumatra Province (2.5%) and South ber of sterilization participants for the period of voluntary by Central (2.3%). A complete breakdcwn of the number been found in East Java Province (20.8%), followed is as sterilization participants during 1978/1979 province wise Java Province (18.1%), Metropolitan Jakarta Province(16.0%) Java follows: and West Java Province (14.6%). For the regions outside
41 NUMBER OF STERILIZATION ACCEPTORS PROVINC WI.R IN 1978/1979
No. Name of Province Male Female Sterilization Sterilization Total %
1. Metropolitan Jakarta 293 6.083 6.376 16,0 2. West Java 1.853 3.963 5.821 14,6 3. Central Java 3.122 4.107 7.229 18,1 4. Yogyakarta Special Region 867 1.592 2.459 6,2 5. East Java 232 8.070 8.302 20,8 6. Bali 250 2.000 2.250 5,6 7. Aceh Special Region 5 181 186 0,5 8. North Sumatra 579 2.583 3.162 7,9 9. West Sumatra 2 1.014 1.016 2,5 10. South Sumatra 39 890 929 2,3 11. Lampung 106 185 291 0,7 12. West Nusa Tenggara 1 208 209 0,5 13. West Kalimantan 26 111 137 0,3 14. South Kalimantan 7 149 156 0,4 15. North Sulawesi 2 728 730 1,8 16. South Sulawesi 60 556 616 1,5
Total 7.444 32.425 39.869 100,0 d. The Trophoblestic Disease factor in treatment.
In Indonesia, as in other Asian countries, the incidence of 3. Chemotherapy as adrug of choice is too expensive for the trophoblastic disease is notoriously high, in the form of Hydati- majority of the patients. Consequently we have to rely on diform Mole as well as Choriocarcinoma. The obscurity of its surgical treatment as a second best method, even if the etiology and the difficulty in the management of the disease is patient is still young and childless. But surgery alone is no novelty. Our hope that chemotherapy could be a real pana- only for non metastatic cases, beside the fact that the cea did not always come true. Too many patients still lost their patients have to sacrifice their reproductive function. Our lives in spite of rigorous treatment with chemotherapy. hospital record shows that the disease attacks mostly women in the reproductive period, and many of them are In addition to those above mentioned problems, we are nullipara. In Indonesia, women who cannot bear children also burdened by social constraints which have much in- might be divorced by their husbands. fluence on the outcome of the therapy. These following examples are just some of the many: In short it can be stated that management of the tropho- blastic disease in our country is inadequate, and it deprives 1. Ignorance and poverty are two factors which make many many women their reproductive function, their marriage of the patients come to the hospital in a very advanced security and ultimately their lives. stage. The risk of having mole is greater in women: 2. We have never been able to obtain precise data of the in- a. under 20 year and above 40 year cidence of the disease, because many of them are lost to b. with high parity follow-up. Unmindfulness on the part of the patients and c. with low socio economic level lack of funds make follow-up very difficult. It could be that the incidence of malignancy and mortality rate are The malignancy rate is about 10%. much higher than we realize. And yet we all agree that early detection of the disease isone of the most important The following tables will show the magnitude of the disease in Indonesia.
TABLE I INCIDENCE OF TROPHOBLASTIC DISEASE IN 1iASAN SADIKIN HOSPITAL, BANDUNG, WEST JAVA, INDONESIA No. of Incidence Incidence Year No. of No. of other of of Hyd. mole Chorlo Ca Pregnancies Hyd. mole Chorio Ca 1964-1966 126 9 7876 1:63 1:875 (3 years) 1970-1977 323 57 19625 1:60 1:344 (61 years)
42 TABLE I
INCIDENCE OF TROPHOBLASTIC DISEASE IN OTHER HOSPITALS IN BANDUNG, WEST JAVA, INDONESIA
Hospital No. of Incidence Incidence No. of No. of other of of Hyd. Mole Chorio Ca pregnancies Hyd. Mole Chorio Ca
St. Borromeus 28 8 7546 1:270 1: 945 Beatrix 32 1 4128 1:129 1:4126 Immanuel 182 30 13398 1: 74 1 : 447 Advent 5 1 1075 1:215 1:1075
TABLE III
INCIDENCE OF HYDATIDIFORM MOLE IN OTHER CITIES IN INDONESIA Cities Incidence
Jakarta 1: 82 Ujung Pandang 1: 51 Surabaya 1:84 Padang 1:53 Manado 1: 256 Yogyakarta 1: 89 Medan 1:132
TABLE IV
INCIDENCE OF HYDATIDIFORM MOLE IN SEVERAL COUNYRIES Countries Incidence
USA, Novak 1: 2500 Hertig 1: 2000 Netherland 1: 2000 Mexico 1: 200 Brazil 1:1071 Rep. of China 1: 940 Philippine 1: 200 Hongkung 1: 530 Japan 1: 232 Singapore 1: 823
SUMMARY A. REFERENCES OF THE INTRA UTERINE DEVICES
From research and studies conducted in Indonesia, 1. Agoestina T., IV Indon. Congress of ob. E Gyn., Double The use although limited in scope and intensity, the national family blind study Plain Latex Leaf versus Lippes Loop; Yogyakarta, planning programme has gained important information on of Cu 7 200 and Cu T 200 in 3 years period; various aspects of contraceptive use. Other important issues Indonesia, June 10-15, 1979. related to the use of contraceptives have been identified like on the suppressive effect of oral pills on lactation, the most suit- 2. Batar I., Taylor R.N., and Lampe L., Intern. Symp. (Lippes able IUD's for Indonesian women, the epidemiology of tropho- IUD, Can the Inert IUDs be Further Improved? Amster blastic diseases and the effect of sterilization on the socio- Loop D Intra Uterine Membranes and Ypsilon-y), cultural life in Indonesia. dam, June27-30, 1979.
The need of having a large number of continuing users of 3. Hasson H.M., intern. Symp. on IUD, Uterine Geometry 27-30, 1979. contraceptive inthe Indonesian family planning programme at and IUD Performance, Amsterdam, June the end of 1990, makes us aware of the need of more effective, IUD and Fain. Plan. safe and acceptable means of contraception. 4. Judono M., Intern. Symp. on IUD, in Indonesia, Amsterdam, June 27-30, 1979. A continuous exchange of research data and experience B, No. among countries in the region would enhance the cooperative 5. Population Reports, Intra Uterine Devices, Series spirit among countries and strengthen the national family 3, May 1979. planning and population programmes in the region.
43 6. Wagatsuma T., International Symposium on IUD, IUD 13. WARDHINI, S.: Beberapa efek sampingan dari obat kon and Family Planning in South East Asia, Amsterdam, traseptip oral, Obat dan Pembangunan Masyarakat sehat, June 27-30, 1979. kuat dan cerdas, Ed. B. Suharto, Bagian Farmakologi FK.IU, Jakarta, 1975, hal. 47. 7. World Health Organization (WHO), Intra Uterine Devices: physiological and clinical aspects; Geneva, WHO, 1968. C. REFERENCES OF TROPHOBLASTIC DISEASES
1. Hertig A.T. and Mansel H., Atlas tumor of the female B. REFERENCES OF ORAL CONTRACEPTIVES organ Part I, Hydatidiform Mole and Chorio Cardinoma. Armed Forces Inst. of Path., 1956. 1. AGOESTINA: Frekwensi gejala sampingan dan sebab sebab berhenti dari penggunaan obat kontrasepsi oral 2. Kloosterman G.J., De voorplanting van de mens; Leer dibandingkan dengan IUD, Naskah Lengkap, KOGI--Il, boekvoor Obstetris en Gynecologie, Tweede druk, Uit Surabaya, 1973, hal. 334. gevers maatschappij Center Bussum 616, 1974.
2. HOPPE GUNDOLF: Recent metabolic findings with a new 3. Litouw W., Mola hydatidosa dan choria carcinoma di low dosed oral contraceptive, Naskah lengkap KOGI-I1, RSU Gunung Wenang. Medan, 1976, hal 124. Naskah Lengkap KOGI-I, Surabaya, 37, 1973.
3. MARSIANTO, PRIHATINI: Pengaruh kontrasepsi oral 4. Liu B.L. and T'ien G.J., Gynecologic malignancy regis terhadap faal hati, Naskah Lengkap KOGI- III, Medan, tration in Nanking area, A 5 2 years survival rate. 1976, hal 340. Chinese Med. Journal, 83: 171, 1969.
4. MOCHTAR, RUSTAM, ISKANDAR, J. TARIHORAN S.: 5. Martaadisoebrata Dj., Penyakit trofoblas, Skripsi bagian Evaluasi pemakaian kontrasepsi oral (Pil), KPPIK, FK. Obstetri dan Ginekologi FKUP/RSHS, 1970. USU MEDAN, 1975. 6. Marquez-Monter H., Alvaro de La Vega, G., Robles M. 5. OEN L.H., KUNTARYAH S., LOECKE S.: Penghambatan and Bolio Cicero A.: Epidemiology and pathology of ovulasi dengan tablet kontraseptip Agestin, Obat dan hydatidiform mole in General Hospital of Mexico. Pembangunan Masyarakat sehat, kuat dan cerdas, Ed. B. Am. J. Obstet. Gynecol. 85: 856, 1963. Suharto, Bagian Farmakologi FK.UI Jakarta, 1975, hal. 53. 7. Novak's Textbook of Gynecology, 9th ed., The Williams & Williams Company, 1975. 6. PANJAITAN S: Program Keluarga Berencana di Indo nesia, KPPIK, FK.USU Medan, 1975. 8. Prawirohardjo S., Kun S. Martono and Tiondronegoro S., Hydatidiform Mole and Chorio Carcinoma in Indonesia. 7. POPULATION REPORTS: Series A, No. 5, Jan. 1979, Asiatic Congress of Obstet, Gynecol, Tokyo, 1959. No. 1, 1974, No. 2, 1975, No. 4, 1977. 9. Sitompul RPO, Siddik Dj., Nababan U. and Hutapea H., 8. PRAWIROMOERSITO, S.H.: Penggunaan kontraseptip Hydatidiform Mole in Medan Central Hospital. oral dan kemungkinan timbulnya kenaikan tekanan darah, 5th Asian Congress of Obstet. Gynecol., Jakarta, 227, Obat dan Pembangunan Masyarakat sehat, kuat dan 1971. cerdas, Ed. B. Suharto, Bagian Farmakologi FK.UI, Ja karta, 1975, hal. 41. 10. Soejoenoes A., Djoyopranoto M. and Poen H.T., Obser vation on some aspect of hydatidiform mole and chorio 9. SUHARTI K.: Oestroprogestative dan metabolisme carcinoma in Indonesia. lemak, Obat dan Pembangunan Masyarakat sehat, kuat U.I.C.C. Monograph series 3: 58, 1967. dan cerdas, Ed. B. Suharto, Bagian Farmakologi FK.UI, Jakarta, 1975, hal. 23. 11. Suharjono, Mola Hydatidosa di Bagian Obstetri-Gineko logi Univ. Gajah Mada, Yogyakarta. 10. SIDDIK, DJ., LIEW D., HANAFIAH, M.J.: Metabolic Naskah Lengkap KOGI II,Surabaya, 613, 1973. effects of the combined oral contraceptive pills on women inMedan, MOGI 4: 79, 1978. 12. Teoh E.S., Dawood M.J. and Ratnam S.S., The epi demiology of hydatidiform mole in Singapore. 11. TANDIRERUNG, K.:Obat antifertilitas pada wanita., Me- Am. J. Obstet. Gynecol. 110: 415, 1971. milih preparat yang sesuai, Obat dan Pembangunan Masyarakat sehat, kuat dan cerdas, Ed. B. Suharto, 13. Wim Theodorus, Komar A. Syamsudin dan Sukartono Bagian Farmakologi FK.UI, Jakarta, 1975, Hal. 9. S., Mola hydatidosa di Palembang. Buku Petunjuk KOGI Ill, Medan, 383, 1976. 12. THOUW J., ISMAIL, S., SAlMAN, R.: Pengaruh De poprovera, pil kontrsepsi, !UDpada gambaran sitologi 14. Juul Manus, Agustinus Sopacua, Fred Wulur, Mola epitel vagina dan cervix, Naskah lengkap KOGI-Ill, hydatidosa di RSU Ujung Pandang. Medan, 1976, hal. 334. Naskah Lengkap KOGI III, Medan, 715, 1976.
44 PAPER 9
MALAYSIA
Country Paper
I. INTRODUCTION 3. Previous Biomedical Research Related to Family Planning In Malaysia Since its inception in 1966 the National Family Planning Board Malaysia has undergone tremendous growth and ex- In the area of contraception research, the stress has been pansion in its activities. Initially the national programme was on clinical trials of various types of contraceptives. The limited focussed on contraceptive service delivery. Today, the pro- number of biomedical researches in the past were conducted gramme is more broadbased and multi-disciplinary in nature. by individuals on his/her own initiative without much funding Very little emphasis was put on biomedical research in the past from any source. There were several researches conducted by due to its low priority within the context of the development of the Department of Obstetrics and Gynaecology University of the total national family planning programme. However, as the Malaya with internal funding through departmental research programme grew, the need to develop the area of contra- vote. There are several researches that are collaborative in ceptive and reproductive research became more evident in nature and funded by the NFPB and conducted by members order to ensure the continuing success and acceptance as well of the Department of Obstetrics and Gynaecology University as safety of the various contraceptive methods. of Malaya. Intemational agencies such as IDRC and WHO also funded some of the research projects related to family plan- The national programme is today in the stage where it is ning. Medical research in family planning was at that time co now prepared to embark on biomedical research with capabi- ordinated by the Service and Training Division in the NFPB. lity and capacity for supporting and conducting such re- The list of previous clinical trial and researches are enclosed in searches within its premises as well as coordinating the work Appendix II.The following are some of the highlights abstract of other researches in the country. This has been made posii- ed from those research papers: ble through the establishment in November, 1978 of a new division in the NFPB, which will be responsible for the deve- 3.1. Hormonal Contraceptives lopment, implementation and coordination of specialised family planning services as well as biomedical research in rela tion to contraception, reproduction and fertility. This is indeed 3.1.1. Pills - the most appropriate dose for an important milestone in the history of biomedical research Malaysian Women in relation to contraception, reproduction and fertility. It must On reviewin the local literature of the pills pro be emphasised and initially the nature of biomedical research reewinggo whe al liica l trils re findingswould bewouldmainlybe problemutilised toordetermineprogrammethe oriented operational where policiesthe thevious efficacy, research side were effects mainly andclinical the trialsacceptance to test findingwon the . ational pr rate of the various types of pills. Although the inthe national programme. Pill is the mainstay in the national family plan ning programme accounting for 82.3% of the 2. Previous Trends and Priorities of Research acceptors, very little metabolic on other studies have been carried out. The emphasis on programme research in the past has been on surveys/research related to the socio-economic, Studies conducted in the Department of Obste cultural and demographic aspects of family planning. Due to trics and Gynaecology University of Malaya in many important findings of these surveys, particularly in rela- dicate that the low dose pills containing 30 ug of tion to the socio-economic status among the people of various ethynyl oestradiol are most suitable for Malay races in Malaysia, their differing cultural practices and atti- sian women. The contraceptive efficacy is about tudes towards family planning, they have been carefully uti- 99.5% with minimal side effects. The common lised to guide programme implementation as well as policy minor side effects are weight gain, amenorr direction of the national programme. The list of previous re- heoa, scanty period and break through bleeding. searches and surveys is enclosed in Appendix I. Studies among NFPB clients also showed that
45 continuation rate among low dose pill users are shown favourable results for Copper T. These devices are higher than the higher dose pill. generally easier to insert than the Lippes Loop and this factor is an important consideration for large scale usage The Department of Obstetrics and Gynaecology, of IUCD such as in our National Family Planning Pro University of Malaya in conjunction with IDRC gramme. However, on the other hand, copper devices is currently conducting metabolic studies among tend to corrode after three years or more and this is a pill users. This study is still ongoing and is in disadvantage because if IUCD were to make a demo collaboration with other departments of Obste- graphic impact in the National Family Planning Pro trics and Gynaecology University of Singapore gramme, it should be effective in utern for at least 3 to 5 and Medan, North Sumatra. Preliminary results years (Taturm 1977). showed a favourable picture of low dose pills in relation to carbohydrate and lipid metabolisms Studies are on the way now in collaboration with the IFRP and also coagulation factors where disturbances on Sutured IUCD (Lippes and Copper T) inserted im are found to be very minimal, mediately post-partum or at delivery. If this study proves successful, this mode of insertion may make a positive 3.1.2. Depo-Provera impact on the National Programme because during con finement, women are supposed to be at the peak of moti The use of Depo-Provera in the National pro- vation for contraception. gramme still remains limited. Two of the studies conducted locally concur with results of other 3.3. Traditional Methods of Abortion international studies in that menstrual irreguh ries were the main side effects experienced by In ;he report on maternal health and early pregnancy acceptors and in our Malaysian women these wastage in Peninsular Malaysia 1977, it was shown that were their main reasons for terminating this about 10.7% of women surveyed reported having had method. one or more induced abortions. Of these, nearly half (44%)to have been affected by "injections" while appro Currently the Department of Obstetrics and ximately 10% were through dilatation and curettage Gynaecology University of Malaya is conducting (DEtC)and 9% by using "medicine" from doctors. Medi a comparative study of Depo-Provera and Nori- cine from 'non-doctors' and herbs were used in 18% of gest (Norethisterone oenanthate 200 mg.) in the induced abortions. The remaining 18% included terms of acceptance, tolerance and side effects. massage, insertion of foreign bodies and others. The Another study planned intends to evaluate the survey concluded that the majority of those seeking in menstrual pattern of women on the injectable duced abortion were utilizing Western type medical ser progestogens of those with regular cycle and vices. those amenorrhoeic (post partum) on commen cing the method. Morbidities and mortalities associated with abortions are very difficult to assess. Hospital returns from Peninsular 3.2. IUCD Studies - Some Highlights Malaysia for 1972 showed that there were 1,076 'septic' abortions" with 152 maternal deaths and 13,665 "spon There are several publications related to studies on IUCD taneous abortions" with 112 maternal deaths occuring in in Malaysia. Most of them were concerned with the con- government hospitals. Most resultant morbidities and traceptive efficacy, side effects and complications. The mortalities from abortions are usually not reported. A most commonly used IUCDs in Malaysia are Lippes Loop study is now being carried out to determine the extent of and the recently introduced copper bearing devices, morbidity as a result of abortion from cases admitted to hospitals, popular Intra uterine contraceptive device is not very among the acceptors and in 1978, it accounted for only Though traditional methods of abortions are still practised 1.9% of acceptance by method in the National Family in Malaysia, it is very difficult to obtain accurate informa Planning Programme. The presence of a foreign body is tion because most patients involved refused to reveal any cited as one of the reasons for low popularity especially information for fear of incriminating a third party. Tradi among the Muslim women. Other reasons include preg- tional practice of abortion needs a detailed study in view nancy rate, side effects and complications. Further the of the health hazards involved. There are definitely ethnic programme had emphasised the Pill and has not propa- differences (Malay, Chinese and Indians) in the methods gated the IUCD because of lack of trained "personnel" to used to induce abortion and perhaps also in the outcome. the insertion as well as follow up cases. Initial efforts have Malays and Indians being that rural and suburban might been made to utilised para medical personnel to insertion, perhaps succumbed more to the dangerous procedure and if this project proves to be successful, then this would especially when their initial health status is poor and ex be expanded on a national scale. cessibility to immediate emergency help remote.
Most of the problems associated with IUCD among Malaysian women are very similar to those encountered 3.4. Trophoblastic diseases in Malaysia by Western women. The pregnancy rate among the copper devices namely Copper 7, Copper T and Multi- It is very difficult to get an accurate figure for the inci load Cu250 is about 2%. (Goh et al 1977). From the same dence of trophoblastic diseases in Malaysia. In Singapore study, the removal rate for pain/bleeding was about 3.1/ the incidence is 1 in 169 pregnancies. (Tow and Fox 1000 users and this is in contrast with the Lippes Loop 1966). Some aspects of trophoblastic diseases are high which is reported to have a comparative rate of 9.9 at 6 lighted in the previous researches: months (Orlan 1974). (a) Problems in early diagnosis of hydatidiform Among the three copper devices studied, preliminary data mole.
46 Hydatidiform mole have varied and diverse clinical 4.1. Role of NFPB In Biomedical Research presentations and very often it mimics the symptoms of threaten abortion. (Khairuddin Yusof 1973). This With the establishment of Specialist & Medical Research make early diagnosis of molar pregnancies very Center, research activities related to family planning difficult. However, with the advernt of ultrasound would be more well organised and better coordinated in facilities, these difficulties would soon be overcome, future. The roles of this new division are as follows:
(b) Problems of predicting the natural history and 1. To conduct its own researches in fertility and human follow-up of molar pregnancies, reproduction.
About 6-10% of cases of hydatidiform mole would 2. Initiate and motivate local scientists and physicians progress to choriocarcinoma and the risk increases interested in the reproductive research to conduct with parity (more than 3) and age (more than 35 researches. years). Patients within these risk groups should be treated by hysterectomy (Chun et al 1967). 3. Provide financial support and infra-structure for re search to researches involved in reproductive re Strick surveilance of patients during follow-up is search. extremely important using reliable and accurate indices such as radio-amnioassays of HCG for detect- 4. Coordinate all fertility and reproductive research ing choriocarcinoma in early stage. However, at this activities that are being conducted by scientists in the stage, the HCG assays is not available yet, but LH local universities and research institute. assay is being used and evaluated to monitor the natural history of trophoblastic diseases. This test 5. Collaborate and/or participate in the international proved to be important for early detection of chorio- research project undertaken by International Orga carcinoma and at the moment it is the only radio- nizations such as WHO, IFRP, JOICEF, ICARP, IDRP amnio-assay method available locally. etc.
Sivanesaratnam and Ng (1977) suggested pro- 6. The NFPB would play the role of subgranting agent phylactic use of methotrexate 20 mg given intra- for international funding agencies for all researches venously in 500mls of 5% detroxe solution at com- related to family planning. mencement, during and after surgical evacuation of hydatidiform mole. Of the 36 patients treated by this 4.2. Participation In biomedical Research regime and follow-up for three yeers or more none so far develop choriocarcinoma. All physicians and scientists from the following Institu tions. Another controversial area regarding molar preg nancy is on how long should the patient practice 4.2.1. The National Family Planning Board contraception after surgical evacuation of molar 4.2.2. Department of Obstetrics and Gynaecology, pregnancy and what isthe most appropriate method National University Malaysia. of contraception during these period. 4.2.3. Department of Obstetrics & Gynaecology, Uni versity Malaya. Most authorities believe that following hydatidiform 4.2.4. Maternity Hospitals Ministry of Health mole, patient should avoid pregnancy for at least 1 to 4.2.5. Institute of Medical Research 2 years. It has been found that if choriocarcinoma 4.2.6. University Science Penang were to develop following hydatidiform mole it is 4.2.7. Agriculture University Kuala Lumpur during the first two years. As regards to the most 4.2.8. Individual physician and scientist interested in suitable method of contraception, this issue is still reproductive research. very controversial. Many people believe that the use of oral pills is acceptable while others believe that 4.3. Implementation of biomedical research programme other methods such as intra-uterine contraceptive device or condom be used for contraception. It is estimated that the physical facilities for the Specialist & Medical Research Center would be fully completed by 3.5. Vasectomy 1983. The center would then have complete complement of a research laboratories namely endocrine, cytogenetic, In a study of the psychosexual after effects of Vasec- physiology, biochemistry, pharmacology and reproduc tomy (Wolfers, Subbiah & Ariffin, 1971) it was shown tive physiology laboratories. It would also have a com that not operative anxiety coordinated significantly with prehensive family health clinic which offer services related parity. Those with less than 4 children and only of one six to problems of contraception, infertility, marriage & sex (daughters) tend to express regret after the operation. counsel;ing and also genetic counselling. It would also be acenter for surgical contraception since it would have full Of t;;,6 problems quoted "general weakness" appears pro- facilities for day ward and surgery. Specialised training in minent and a few respondents were able to identify sexual family planning and human reproduction would be orga problems such as loss of libido as the undertrying factor. nised for all categories of staff including physicians and However the study also elucidated the fact that if detailed the para medics. It is emphasised that this center would pre-operative counselling was given Vasectomy could ultimately develop into an institute for fertility and repro remain acceptable. ductive research for Malaysia. When the center is completed, it will have full comple 4. Future Plans E Policies on Biomedical Research ment of staff with special training in family planning and
47 reproductive research methodology. The new speci.hity (d) review the action of research task force would enable physicians to be trained to become specia lists in family planning. The curriculum for training of 4.4.2. Research Task Force family planning specialists is being developed and the major component of this training programme would be This subcommittee consists of the Director and clinical based. A core of research scientists would also be the Assistant Directors of the Specialist Center created and they would consist of endocrinologists, bio- with representatives from the administrative and chemists, pharmocologists, reproductive physioloigists finance division and also the project and plan and genetitists who would be given special training on ning units of the NFPB. The main function of research methodology in human reproduction. These this task force is to look into the research pro scientists would formed the nucleus of fertility and re- posals particularly to its budgeting. Research productive researchers who will conduct research within proposals would then be submitted to the the premises of the specialist center and also coordinating Medical Advisory Committee for approval. research activities with other scientists in the universities and research institutes. 4.4.3. Research Grant
Since the Medical Research Center would take about five Under the 2nd Population Project, substantial years to establish, interim activities need to be organised allocation have been made for research grants. particularly pertaining to specialised services and bio- Local scientists and physicians who are interest medical research. At present, the reproductive com- ed in reproductive research could apply for these ponents in the Institute of Medical Research, Malaysia grant. The NFPB would fund research projects particularly the endocrine laboratory, the cytogenetic and up to maximum of $30,000 and those exceeding cytology laboratory are being strengthened by provision this amount are usually channelled out for Inter of additional equipment and trained staff to cater for the national Funding such as from UNFPA. research and service needs of the Specialist & Medical Research Center. 5. Some Constraints
Expertise in specialised family planning services and 1. One of the major constraints in planning and con medical research are gathered from ths local universities ducting biomedical research programme in human particularly the Department of 0 & G, University Kebang- reproduction is the shortage of trained manpower not seen Malaysia, University Malaya and also from the Gene- particularly physicians and scientists. Research is ral Hospital. The organizational set up of the medical re- attractive because of low financial returns and as a search component of the Specialist Center is in the chart result most of them move out to the private sector. phy (Appendix Ill). The Research Secretariat will have an The number of locally available scientists and epidiomologist or atrained medical statistician who would sicians already trained in reproductive research assist in preparing research protocol and data collection methodology isvery scanty indeed. and analysis as required by researchers. This secretariat moti would be linked very closely to the computer in the Re- It is the responsibility of the NFPB Malaysia to search Evaluation and management information division vate scientists and physicians to conduct reproduc of the NFPB. tive research and assist them in special training in research methodology, by provision of study grants 4.4. Areas of biomedical research or fellowships.
Some of the aspects to be covered in the biomedical 2. Laboratory facilities for biomedical research in human research are as follows: reproduction are grossly inadequate. The Institute of 1. Medical aspects of contraceptive technology Medical Research (IMR) Malaysia has limited faci 2. Biology of fertility and reproduction relevant to lities for reproductive work since its major role is in Malaysian population. providing laboratory backup services to government 3. Infertility and reproductive endocrinology hospitals in the Ministry of Health. Reproductive re 4. Perinatal and maternal mortality search has been given low priority. 5. Human sexuality in relation to marriage and sexual problems these laboratory facilities 6. Female genital cancer with emphasis on early detec- The NFPB is strengthening of additional equipments and staff to tion by provision cater for the needs in reproductive research. This Is 7. Abortions an interim measure before the Institute of Fertility and Reproductive research, NFPB is fully established 4.4.1. Medical & Research Advisory Committee in 1983. An Advisory Committee consisting of physicians 3. Reproductive research activities had been hampered who are interested in family planning researches, by lack of finance. There was no national body that social scientists and basic scientists with special would finance research projects. Prior to 1979, the interest in human fertility and reproduction, has NFPB only allocated $15,000/- in its budget for been formed to advise the NFPB on various medical research but this has been beefed up to matters: about $1 million for the next 5 years. This is not in (a) indontifying areas requiring biomedical re- cluding financial allocations from external funding search agencies. (b) identifying research priorities the Universities of Malaya (c) advice on ethical aspects of research 4. Academic institutions like
48 and Kebangsaan have in the past placed medical It can no longer be denied that contraception/reproduc research as low priority whilst they are developing tion/Fertility research must be given high priority in pro and consolidating the undergraduate teaching pro- gramme development especially in view of the fact that the grammes. However, the two local medical schools national programme is now 13 years old arid the emphasis in are in the stage where they are more prepared to contraceptive usage has always been on the hormonal contra participate actively in reproductive research. The ceptives. The lack of hormonal research supports, if allowed to department of Obstetrics and Gynaecology University continue will be detrimental for the programme as awhole. As of Malaya had been inthe past fairly active in contra- there is continuing new evidence on the possible 'danger' of ceptive technological research, however, most of the hormonal contraceptives especially for long term use, the their works are mainly clinical trials, need to look for other 'alternatives' is now evident. There is also a need to determine the duration of use to ensure com CONCLUSION pletes "safety". In addition studies must be carried out to develop locally available and 'acceptable' contraceptives The establishment of the Institute of Fertility and Repro- which could be easily and safely used. ductive Research under the NFPB Malaysia would act as sti mulus to the scientists and academacians to participate in The scope for contraceptive/Reproductive/Fertility re research particularly with the availability of Research labora- search to Malaysia is indeed very broad. The success of pre tory facilities, research grants, study fellowships, financial sent efforts would indeed support the total national pro support for attendance in international Congresses and se- gramme as well as provide a broadening scope of activities for minars and infrastructure for supporting researches. all levels of workers and researches inthe field.
APPENDIX I
LIST OF SOCIO DEMOGRAPHIC SURVEYS
1. West Malaysian Family Survey 1966/67 13. Study of Social Factors Affecting Fertility 2. Acceptor Followup Survey 1969 14. Analysis of Inter-relationship between Social Political and Economic Goals 3. Post Enumeration Survey 1970 15. Analysis of Inter-relationship of Composition Labour 4. Malaysian Family E Fertility Survey 1974 Force between Population Growth, Age, Employment and Economic Development 5. Staff Baseline Survey of Intensive Input Demonstration Areas 1975 16. 3rd. Malaysian Family Survey 1982/83 6. Family & Health Survey in the Intensive Input Demon- 17. Defaulters Survey inThree East Coast District 1971 stration Areas 1976 18. Summary Report on Rate of Acceptors Having Multiple 7. Family & Health Survey in the Federal Territory and Acceptance and rate of Mjltiple Acceptance 1972 Petaling Jaya 1977 19. Evaluation Summary of Family Planning Performances by 8. 2nd. National Acceptor Followup Survey 1977 Main Clinic 1972 9. Match Acceptor & Non Acceptors Birth Rates 20. Ranking of Coverage Performance of NFPB Clinic by State and District 1972 10. Analysis of Cultural Factors Affecting Fertility from Past Survey Data 1977/78 21. Assessment of Family Planning Programme Effects on Birth 1972 11. Pilot Survey on Cultural Factors Affecting Fertility 1978 22. Continuation Rate of Acceptors Using Injectables in Sg. 12. 2nd. Family E Health Surveys IIDA 1978/79 Besar 1976
APPENDIX II
LIST OF PREVIOUS MEDICAL RESEARCH IN FAMILY PLANNING
1. ABORTION PU VAN, I.S. (1974) Psycho-social aspects of abortion in Malaysia, Proceed ARIFFIN, Marzuki and THAMBU, Johan A.M. (1971) ings of the Asian Regional Research Seminar in Psycho- Septic abortion. Medical Journal of Malaysia 26: 2 (77- Social Aspects of Abortion, Nepal. (pp. 56-62) 83) SINNATHURAY, T.A. (1975) HAMID, Arshat (1977) Pregnancy and abortion inadolescence, report of a WHO Extra-amniotic prostaglandin E2 and intravenous oxytocin meeting (WHO Technical Paper No: 583) in termination of mid-trimester pregnancy and in the management of missed abortion and hydatidiform mole, THAMBU, Johan A.M. (1975) Med. J. Malaysia 31:3, 220-225 Abortions - Government Hoopitals Peninsular Malaysia 1960-1972, Medical Journal of Malaysia 24:4 (258-262)
49 THAMBU, J.A.M (1974) TAN, E.H. 119721 Injury to small intestine in induced septic abortions, Pro- Intra-uterine contraceptive device causing ante-partum ceedings 6th Asian Congress of Obstetrics &Gynaecology haemorrhage, Asian Journal of Medicine 8: 67-69
2. FERTILITY It STERILITY GOH, T.H. at al (1978) Early experience with the copper-7, copper T220c and PUVAN, I.S. (1973) multiload 250 intra-uterine devices, Medical Journal of Varicocele and male infertility, Proceedings of 8th Singa- Malaysia 32:4 (304-307) pore, Malaysia Congress of Medicine, 8: 242-244 4. INJECTABLES Investigations of an infertile couple, Family Practitioner 1:2 (16-18) ARIFFIN, Marzukl, HEW Wal Sin, J.Y. Peng 11973) A field study of Depo-Provera: Its use as a contraception HAMID, Arshat (1979) method by women in a rural town in West Malaysia, Management of infertility, Scientific Meeting, Penang Medical Journal of Malaysia, 27: 299-305
Evaluation of various techniques in tubal plastic surgery 5. ORAL CONTRACEPTIVES for infertility - Malaysia and Singapore Congress 1978 WONG, W.P. and I.S. Puvan (1978) 3. INTRA-UTERINE DEVICES Current status of oral contraceptives, Medical Journal of Malaysia, 30:173-177 ARIFFIN, Marzuki (1964) Clinical use of the nylon coil in lpoh, Malaysia Proceed- SINNATHURAY, T.A. (1976) ings 2nd International Conference intra-uterine contra- Recent trends and advances in contraceptive technology ception, New York 1964 and its applicability in the reduction of fertility in the Malaysian context, National Seminar on Fertility Planning CHONG, H.L. and NG. K.H. (1974) Towards Achieving Greater Social and Economic Pro Problems and management of pregnancy with IUCD gress, Kuala Lumpur lodged at the cervical canal, Asian Journal of Medicine, 10:248-249 SINNATHURAY, T.A. (1974) Human reproduction and recent advances in contracep LOURDENADIN, S (1964) tion 1974 UNESCO Report of a Seminar on Population Experience with Brinberg's intra-uterine device in Kuala Problems (pp. 40) Lumpur, Proceedings 2nd International Conference on Intra-Uterine Contraception, New York 6. OBSTETRICS 8 GYNAECOLOGY
LOURDENADIN, S (1966) CHEAH, S.F. 8 Khalruddln Yusuf (1973) Evaluation of intra-uterine contraceptive devices, Medical Prostaglandin F2 alpha for induction of labour, Medical Journal of Malaya 19:277-285 Journal of Malaysia, 27: (211-216)
PUVAN, I.S. V. Sivanesaratnam and T.A. Sinna- HAMID, Arshat (1977) thuray (1974) Clinical applications of serum FSH estimation by radio An evaluation of Cu7 IUCD in Malaysian women, Hand- immuno assays, Proceeding of Asian Congress of Obste book of 6th Asian Congress of Obstetrics and Gynaeco- trics and Gyneecology 1977. logy, Kuala Lumpur (pp. 212) Comparison of oral and intravenous glucose tolerance Pregnancy associated with copper containing IUD, British tests in the diagnosis of diabetes in pregnancy, British Medical Journal 2: (561) Journal of Obstetrics and Gynaecology 85: (536-546)
SAMBHI, J.S. (1968) Comparison of oral and intravenous glucose tolerence The concept of the action of the IUD in the human, Far tests in third trimester of pregnancy. Medical Journal of East Medical Journal 4: (346) Malaysia 31: 2, (133-139)
SIVANESARATNAM, V and I.S. Puvan (1975) HAMID, Arshat (1978) Asymptomatie perforation of the uterus with the copper-7 Danazol: treatment for endometriosis, Scientific Meeting IUD and its management, Singapore Medical Journal 16: Sungai Petani, 1978. 312-314 Foetal distress and labour monitoring, Scientific Meeting SIVANESARATNAM, I.S. Puvan and Sinnathuray in Kota Bharu, 1976. T.A. (1975) Evaluation of copper-7 intra-uterine in Malaysian women, HAMID, Amhat (1978) Medical Journal of Australia, 2: pp. 298-301 Lactation and Fertility regulation, Annual General Meet ing of Obstetrics and Gynaecology Society Malaysia, 1978 SIVANESARATNAM, V, I.S. Puvan 8 D.K. San (1974) The symptomatology and diagnosis of endometriosis: a Pregnancy associated with copper containing IUD, British review of 76 cases, Majallah Obstetrics and Gynaecology Medical Journal, 2:561 4:3 Indonesia
50 KHAIRUDDIN, Yusof (1973) ing Country. Proceedings of 8th Singapore Malaysia Hydatidiform mole: problem in early diagnosis, Medical Congress of Medicine, 8. 254-256 Journal of Malaysia 27: (pp. 275-279) CHAN, W.F. Puvan I.S. and Sinnathuray T.A (1974) Prostaglandin F2 alpha for induction of labour, Medical Laparoscopic sterilization: The Malaysian experience, Journal of Malaysia 27: (211-216) Handbook 6th Asian Congress of Obstetrics & Gynae cology, Kuala Lumpur, July 1974. (pp. 190) NG. K.H. and Prathap, K. (1975) Intestinal leiomyosarcoma simulating malignant ovarian HAMID Arshat (1979) neoplasm, Journal of International Surgery, 60: (237- Towards better success in tubal plastic surgery (Malaysia 238) and Singapore Congress 1978
NG, K.H. et al (1974) KUAH, K.B. 11976) Longitudinal studies of amniotic fluid lecithin and Vasectomy. Medical Journal of Malaysia 31:1 (26-32) sphingomyelin values during normal pregnancy, Proceed ings 6th Asian Congress of Obstetrics & Gynaecology, LEE, T.T. (1971) Kuala Lumpur (pp. 174-175) A modern incision for postpartum sterilization, Handbook of the 5th Asian Congress of Obstetrics & Gynaecology NG, K.H. Wong W.P. Et Chai K.H. (1974) (184) Trimethoprim sulphamethoxasole in the treatment of infection in Obstetrical and Gynaecological practice: a NG, K.H. and Wong Wai Pang (1974) bacteriological and clinical study, Medical Journal of Postpartum tubal ligation under epidural block, Proceed Malaysia, 28: (260-262) ings of 8th Singapore Malaysian Congress of Medicine, 8: (300-3r2). SEN, D.K. St al (1974) Hemoperitoneum and defribination in gynaecology, Inter- PURAVIAPPAN, A and I.S. Puvan (1974) national Journal of Gynaecology & Obstetrics 12: 124 The anatomical and physiological aspect of vasectomy, Medical Journal of Malaysia 29:1 (64-65) SEN, D.K. T.A. Sinnathuray and K.S. Lau (1973) The ultrastructure of molar trophoblast, Australian New Vasectomy for population limitation, Medical Journal of Zealand Journal of Obstetrics & Gynaecology 13: (pp. 35) Malaysia, 29: (230)
SEN, D.K. (1974) PUVAN, I.S. (1974) Ultrastructure of molar trophblast in mitosis, Australian A long term study of the effects of sterilization in Malay & New Zealand Journal of Obstetrica & Gynaecology 14: sian women, Proceedings of 6th Asian Congress of (235-7) Obstetrics &Gynaecology, Kuala Lumpur.
SINNATHURAY, T.A. (1974) Comparison of the use of local analgesia and epidural Current views of the management of pregnancy toxaemia block in post-partum tubaligation, Handbook of 9th and eclampsia, Proceedings of the Obstetrical and Gynae- Malaysian Singapore Congress of Medicine. cological Society, Vol. 5: (pp. 57-59) Laparoscopic sterilization: The Malaysian experience, SINNATHURAY, T.A. (1975) Proceedings of 6th Asian Congress of Obstetrics and Hormonal therapy in Obstetrics & Gynaecology, Family Gynaecology, Kuala Lumpur. Practitioner 2:1 &2 (40-42) Reversible tubectomy, Proceedings 6th Asian Congress PONNUTHURAI, C.E. and J.C. White (1971) of Obstetrics and Gynaecology, Kuala Lumpur (pp. 320) Hydrops foetalis due to alpha thalassaemia: a case report, Medical Journal of Malaysia, 26: (pp. 102-108) Vasectomy for population limitation, Medical Journal of Malaysia 28:251-254 SINNATHURAY, T.A. (1971) Ovarian tumours in ,jregnancy, International Surgery, 55: PUVAN I.S. (1973) (422-430) The place of laparoscopic tubal sterilization in adevelop ing Country, Proceedings of 8th Singapore - Malaysia The pattern of the pathology of ovarian tumours in preg- Congress of Medicine, Kuala Lumpur nancy in the Singapore - Malaysia region, Medical Journal of Malaysia, 26: (pp. 53-56) SIVANESARATNAM, V. at al (1974) A Ic' .g term study of the effects of sterilization in Malay SINNATHURAY, T.A. (1976) sian women, Proceedings 6th Asian Congress of Obste Use of oral prostaglandin E2, tablets in the induction of trics & Gynaecology (pp. 339-343) labour Handbook Congress of Medicine. SWANESARATNAM, V. (1975) WONG, Wal Pang "Delayed small bowel perforation following laparoscopic Sperm antibodies in fluids of reproductive tract. nd. tubal cauterization", International Surgery 60: (pp. 560 561) 6. STERILIZATION Tubal pregnancies following postpartum Sterilization CHAN, W.F. and Puvan I.S. (1973) Fertility and Sterility, 26: (945-946) The Place of Laparoscopic tubal sterilization in a develop
51 THAMBU, Johan A.M. (1970) Copper T outured at Maternity Hospital, Kuala Early discharge of female sterilization cases, Proceedings Lumpur Inter Regional Seminar on Family Planning, Bangkok 6. Depo-provera study - menstrual pattern at Specia lists Centre and University Hospital Clihic of NFPB THAMBU, Johan A.M. and ARIFFIN Marzuki (1971) 7. IUD photo-reduced Lippes Loop at NFPB, Kuala Female sterilization by culdoscopy, Medical Journal of Lumpur Malaysia 26:2(120-121) 8. Maternity care monitoring - delivery records bv Traditional Birth Attendants (Pretesting done) WONG W.P. Ng K.H. and I.S. Puvan (1975) 9. Delivery records by physicians at Maternity Hospital Puerperal sterilization: comparison of the use of local Kuala Lumpur anaesthesia and epidural lumbar anaesthesia, Medical Journal of Malaysia 29:4 (293-298). 10. ONGOING RESEARCH STUDIES OF NFPB MALAY- SIA ALONG WITH VARIOUS ORGANISATIONS 7. TROPHOBLASTIC DISEASES 1. IUD Study - post insertion management KHAIRUDDIN Yusof (1973) Coordinators: Dr. Mahroof - University Ke- Hydatidiform mole: Problems in early diagnosis Medical bangsaan Journal of Malaysia Z: 4 (275-279) Dr. Solai Velayudham - NFPB
SEN D.K. E T.A. Sinnathuray (1973) 2. Evaluation of Condom Usage The ultrastructure of molar trophoblast, Australian New Coordinators: Dr. S.K. Teoh - University of Zealand Journal of Obstetrics and Gynaecology 13:35 Malaya LPKN Clinic at University Hospital SEN, D.K. (1974) The ultrastructural appearance of molar trophoblast in 3. IUD Study - small frame gravigard metaphase, Australian New Zealand Journal of Obstetrics Coordinator: Dr. E.S. Ang Gynaecology, 14:235 4. Sperm antibodies in fluids of the human female re- SIVANESARATNAM, V & Ng. K.H. (1977) productive tract Prophylaxis against choriocarcinoma, Medical Journal of Coordinator: Prof. W.P. Wong, University of Malaysia 31: 229-231 Malaya
SIVANESARATNAM, V (1976) 5. Laparoscopic sterilization study Transient hyperthyroidism complicating hydatidiform (a) as out-patient procedure mole, New Zealand Medical Journal, December 8, 1976 (b) comparative study (cautery/fallope rings/clips) Coordinators: Dr. Hamid Arshat 8. LIST OF RESEARCH STUDIES COMPLETED AT THE Dr. Mahroof NFPB, MATERNITY HOSPITAL CLINIC Dr. E.S. Ang 1. Ovostat study (1970) 2. Q1 - 02 Once amonth pill (1970) 6. Changes in coagulation profile of contraceptive pill 3. Acceptor Followup study (1967-70) users in Malaysia 4. Exluton mini pill trial (1972) Coordinators: Dr. H.C. Ong 5. Amenorone forte (1972) Dr. Elizaberth George of National 6. Neogynon pill trial (1972) University 7. Yermonil pill trial (1976) 8. Nordette Study (1976) 7. Establishment of sperm bank 9. Pap-smear study (1975) Coordinators: Prof. W.P. Wong and Prof. Khai 10. Copper 7/Lippes Loop Study (1977) ruddin Yusof of University of 11. 3 months followup of Provisional Acceptors in Post Malaya Natal Words (1978) (in the process of procuring equip 12. Albothy concentrate and vaginal suppository (Meta- ments for an immuno-essay cresolsulfaric acid and formaldehyde) study (1978) laboratory) 13. Sagami Condoms study (1978) 14. Injection Norigest study (1975) 8. Psychosexual profile of Malaysian women: a study 15. Injection Norigest study (1978) of human sexuality Coordinators: Prof. Khairuddin Yusof 9. STUDIES IN PROGRESS AT NFPB WITH COOPERA- Dr. E.S. Ang TION FROM INTERNATIONAL FERTILITY PRO- GRAM 9. Morning after pill - 600mg d-Norgestral Coordinators: Dr. C.K. Poh 1. Progestogen - only pill for lactation study at NFPB Dr. E.S. Ang Clinic, Kuala Lumpur 2. High-dose to low-dose crossover study at NFPB Clinic, Johor Bharu 11. ONGOING PROJECTS ATUNIVERSITYOF MALAYA 3. Low-dose vs low-dose comparative study at NFPB Clinic, Kota Bharu 1. Use of pewter as a material for IUCD 4. Post-partum, IUCDs - Lippes Loop 'D' vs satured 2. Techniques of reversible tubal ligation Lippes Loop 'D' at Specialists Centre, NFPB 3. Sperm agglutination and sperm antibodies in fertile 5. Post-partum IUDs - Lippes Loop 'D' outured vs and infertile women
52 4. Vasectomy: accepta.ice, side-effects etc. in local 2. Mini-laparatomy: a female sterilization as a clinic population procedure 5. Testing of Lau pregnancy diagnostics 3. Perinatal Project - to identify the following: 6. Evaluation of PIEGO double ring applicator (a) Identification of risk factors of morbility and 7. Evaluation of menstrual regulation mortality in maternal care 8. Evaluation of interval laparoscopic sterilization with (b) Identification of perinatal risks monitoring Silastic ring measurement of high risk pregnancy and labour 9. Evaluation of.Laparoscopy - second puncture - (c) Early identification and management of con- Silastic ring - immediate versus 24 hours post genital magormationri. abortal (d) Neonatal screening for mortality and morbidity 10. Prospective study of an induced abortion in West (e) Breastfeeding promotion in order to reduce neo- Malaysia (Study of Hospital Resources involved) natal morbidity 11. Metabolic effects of the pill on local population 12. Comparison of varirus IUCD 4. Evaluation of fallope ring for female sterilization 13. Field trial comparifon of injectables laparoscopy and mini laparotomy method 14. Field trial comparison of low-dose pills 5. Pattern of congenital abnormalities (Maternity Hos 15. Comparison of laparoscopy, mini-laparotomy and pital Kuala Lumpur) culdoscopy 6. Human sexuality (University Malaya) 7. Oral contraceptive agents and hypertension (National 12. ONGOING PROJECTS AT SPECIALISTS CENTRE, University of Malaya) NFPB, MALAYSIA 8. Use of Panstan, Baralgin and Endocid in controlling pain due to IUCD (Researcher: Dr. Mahroof Hj. 1. Evaluation of induction of ovulation Mohideen)
APPENDIX III
ORGANISATIONAL CHART
SPECIALIST AND MEDICAL RESEARCH CENTRE
NATIONAL FAMILY PLANNING BOARD MALAYSIA
MEDICAL RESEARCH%"SERCH Epidem
SRESEARCH ADVISORY COMMIEE I I I!Basic Sciences RESEARCH TASK FORCE (Executive) ______n__ __ ca ______
A LA Y A S RIX U N IV ERS ITY M AND AGENCIES ]CLINICIANS I - IFRP/IFFHR S]EPIDEMIOLOGIST/" SCIENTISTS NATIONAL UNIVERSITY STATISTICIAN (1) - WHO - UNFPA UNIVERSITY SCIENCE - JAPAN EPIDEMIOLOGIST/ PENANG MEDICAL SECRETARY- etc. SOCIOLO- E
RESEARCH ASST S COMPUTER LINKAGE GOVERNMENT HOSPITALS (6) TO REMIS DIVISION
OTHER
53 PAPER 10
NEPAL
Country Paper
Although MCH programme in Nepal was started quite clinics, community based workers, mobile clinics and camps. early, that is, since the beginning of the hospital-era, like 'The community based worker bring services to the doors of family planning, this programme was also expanded sub- the rural population. Mobile camps are special feature of Nepal stantially with the inception of NFP & MCH Board in Nov., and they have proved highly effective over the last few years. 1968. Before this period FP and MCH Programme in Nepal The laparoscopic camps are gaining great popularity. As these was only centred within the valley and few other cities of surgical methods are permanent and have an effective impact Nepal. over ten years of potential fertility, the provision of surgical services, as close to the home of the acceptor as possible, Initially the FP component was linked with the MCH sec- encourages these methods. A recent study of acceptors tion of Department of Health, with the understanding that if characteristics has shown that average contraceptive user is the mother and child care is adequately provided, people will 32.0, 31.5, 30.4, 29.4, and 30.4 years of age respectively for tend to accept the contraceptives. Since then this basic phiho- vasectomy, laparoscopic sterilisation, Depo-provera, IUD and sophy continues with FP and MCH components beiiig cairied pills, similarly the average user accepts family planning ser out together and by the same organiz.ton NFP/MhCH Project. vices only when he/she has 4.7, 4.4, 3.6, 3.0 and 3.5 children This has helped to increase the willingness of mother to prac- respectively. tice FP. During the current five year plan the project aims to reduce the estimated C.B.R. of 40 per 1000 to 38 per thousand At present time, family planning information and contra and at the same time it also aims at reducing ,he estimated ceptiv) services are being provided by a number of different infant mortality of 200 per 1000 to 150 per 1000 live fifth at the government, non-government, and voluntary organizations end of the plan period and FP target is to recruit 140,000 new and agencies such as the Nepal FP/MCH Project, the Inte acceptors annually. This (reduction in infant mortality), the grated Health Service, the Family Planning Association of project hopes to achieve by providing services to under-fives Nepal, and the Nepal Women's Organization. through its different service points. More over two types of activities are carried out viz curative i.e. offerin2 traatment to The Nepal Contraceptive Retail Sales (CRS) Project is a under-fives and preventive i.e. carrying out immunization ion-profit programme developed by His Majesty's Govern services such as small-pox, B.C.G. and D.P.T. as well as the ment of Nepal's Family Planning a Maternal and Child Health nutrition programme, rehydration activities, health education. Project to commercially distribute contraceptives throughout Nepal in order to encourage more people to practice family The available family planning methods offered by the pro- planning. gramme are pills (Norinyl 1.50 or 1.80), IUD like L. Loop, Saf. T Coil of varying sizes, injectable contraceptives D MPA dose The goal of the Nepal CRS Project is to distribute two of 150 mg given once in 3 months, condoms, vasectomy, contraceptive products - condoms for men and oral pills for laparoscopy and minilap. Since the inception of the FP pro- women - through existing retail outlets under the brand name gramme, total number of women who adopted pills and IUD like - DHAAL (Shield) for the condom, and GULAF (Rose) are 258835 and 15,529 respectively while the number of men for the pills. who used condom and vasectomy operation are 539,907 and 65,054 and the number of women who accepted laparoscopic Since the actual distribution of Dhaal and Gulaf began operation are 20,684 (achievement by method and year Table from June, 1978, the Nepal CRS Project has been expanding 1). its distribution to different part of Nepal. So far it has covered seven major urban areas of Nepal and the programme will The services are provided free of cost, to the needy popu- gradually expand to smaller villages inthe hills and terai. lation. The principle mode of service delivery has been through
54 Pill to developing countries like Nepal. Lack of effective media have paved way to the rumors initiated by some From the inception of the family planning programme in disatisfied users which seriously effects the new users. In Nepal, contraceptive pill has been available as a popular this connection communication barrier must be broken to method of family planning among the Nepalese women. In achieve programme effectiveness. comparison to other methods it is the second most popular method of family planning. Until FY 1977/78 atotal of 226,212 As shown by various studies, the mean age of pill accep women have ever used the pill. It is also important to point out tors was found 30 years at the time of acceptance, whereas that there has been neither asharp increase nor decrease in pill from the acceptors follow-up survey the mean age was found acceptors for the last seven or eight years. Each year approxi- to be 32 years. It is quite obvious that the survey covered the mately one-third of all new acceptors are pill users and this pill acceptors who accepted the method about 2 years before percent has remained relatively constant suggesting that there the survey was carried. may have been alevelling off of new pill acceptors in relation of other methods. Indeed, Table 2 indicates tha( since 1972/ The number of living children of the pill acceptors remain 73, there has been aslight decline in the percent of new family ed almost constant at 3.6. At the time of the survey 2 years planning acceptors who use pill from 37 percent to 25 percent. later they had a mean of 3.9 living children. As with number of living children, the mean number of living sons of pill accep It is surprising that recently there has been a drop in the tors has also remained almost constant at 2.0 and increased to proportion of pill users. Pill users used to constitute about 37% 2-1 at the time of survey. of the total FP users but currently they constitute only 25% of illiterate the total FP users. A look at the total pill acceptor figure shows It can be seen from Table 3 that more and more a slight increase over the previous year but relative to other females are accepting pills. On the whole, over three-fourth of of contraceptive users the increase is very small. Although no the pill acceptors were illiterate. Regarding the occupation studies have been conducted to find out as to the reasons for the acceptor's husbands, 71 % were reported to have been the decrease in the proportion of pill users it is hoped that engaged in agriculture. currently on going National Acceptors Survey could provide some explanation to it. Some possible reasons could be as The continuation rates of pill acceptors at the end of cer follows: tain length of time is an important index of measuring the effectiveness of the programme. It was found in the National 1973-74 that 1) A dramatic increase in the number of condom users and Follow-up Survey of Family Planning Acceptors pill acceptors at the same time small though significant increase in the at the end of one year, the continuation rate of as well as the D.P. users. This has been in- was 36.7% which is a little lower than the continuation rate of sterilisations The creasing so with the opening of the panchayat based pill users in Korea in 1968, (38% at the end of one year). months are where FP service is provided by field workers with continuation rate at the end of 24 months and 36 centres continuation relatively inadequate clinic background. respectively 19.8% and 13.2%. In Korea also the rate of pill users at the end of 36 months was 12%. In Nepal a high dose pill is currently being used. It has 2) 2, Popu been shown that high dose pill have beer associated with -1 United Nations, country monograph Series No Bangkok, Thai relatively large number of side effects especially its effects lation of the Republic of Korea, ESCAP, on lactation and nutrition status of the user is not suitable land, 1975, F. 215.
TABLE I - FAMILY PLANNING PROGRAMME ACHIEVEMENTS, NEPAL, 1966167 - 1977/78 R IUD Vasectomy Pill No. of Condom No. of Laparos Depo- Total Methods: copic provera Couples E acceptors acceptors acceptors pill cycles acceptors Condom (New) M (for the (New) distributed {New) distributed acceptors R first time) Fiscal K Year S
1852 1806 N.A. 13 13 33 495 - - 1966-67 - 5132 1967-68 2614 1062 200 1203 1256 113130 - - - 7744 196R-69 1183 3292 1255 8133 1914 172260 3888 10263 36329 14480 227636 - - 29740 196t- 70 1109 37433 711 4441 13496 62865 18785 327098 - - 1970 -71 - 43838 -72 1162 3900 15868 86831 22908 479326 - 1971 - 65095 1972-73 607 4161 24056 125173 35713 725016 558 5166 27141 202590 52075 1233624 810 25 86079 1973-74 862 98312 1110 3702 26943 197061 65814 1207731 662 81 1974-75 152 138634 1635 9169 37640 254311 87876 1333425 2162 1975-76 976 126532 1976- 77 1149 10953 33250 266594 74782 1929975 5422 7470 1690 146635 1977-78 863 8443 35987 273607 92182 1923417 Total up to 2924 787026 1977 -78 14811 58177 226212 1514715 467818 9673133 17084
Source. NFP/MCH Project, Evaluation Division, Various Reports.
55 TABLE II- CONTRACEPTIVE MIX IN A GIVEN YEAR: PERCENT OF ALL NEW ACCEPTORS
USING A PARTICULAR METHOD
Percent Using
Year IUD Vasectomy Pills Condom Laparscopy Depo- Total Number Provers Percent of New Acceptor
1966/67 97.5 - 0.7 1.8 - - 100 1,852 1967/68 50.9 20.7 3.9 24.5 - - 100 5,132 1968/69 15.3 42.5 17.5 24.7 - - 100 7,744 1969/70 3.7 13.1 34.5 48.7 - - 100 29,740 1970/71 1.9 11.9 36.0 50.2 - - 100 37,433 1971/72 2.6 8.9 36.2 52.3 - - 100 43,838 1972/73 0.9 6.4 36.9 54.9 0.9 - 100 65,095 1973/74 1.0 6.0 31.5 60.5 0.9 0.1 100 86,079 1974/75 1.1 3.8 27.4 66.9 0.7 0.1 100 98,312 1975/76 1.2 6.6 27.1 63.4 1.6 0.1 100 1,38,634 1976/77 0.9 8.6 26.3 59.1 4.3 0.8 100 1,26,532 1977/78 0.6 5.8 24.5 62.9 5.1 1.1 100 1,46,635
TABLE III - CHARACTERISTICS OFTHE PILLACCEPTORS BY YEAR OF ACCEPTANCE
Characteristics Occupation of Spouse
Year Sample Mean No. of living No. of living Literacy Agriculture Non- Size age children sons Illiterate Literate agriculture
1970-71 (a) 9458 29.7 3.4 1.9 72.2 27.8 1971 -72(a) 10829 29.9 3.6 2.0 75.5 24.5 1972-73(a) 1843 30.0 3.6 2.0 77.8 19.7 1973-74(a) 2015 30.0 3.6 .0 78.8 1.5 1975-76(b) 2712 30.3 3.6 2.0 3.5 16.5 71.0 29.0 1973-74(c) 692 31.9 3.9 2.1 2.0 1.0
Sources: (a) Joshi, P.L., Evaluation System of the Family Planning Programme in Nepal, Proceeding of the Workshop Conference on Population. Family Planning and Development in Nepal. Berkeley, California, Aug. 24.29. 1975. P. 223.
(b) NFP/MCH Project, Evaluation Division, Socio-Demographic Characteristics of Family Planning Acceptors during 1975-76.
(c) A Report or National Family Planning Acceptors Follow-up Survey 1973-74, Kathmandu Nepal, 1976.
Side effects reported by Pill users: threatening. Those side effect respond to treatment and seem to be reduced with reason and good follow-up. No clinical In Nepal, different types of oral contraceptive pills have research have so far been conducted in order to find out the been available from time to time. Among these were, OVULEN short term as well as long term health risks associated with the Fe-28 Ovral, Lyndol and Demulen Fe-28. But for the last 4-5 pill in the Nepalese women. Experience has shown that most years, Norynil Pill is being used. A National Family Planning contraceptives have given rise to different degrees and pattern Acceptors Follow-up Survey was conducted by FP/MCH Pro- of side effects and complications. And the research conducted ject in 1973/74. The major side effects reported by the Pill in different countries have clearly indicated that the oestrogen users in that study were, giddiness, headache, loss of appetite content of the pill tends to increase the blood clotting and also and bleeding. long term usq of oral is associated with increased risk of heart attack and hypertension. This creates a grave concern to us Many women discontinue using the pill because of so although it has been mentioned that the proven risk of orals called side effect which, though, trouble-some are not life are considerably less than the risk of unplanned pregnancy.
56 In a developing countries like Nepal the problem of mal- Nepal, IUD was very popular. Table 1 shows that there was nutrition is relatively severe. More over virtually all the mothers one-third increase in IUD acceptors between 1966-67 and lactate their babies. Studies, carried out both in the developed 1967-68. In the later years, the new IUD acceptors declined and developing countries have shown that the low dose com- by over 50%. This may be due to the major side effects pro bination pill is associated with lower side effects than the high duced by IUD. With the result that new IUD acceptors con dose ones. Moreover some of these studies have shown that tinued to be very low until. Table 2 shows that IUD acceptors low dose combination pill have an edge over the high dose have declined to the point where they constitute an insigni ones with respect to lactation and nutrition. Although no such ficant percentage of new acceptors approximately one percent studies have been carried out in Nepal as yet, it seems that low of the yearly total. To boost up the IUD acceptors, the FP/ dose pill is suitable for Nepal. It is suggested however, that MCH Project started a training programme for senior public before the full scale availability, a pilot study in limited area be health nurses and staff nurses for IUD insertion. carried out to sort out some of its culture-boond side effects.
Characteristics of IUD Acceptors: IUD The characteristics of these acceptors can be seen from In the beginning of the family planning programme in Table 4 below.
TABLE IV - CHARACTERISTICS OF IUD ACCEPTORS BY YEAR OF INSERTION
Characteristics Literacy Occupation of Spouse Year Sample Mean No. of living No. of living Illiterate Literate Agriculture Non Size age children sons agriculture
19 70-71 (a) 493 30.9 3.9 2.2 75.5 24.5 197 1 -72(a) 422 30.2 3.7 2.2 68.2 31.8 1972-73(a) 490 30.5 3.8 2.2 65.1 34.9 1973-74(a) 688 30.4 3.6 2.0 62.5 37.5 1975-76(b) 399 29.2 3.5 1.9 61.6 38.7 37.6 62.4 19 73-74(c) 101 30.2 3.9 2.1 67.3 32.7 49.5 50.5
Sources: Ial Joshi, P.L., op. Cit. p. 223. (b) NFP 1 MCH Project op. cit. (c) op. cit.
As with pill acceptors, the mean age of IUD acceptors Side effects reported by IUD users: was also between 30 to 31 years. The mean number of living children of IUD acceptors has decreased from 3.9 in 1970-71 The major side effects reported by IUD users in National to 3.5 in 1975-76. Similarly the mean number of living sons Family Planning Acceptors Follow-up Survey 1973/74 were has also decreased from 2.2 to 1.9 during the same period. As bleeding, weakness and giddiness. far as the literacy of the IUD acceptor is concerned, in the year 1970--71, over 75% of the females accepting the IUD were illiterate. The proportion of illiterate females accepting IUD has Abortion been declining continuously and in 1975-76, a little over 60% of females accepting IUD were illiterate. A lower proportion of The practice of abortion has probably existed for many husbands of IUD acceptors were engaged in agriculture occu- years. Without the availability of reliable satistics, it is not pation. possible to give any guide on whether the incidence of induced abortion is increasing or decreasing. As in any developing countries in Nepal too, illegal abortions are performed either Regarding the IUD acceptors, their continuation rate was by trained medical personnel or by untrained indigenous mid found to be higher. As noted in the National Follow-up Survey wives. The tradilised method used by indigenous midwives of Family Planning Acceptors 1973-74, 34.3 percent of the to perform abortion are varied. IUD acceptors discontinued use 12 months after first insertion and half of the IUDs inserted were in situ 24 months after first (1) By introducing medicated stick into the cervix. insertion. The discontinuation rate of IUD acceptors 12 months after first insertion was 43 percent in Korea in 1969 (2) By uterine massage. and this proportion increased to 51 percent in 1971. (3) Cooked alum and bamboo bark if taken for 5 - 7 days continuously. Though the proportion of women wearing IUD in Nepal is low, nevertheless, the continuation rate of IUD acceptors (4) The seed oil of ricinus communis linn (Euphorbraceae) is in Nepal is higher than in Korea. used for abortion.
57 (5) Potentilla peduncularis D. Don (Ros a cool) plant bark is Kathmandu valley, about 550 cases of incomplete and septic powdered and given to pregnant women. abortion are dealt with every year. All of the hospitalised cases are married women of upper socio economic class who simply (6) Abromo angustic (Aloes) level are used as abostificient. want to limit the size of the family. Widow mother or widows do not seek hospital care for complications. They are the ones (7) Plumbugo Zedomica stick is used as abostificient. who terminate their pregnancies at whatever risk obtaining I their abortion mostly from unqualified personnel for essentially (8) By introducing metal catheter into cervix and then push- social reason. At the same time must couples rely on the con ing nearly 5 cc of mixture of premasin glycerine and little dom, which has a high rate of failure. Vasectomy, though con Acriflavin within 12-48 hours abortion takes place. sidered as afailure method has a high failure rate. When these means fail, the women seek abortion. Although no clinical Other methods of abortion used by trained personnel are studies have been conducted to estimate the complication rate as follows: it is indicated from hospitalised cases that illegal septic abor tions continue to the leading causes of maternal morbidity and (a) By introducing laminaria tents, mortality, commonest causes of death being the haemar (b) By menstrual regulation shage, tetanus, peritonitis. (c) ByDandC (d) By Hysterotoncy
In Nepal not only to perform abortion is regarded as a crime against the existing law, but also any body seeking Source: Dr. B.P. Sharma, Sir Hospital Pschosocial Aspect abortion or practicing it or willing to be an accomplice to such of Abortion in Asia, Kathmandu 26-29 Nov. 1974 an act is punishable with long term imprisonment. p.p. 64-68. In this context it is not possible to identify the abortion service provider to get the reliable statistical data. So far no Trophoblastic Diseases: research concerning abortion has been conducted in Nepal. However there are some reliable guesses. It is estimated that Although trophoblastic diseases are common and are about 1,100 to 1,200 induced abortion per year are performed responsible for significant maternal mortality and morbidity in the Kathmandu valleys with the population of 600,000 (1 in Nepal, no research concerning this disease has been con percent of the country total population. In the hospital of ducted and therefore accurate data are not available.
58 PAPER 11
PHILIPPINES
Country Paper
PREVIOUS AND ON-GOING RESEARCHES IN THE PHILIPPINES Points workers growth has multi- strategy through the 30,000 Barangay Service It is recognized that rapid population Development Workers of the Minis- on the citizenry of a country. and 5,000other Barangay facelied and multifarious effects and Natural Resources, Social Services are detrimental not only to the develop- tries of Agriculture Most of the effects Development, Local Government and Community Deve of the country but also to the total development and back ment efforts lopment and Labor and from the private sectors. This is of its people. For this reason, the Philippine various anid well-being stopped by public information campaigns through the commitment in the pursuit of the programme of etc. Government's effort is media - radio, television, folk media, newsprints, population control as part of the national development arnd absolute. total Research is a basic activity in the national programme start. Findings from studies undertaken enable policy The enrichment of life is the primary concern of the from the makers and programme managers to adopt necessary policy Philippine Population Programme. to help lies) and programme strategy(ies) that are deemed goals of population growth reduction and the en In line with that concern, the Philippine Population Pro- achieve the life. gramme has developed four component programme activities, richment of Filipino Training, Information/Education/ namely: Service Delivery, research activities in the Philippines CommunicationPopulation-related can be categorized broadly into: (1) Research on Demographic levels, patterns and trends; Service Delivery Programme component provides for services as part of overall health care. All family planning Research on Socio-Economic and DemogrAphic inter methods of contraception, except abortion, that (2) acceptable of relationships; and, are safe and effective are available to all citizens desirous preventing pregnancies. Todate, there are it spacing, limiting or Programme-oriented Research. This paper addresses clinics and mobile family planning teams, and (3) 3,600 hospitals, self largely to the last category - programme oriented Outreach Workers as well as 30,000 Barangay 3,100 Full-Time research. Service Points deployed all-over the countryside providing services to the people. An estimated 'four Research family planning practiced a Programme-Orlented plus acceptors, who at one time or another million population programme-oriented research method, have been registered. The prevalence rate among The numerous (MCRA) at community activities in the country have concentrated on the assessment married couples of reproductive age some results of level was estimated at 37.7% as of March 1 . of family planning programme effectiveness, which have led to changes in the family planning programme the 1974 National Accep service in the programme, training has policies and strategies. For example, To ensure quality which showed Io rates of contra a major activity. The major thrust of training is to in- tors Survey (NAS) findings been couples who live far from towns where crease knowledge and develop and/or improve skills and ceptive use among (beyond a 3-kilometer radius) led to a major capabilities of clinic personnel and fieldworkers. Special orien- clinics are located delivery strategy by the introduction of the tation programmes are available to policy and decision makers, change in service Programme, the chief feature of which is service de managers, media people and local leaders. Outreach livery at the doorstep of the barrios and remote communities. of a major policy authorizing non the IEC programme, the policy of making family It also led to the adoption Through workers to dispense pills after training a part of the broad educational programme and as a medical family planning planning been duly certified by the Commission on way of life for Filipinos is being realized. For this activity, the and after having programme has made provision for the face-to-face motivation Population.
59 Findings from behavioral research studies have indicated Findings from some of the completed studies have led to that IEC and training programmes should place heavier em- the adoption of a policy licensing nurses and midwives to phasis than they do now in informing both programme workers insert IUD after training and after having been duly certified by and clients about the actual differences in use-effectiveness of the Commission on Population, and the IEC drive to combat the various methods in the Philippine setting and its importance myths and rumors. Hopefully, the evaluation of the other as a criterion for method selection, and the provision of alter- studies will indicate the best way to treat side effects, parti native brands of present programme methods for increasing cularly, the bleeding and how the IUD can be prevented from continuation rate. being expelled.
The findings led to the repackaging of the IEC modul.-s and the Training modules, the addition of surgical sterilize.on Oral Contraceptives service in the array of contraceptive methods offered ir,the programme and the adoption of a National Guideline on Ser- With the government policy of free choice on the selec vice Delivery Promotion and Coordination. tion of a family planning method, the pills have remained on top of the preference list although the trend in method six in Studies in the biomedical field antedate the start oi the dicates a steady downward trend from 1970 to the present. population programme by many years. For example, studies on Trophoblastic Diseases were started at tha,Uiversity of the There are several studies on oral contraceptives. Most of Philippnes-Philippine General Hospitfi (UP-PGH) as early the studies were along the line of efficacy and safety of pills as the 30's. Findings have guided physicians in the detection of dose formulation prepared for the Caucasian women. and management of Trophoblastic diseases. Studies in England have shown that the pill is responsible for metabolic changes and increased incidence of thrombo-em Trophoblastic Diseases bolic phenomena and other myocardial and circulatory dis order among Caucasian women. The question is whether In a six-year study done at the Philippine General Hospital Filipino women are as prone to the hazards of pills. One study (1969-1975) the incidence of Hydratidiform Mole (H. Mole) is under process for implementation is the Trial Study 1:144 on live births. In 77.5% of cases, H. Mole was observed in Different Dose Combinations of Oral Contraceptives. Hope multiparous women. In all cases, the initial symptom was fully, this study would indicate the formulations suitable to vaginal bleeding. the Filipino women. Eventually, further in-depth clinical study may provide the answer to the question. A disproportionate enlargement of the uterus was noted in only 57% of cases. This same study demonstrated that the prophylactic use of Methotrexate within two weeks after molar Studies on abortion and folk methods of fertility control evaluation appreciably reduced the incidence of persistent Trophoblastic disease. The incidence of mortality from those Researches on folk methods of fertility control and abor which became malignant in this study was 0.4%. tion have been undertaken primarily to identify traditional methods of abortion and contraception to test the pharma Malignant Trophoblastic Disease: cological effectiveness of local plants, to ssess the effects of Incidence 1:442 live births training programmes for traditional birth attendants (hilots), to In 76.0% of cases preceded by H. Mole determine the characteristics of mothers with abortion cases, Therapy - on a selective basis - suigery and chema- and to determ;,e abortion rates in certain Philippine popula therapy are the modes of therapy tion groups. Mortality rate was directly related to the durationi of the disease prior to therapy and to the presence The general findings of such studies indicate adherence and location of the metastases, to traditional methods, reluctance to use modern contracep tive methods, and inadequate knowledge and practice of family planning on the part of the groups studied. Specific findings revealed the following: Intra-Uterine Device (1) Traditional birth attendants recommend traditional prac In the early years of Family Planning in the Philippines tices which have been in use for quite a time because both (late 60's and early 70's), the intra-uterine device was the "hilots" and the acceptors are familiar with the plants and second method of choice. However, IUD acceptance and use objects used to prevent conception or induce abortion. started to decline since 1972 and had dropped to 4th place todate. Two major reasons were identified for the decrease in (2) There are four traditional methods of inducing abortion, IUD acceptance: namely; manual or abdominal massage, use of inanimate objects, i.e magnetic lead stone (bato balani), use of I1) The external influence like myths/rumors and the clinic herbs (PANAKTOK, HUMAY, KUMINTANG, MAKA- situation vis-a-vis availability of service, knowledge/con- BUHAY, AMPALAYA) and the use of sharp instruments petence of service providers; (coconut husks and wire). (2) The inherent deficiencies of the method itself - IUDs (3) In a sample survey done in one community, the abortion produce bleeding and pain, are expelled and are not 100% rate for the period 1964-67 was 8.48% (of which 4.6% effective in preventing pregnancies. was illegally induced). Among the reasons given for in duced abortion were to limit family size and to avoid Studies conducted and being conducted are along the further economic difficulties. The characteristics asso area of minimizing side effects - selection of the device, time ciated with cases are: older age, longer marriage, more of insertion, training of service providers and the IUD Delivery pregnancies, better education, higher income and less System itself. knowledge and practice of family planning.
60 (4) Other traditional methods of contraception are absten- SELECTED REFERENCES tion, coitus interruptus and herbal methods. The roots of SAMBONG, KAMARIA, MAM-IN, SARSAPARILYA, 1. "Four-Year Population Program '73-'74 Through '76 AGOHO or MAKABUHAY were mentioned as common '77', Commission on Population, Social Communication contraceptives. DRUGS - CORTAL, ASPIRIN, QUININE Center. and large dose of hormonal pills were also mentioned as abortifacients. 2. "Population Commission Annual Report 1973-1974", Commission on Population, National Media Production Studies on traditional methods of fertility control are still Center, 1975. being pursued. The UP-College of Medicine is currently con ducting a three phase research which will involve a study of 3. "Commission on Population Annual Report 1974- 1975", the action and effects of the chemical substances of some IEC Division, Commission on Population; National Media herbs (Phase I) and pharmacokenitic and toxilogical studies Production Center. of the said herbs (Phase 2). 4. "Commission on Population Annual Report. 1975- 1976", Commission on Population; NEDA-APO Production Unit. Gaps in Population Research 5. Ludivina S. de Padua, Gregorio C. Lugod, Juan V. Pan Considering the volume of available research on popula- cho: "Handbook on Philippine Medicinal Plants", Vols. I 1978. tion, the problem is less on adequacy but more on the utiliza- and II; University of the Philippines, Los Banos, tion of findings and recommendations. 6. Armand Fabella, et. al.: "Final Report of the Special Com Several reasons were identified for non-utilization of mittee To Review the Philippine Population Program", several research studies during the Research Utilization Work- June 1978. shop held in Manila in 1977. These are: 7. Rosario Isidro-Gutierrez, Fe Palo-Garcia, Sol Manarang- (1) It seems that some research projects undertaken were not Pangan and Erlinda Gonzales-Germar: "Hydratidiform evolved from what policy makers or programme managers Mole and Trophoblastic Malignancies, Early Diagnosis perceive as information or knowledge needod for making and Assessment ofthe Different Therapeutic Modalities", decisions, nor presented in a form useful to the policy Reprint from NCRP Research Bulletin Vol. 32, No. 3, pp. makers and/or programme irnplementors. With the ex- 329-359, Biartan, Taguig, Rizal, Philippines. ception of a few, the research work did not satisfy what implementors consider as applicable, practical, feasible 8. "Discontinuance of Contraceptive Use: Abstract Biblio and/or viable, graphy", prepared by the Research Utilization Project on Biomedicine and the Population Center Foundation (2) Research studies do not reach policy makers and users Library, 1979. at the right time. The time lag between start to finish and dissemination for review by users is quite long to be used 9. Valenzuela, Amanda, "Abortion in a Philippine Municipa as basis for decision, development of new strategies or lity, Sta. Rosa, Laguna", the Journal of Phili-pine Medi changing direction of on-going programmes. calAssociation, 46 (1), Nov. 1970, pp. 255-267.
Taking all the above reasons into consideration, the Com- 10. Demetria, Agnes, "Folk Methods of Birth Control', mission on Population has taken steps to develop a research published Master's Thesis, University of San Carlos, Cebu plan wherein priorities are to be clearly established and the City, May 1969. link between research and policy is made clear. Such research plan will indicate for what purpose particular research projects 11. National Acceptors Survey, 1974 Et 1976. are needed and when. Efforts are directed to open communi cations between researchers and users. 12. Community Outreach Survey, 1978.
61 PAPER 12
SINGAPORE
Country Paper
Inventory of Previous and on-going Research by The 2. Medical MR with prostaglandins. Depart of Ob-Gyn, University of Singapore. Abortion Oral Pills 1. Psychosocial aspect of abortion. requires of oral pill; also 1. Trials Comparing various dose national various synthetic oestrogens. 2. Safety of outpatient abortion compared with inpatient abortion. 2. Effect of pills on Carbohydrate metabolism 3. Safety of local anaesthesia. on Coagulation. 3. Effect of pills 4. Prostaglandin for preoperative cervical dilatation in multi- IUD parous pregnancies and midtrimester abortion.
1. Trial Comparing various Type of IUD. Sterilization
2. Extopic pregnancies and IUD. 1. Concurrent vorsus interval sterilization in relation to abortion - both medical and phychological aspects. Menstrual Regulation 2. Sterilization failures. 1. Comparison of flexible and rigid Canulas for surgical men strual regulation. 3. Safety of various method of sterilization.
62 PAPER 13
HONG KONG
Countfy Paper
Inventory of previous on going research In Hong Studies in I.U.D.: Kong on the followings: a) Hong Kong Family Planning Association: Performance of 4 Projects on which are the appropriate Asian women A comparative study of the on oral pills: 1.U.D.'s in Hong Kong. E Gynaecology, University 1. Hong Kong Family Planning Association: b) Department of Obstetrics a) KAP Survey of Hong Kong. of Hong Kong: The dosage and effectiveness of continuous in in first trimester abor b) Impact of Industrialization on Fertility in Hong Kong. fusion of Prostaglandin tions. for the Housing c) The Family Planning Requirements Estates in Hong Kong. Uni- Trophoblastic Diseases: of Obstetrics b Gynsocology, 2. Department of veruity of Hong Kong: Department of Obstetrics & Gynaecology, University a) Coagulation changes in females on oral pills. Hong Kong.
b) Hyperprolactinaemia. Laboratory Researh: profile and Ovarian Maturation in Hong c) Hormonal a) Department of Zoology and Physiology, Uni Kong Adolescence. versity of Hong Kong: Study of Spermatogenesis and Sperm Matura tion. Traditional Methods on abortion and other methods: b) Department of Anatomy, University of Hong Department of Biology & Biochemistry Department, of Hong Kong: Non-staroidal contraceptive Kong: Chinese University Hormonal Influence on tissue culture. compounds from Chinese herbal drugs.
63 PAPER 14
JAPAN
Country Paper
II
ORAL PILLS STUDIES ON IUD The Ministry of Health and Welfare of Japan has not yet It is well known that Japan is one of the few countries approved the use of steroidal preparations as contraceptives, where clinical effectiveness of the IUD has been investigated At present, four different varieties of combined estrogen/ from as early as the 1930's. In 1974, the Ministry of Health and gestagen preparations which contain 50 ug of either ethinyl Welfare changed the regulations which control the approval estradiol or Mestranol are commercially available and phy- of the IUD. Under present regulations, any pharmaceutical sicians are prescribing them for women who wish to use oral agent who plans to obtain governmental approval for either pills. manufacture or import of an IUD, must present clinical data of not less than 500 cases in whom the IUDs were inserted at Strictly speaking, however, these drugs wero approved more than five different institutions. Basic data which prove by the central drug control agency as a therapeutic regimen the safety and non-toxicity of the material of the IUD are also for functional uterine bleeding, dysmenorrhea, or ovarian required. dysfunction and not for use as contraceptives. Thus under these circumstances, no pharmaceutical company has plans In 1974, two ring-type IUDs developed in Japan, the to market the so called 'low dosage estrogen pills.' The medi- Ohta-ring and the Yu3ei-ring were officially approved, follow cal -ommittee of the Japan Family Planning Association now ed by the approval of the Lippes Loop and the FD-1, another has a plan to start a clinical investigation as to the effective- Japanese produced IUD (figure 1)in 1977. ness of these "low dosage pills," however, it is not yet certain whether permission to import the drug can be obtained. Up to now, two other non-medicated IUDs, the SAF-T- Coil and the Dalkon Shield, two copper impregnated IUDs, TRADITIONAL METHODS ON ABORTION the T-Cu 200 and the Cu-7 as well as the progesterone IUD have been clinically tried bnd have shown satisfactory results Since 1948, when induced abortion was legalized, the (Tables 1and 2). Preliminary clinical tests of the ML-250 have standard method for induced abortion at the first trimester has recently been started (Table 3). All of these IUDs except for been dilatation and curettage. Some physicians are also using the Dalkon Shield are presently waiting the approval of the the suction method while laminaria tents have been used to Japanese government. Unfortunately, however, the Ministry dilate the nulliparous cervix, of Health and Welfare holds asomewhat conservative attitude toward the clinical application of medicated IUDs, therefore, Recently, T. Wagatsuma et al. published a clinical study it is not yet certain when they will be approved. of the MR-Kit made by IPAS, and a Japanese company will import the kit as soon as the government's approval on the instrument is obtained. In 1978, T. Wagatsuma received a research grant from the spacial programme of research on human reproduction of As to the technique of mid-trimester abortion, previously the WHO and has started f so-called MBL study with three dilation of the cervix with the laminaria tent followed by an different IUDs: the T-Cu 20 C, the Cu-7, and the FD-1. So insertion of a rubber balloon with a pitocin drip to stimulate far, the amount of menstrual blood loss of normal Japanese uterine contractions was the standard method. Now more and women of reproductive age was determined as background more physicians are using an extra arnniotic infusion of Prosta- data, and their mean value is slightly higher than those obtain glandin F2x. ed in the U.S. or in Scandinavia with the same method.
Recently, clinical tests on the effectiveness of vaginal Aside from those clinical studies, several scientists are suppositories containing a newly synthesized Prostaglandin interested in the morphological and enzymatic changes of the analogue 16, 16-Dimethyl-Trans-deta2-Prostaglandin endometrium caused by the insertion of the IUD, and several E1 methyl ester have been carried out with satisfactory results, papers have been published on this subject.
64 Figure 1: Newly designed IUD, FD- 1 -j
71
TABLE I - RESULTS OF CLINICAL TRIALS WITH NON-MEDICATED IUDS IN JAPAN
NET CUMULATIVE TERMINATION RATES PER 100 WOMEN (12 MONTHS OF USE)
LIPPES LOOP FD-1 Dalkon 1 11 Shield
3.1 3.0 3.7 3.5 Accidental Pregnancy 0.8 Expulsion 9.3 7.3 1.7 Removals 3.8 Bleeding/Pain 5.7 6.9 2.7 Reason 0 0.8 0.7 0.5 Other Medical 1.4 Pregnancy 2.4 5.9 1.3 Planning 1.5 Other Personal Reason 2.6 1.4 0.3 11.5 Total Termination 28.2 25.3 10.4 Net Cumulative 88.5 Continuation Rates 71.8 74.7 89.6 671 761 Number of Insertions 395 568 9,624"'" 8,343 Women-months of Use 2,412- 5,367"
36 months • 15 months 23 months
Source: Lippes Loop Study Group, 1977 (11) Wagatsuma, 1974 (I) Wagatsuma, et al., 1977 Dalkon Shield Study Group, 1970
65 TABLE II - RESULTS OF CLINICAL TRIALS WITH MEDICATED IUDS IN JAPAN
NET CUMULATIVE TERMINATION RATES PER 100 WOMEN
(12 MONTHS OF USE)
Gravigsrd T-Cu 200 Progestasert
Accidental Pregnancy 1.9 0.5 0.8 Expulsion 5.2 1.6 1.2 Removals Bleeding/Pain 2.4 3.4 4.3 Other Medical Reason 2.2 0.3 0.3 Planning Pregnancy 3.2 1.5 1.1 Other Personal Reason 0.9 0.3 1.1
Total Termination 15.8 7.6 8.8 Net Cumulative Continuation Rates 84.2 92.4 91.2 Number of Insertions 346 954 570 Woman-months of Use 5,534* 9,956- 8,343
24 months
Source: Wagatsume, 1974 Copper-T study group, 1978 UPS study group, 1974
TABLE III - RESULTS OF CLINICAL TRIAL WITH ML - 250
NET CUMULATIVE TERMINATION RATES PER 100 WOMEN
6 Months ML-250 Cu 24 Months 12 Months
Accidental Pregnancy 0 0 1.5 Spontaneous Expulsion 1.1 1.1 2.6 Removals: Bleeding/Pain 0 5.0 8.1 Other Medicals 1.1 2.2 4.2 Planning Pregnancy 0 2.5 8.8
Total 2.2 10.8 25.2 Net Cumulative Continuation Rates 97.8 89.2 74.8 Woman-months of Use: - 997.5 1,546 Number of Insertions 91
Wagatsuma, 1979.
66 PAPER 15
KOREA
Country Paper
A. Oral Contraceptives decreasing to 50% after 37 months of oal pill use. 15 ) from Various kinds of oral contraceptives have been used over .(won reported that the volume of breast milk decreases the past 10 years and many clinical and experimental studies mothers using hormonal contraceptive (Eugynon) been conducted with the steroidal contraceptives in in periods between post-1 cycle and post-4 cycles. Starting have there Korea. in periods following the use of the 5th cycles, however, appears to be no noticeable change. There are Leveral research findings on the incidence of the 18 (Lindiol) common side effects or complaints to oral contraceptives Yang ) reported the effect of oral contraceptive The agent was mostly administered from day 5 jn active pulmonary TB patients prevalence and incidence (Table A-i1). con to 25 of the menstrual cycle except Microcult. Individual c cles rates of tuberculosis among oral contraceptive users and varied from 1to 10 or more cycles. trol non-users showed no significant differences for the period study. It would be safe to advise oral contraceptive pill to In all studies, each clients was interviewed to determine of her objective and subjective symptoms and was given a gene- womenculosis. of child bearing age without prior screening of tuber pelvic examina ral physical examination including a complete tion. Lee Chung Bin 16 ) examined four consecutive a typical com- Certain unpleasant but not serious side effects were com- fibroadenoras in women taking oral contraceptives and women pared by various kinds of oral contraceptives. Common side pared with 14 fibroadenomas in lactating and pregnant similar effects reported were related to menstruation: spotting, hypo- and 100 common fibroadenomas. They appeared partly menorrhea, dysmenorrhea, amenorrhea, hypermenorrhea, to those seen in lactating and pregnant period. It was sugges the women re- G- troubles: indigestion, nausea & vomiting, appetite tive that a typicality of the firoadenomas of high hormonal change, leukorrhea, breast tenderness, chloasma, headache, ceiving oral contraceptives may be related to low back pain, weight change, and other minor complaints. millieu. The side effects or complaints were most notable during the first 3 cycles, diminishing spontaneously thereafter. REFERENCE
In the termination of oral contraceptive use, Table 2 shows termination rate for medical reasons accounted. 1. Kim, S.K. & C.H. Yu, "D-Norgestrel Combined with Ethinyl Estradiol as an Oral Contraceptive," Korean Jr. of Lee171 deFcribes the prevalence of candida infestation Ob&Gyn, 15(1): 11-15, 1972. was 69% (out of 200 cases) in pill users. Candide infestation rate was 80% in oral users for the first 6 months of pill use and 2. Kwak, H.M. "Lindiol, an Oral Contraceptive Effects in gradually decreasing to 22.2% in the period 9 to. 12 months Korean Women," Korean Jr. of Medicine, 10(5): 613 then Deaking at 100% in the period 19 to 21 months and finally 615, 1966.
67 TABLEA-I
INCIDENCE OF SIDE EFFECTS BY THE VARIOUS KINDS OF ORAL CONTRACEPTIVES
Kinds 1) 2) 31 4) 51 6) 7) 8) 9) 10) 11) 12) 13) 14) Side D-Norges- Lindlol Norinyl Serial Eugynon Eugynon Demu- Microcult Microgynon Minovular Neovular Various Ovulen E.f.t trel 5mg 1+50 -28 Undiol E.D. Ion 62.D. kinds img 2.5mg Spotting 1.3 0.45 3.4 1.1 0.82 0.92 1.6 6.6 1,7 1.9 0.6 0.5 2.2 1.4 Break through 0.5 1.2 0.2 0.3 2.7 0.5 bleeding Amenorrhea 0.55 0.8 1.1 0.36 0.53 0.6 2.2 0.5 0.2 0.06 0.2 0.8 0.4 Hypomenorrhea 11.90 0.63 5.24 3.7 0.05 1.0 1.3 3.8 4.8 Hypermenorrhea 6.3 0.36 1.36 0.2 0.6 1.0 Dysmenorrhea 0.5 1.7 2.8 0.6 3.1 0.4 Leukorrhea 4.3 5.2 2.45 1.75 2.4 0.2 0.8 1.5 2.8 0.5 1.2 Prolonged mens 0.05 Nausea, vomiting 1.4 2.8 6.0 8.6 3.62 1.46 2.5 1.4 4.1 2.1 2.46 1.4 4.2 2.7 Digestion poor 0.9 7.3 4.5 1.27 2.09 1.1 0.3 0.5 1.3 1.0 0.7 " good 7.9 2.4 0.82 0.15 Appetite poor 11.0 2.2 1.45 0.39 0.2 0.6 0.6 0.1 good 10.9 2.3 0.36 0.15 1.0 1.06 0.1 Weight increase 20.0 16.6 4.2 6.63 2.3 0.02 3.2 3.3 decrease 3.6 13.8 2.0 0.4 2.4 1.4 Lactation increase 3.6 " decrease 11.8 Breast discomfort 5.9 1.9 0.3 0.4 0.2 0.4 0.4 0.2 0.7 0.6 Libido increase 12.2 0.7 (0.2) 0.1 0.4 0.3 " decrease 3.6 0.5 0.01 0.4 0.2 Low abd. pain 1.9 5.7 1.17 1.75 0.3 0.8 1.2 0.2 & backache Headache 2.3 5.9 6.1 2.54 0.92 1.2 0.3 1.5 1.2 0.6 0.4 0.4 Fatigue, dizziness 0.6 0.15 0.03 Chloasma 0.9 1.2 3.9 0.28 0.4 0.05 0.6 2.4 0.4 Nervousness 1.0 1.4 1.45 0.1 0.5 0.2 0.4 Varicosity Urticaria 0.05 0.1 Acne 3.35 0.03
No.of acceptors 209 139 467 441 510 327 418 501 447 420 382 1,389 147 2 12) include Anovular, Lyndiol, Eugynon, Eugynon E.D., Ovulen, Ovural, and Orthonovum. TABLE A-2 ceptives on Tuberculosis," Korean Jr. of Ob & Gyn, TERMINATION RATE FOR MEDICAL REASONS 15(6), June 1972. Author (Year) Kinds Rate 1%) In Korea, the list of titles for the on-going research pro oral contraceptives are as follows: Kwak (1966) 2) Lindiol 5 mg 6.2 jects on 1. Effects of oral contraceptives on metabolic processes Kwak (1968) 5) Eugynon 0.4 Objectives: a) To determine if oral contraceptives influence cortisol, Kwak + Lee (1974) 13) Ovulen 1.0mg 5.4 renin-angiotansin-aldosterone and thyroxine levels. b) To elucidate if oral contraceptives suppress the Kwak + Song (1973) 12) Various kinds* 18.3 secretion of hormons which are involved in lacto 14) genesis and milk ejection. Kwak,et al. (1969) 1Lindiol2.5mg 4.72 c) To demonstrate if oral contraceptive steroids being by lactating mothers pass into milk. taken contraceptive Kwak, et al. (1971)6) Eugynon E.D. 5.2 2. Comparative study of an oral combination preparation in tablet and "paper pill" form. vincludes Anovular, Lindiol, Eugynon, Eugynon E.D., Ovulen, Objectives: Ovural, and Orthonovum. a) To study the effect of a treatment advantages of cost acceptability with conventional tableted Study on Oral Contraceptives, Norinyl and patient 3. , "A Clinical oral contraceptive and "paper pill" form. R1 50," Korean Central Jr. of Medicine, 34(2): 153- + of signs of vitamin deficiency in 157, 1978. 3. Study of prevalence association with.oral contraceptives. 4. ,"Serial 28, an Oral Contraceptive Effects in Objectives: Korean Women," Korean Central Jr. of Medicine, 17(3, a) To determine if the prevalence rate of the clinical 1969. signs and symptoms of vitamine deficiency is signi 5. , "A Clinical Study on Oral Contraceptives, Eugy- ficantly increased in a group for women using oral non," Korean Jr. of Ob & Gyn, 11(9), 1968. contraceptive hormones as compared to a group of contraceptive hormones. Kwon, S.K. Kim, "Clinical Study of an women not using oral 6. Kwak, H.M., B.H. effects of com Eugynon E.D. in Korean Women," 4. Comparative study of the biochemical Oral Contraceptive oral contraceptives contain Korean Journal of Ob & Gyn, 14(9): 443-449,1971. bined estrogen/progesterone or less of estrogen. "A Clinical Study on Oral Con- ing 50mg 7. Kwak, H.N., C.H. Song, Objectives: Demulen in Korean Women," Korean Central traceptive, a) To investigate whether different amounts of the Journal of Medicine, 3113): 239-242,1976. same estrogen, or combination the same proges B. Kwak, H.M., C.H. Song, "A Clinical Study on Oral Con- togen induce different metabolic reactions. traceptive Microcult," Korean Jr. of Ob & Gyn, 17(12): b) Toinvestigatewhetherthesameamountsofdifferent 1-5,1974. estrogen, or combination the different progestogens 9. , "A Clinical Study on Oral Contraceptive, Micro- induce different metabolic reactions. gynon in Korean Women," Korean Central Jr. of Medi- B. Abortion Method cine, 32(3): 277-281, 1977. research findings on the procedures Clinical Study on Oral Contraceptive Mino- There are several 10. , "A abortion (Table B-il). E.D.," Korean Central Jr. of Medicine, 25(5): 529- practicing induced vular 1 ) 533, 1973. Hong revealed that in large city area, 94% of induced procedures. Sur 11. , "A Clinical Study on Oral Contraceptive, Neo- abortions have been performed by surgical include abdominal surgery vular in Korean Women," Korean Jr. of Ob & Gyn, 1617): gical methods, mainly D & C, also 1-6, 1973. and insertion of objects. predo 12. , "A Clinical Study on Oral Contraceptives Con- As revealed in Seoul area, surgical procedures Clinic of Yonsei University," minated, 93% of abortions having been thus performed in ducted at the Family Planning 2 Korean Jr. of Ob & Gyn, 16(2): 83-101, 1973. rural areas ). 3 13. Kwak, H.M. & Y.H. Lee, "The Clinical Study of the Ovu- Hong ) reported that more than 90% of abortees had len 1mg in the Korean Women," Korean Jr. ofOb & Gyn, experienced by curettdge as a whole country and 90% in 12(4), April 1974. Seoul, 93% in urban and 89% in rural area. "Lindiol 2.5, an Oral Contraceptive 14. Kwak, H.M., et al., 4 Effects in Korean Women," Korean Jr. of Ob & Gyn, Hong ) conducted the survey based on the interviews of 12(10): October 1969. providers at clinics and hospitals. 15. Kwon, E.H., et. al., "The Effect of an Oral Contraceptive In the first trimester abortions D Et C technique was one (Eugynon) Upon Lactation," Korean Jr. of Preventive time or another utilized by 95% of providers, suction by 65.7% Medicine, 8(1), October 1975. and MR by 42.8%. About two-thirds (63.7%) of physicians anes 16. C.H., et al., "A typical Fibroadenomas of Breast in practicing menstrual regulation technique administer Lee, The size of cannula Women Receiving Oral Contraceptives," Korean Jr. of thetics and 66.2% provides no analgesics. are 5am in 44.7 percent, 4mm in 18.6%, and 6mm in Pathology, 7(2): 111 -120,1973. utilized electric 17. Lee, Jin Ho, "A Study on the Vaginal Candidiasis among 15.1% respectively. The majority (85.2%) utilizes pump and 7.2% Karman Syringe as asource of nega Oral Contraceptive (Eugynon) Users," Korean Jr. of Ob vacuum tive pressure. Curetting is often (84.6%) used for assurance of & Gyn, 1512): 595-602, 1972. complete evacuation after thj procedure. Administration of in 94.5%. Suction 18. Yang, J.M., et. al., "Studies of the Effect of Oral Contra- either antibiotics or oxytocics are found
69 TABLE B-i: - DISTRIBUTION OF PROCEDURE FOR INDUCED ABORTION Authors Area Et Year of Data Sampling, Study Population Method of (Year) Facility Collection Data Results Collection
Hong (1967) Rural 1965.8- Eligible wives aged 20 to 44 years Interview (1) 1965.10 who were living with their husbands, 2,084 in number.
Hong (1966) Large city 1964.7- 743 women who acknowledged Interview (2) 1964.8 they had experienced at least one induced abortion (1,484 cases)
Hong (1972) Nation-wide 1971.9- Ever married women who acknowledged Interview (3) 1971.11 they had experienced one or more induced abortion, 1,288 in number. No. Case Seoul 356 574 Urban 379 608 Rural 553 788
Hong (1978) Seoul 1977.10- 726 medical facilities where induced Interview (4), (5) 1978.3 abortion was provided. (6), (7) Private clinic: 684 hospital: 41 family planning clinic: 1
(1) Percent Distribution of Cases Grouped on Basis of Method by Agent Performing Abortion
Total Method Used Operative Intrauterine No. % Procedure Drugs Chemicals Others
All agents 142 100 93 93 3 1 Specialist 107 100 69 - 1 - G.P. 20 100 85 - 10 5 Others 15 100 60 27 7 7
(2) Number of Cases by Method of Termination All Cases Method Number % dist.
Curettage 1,390 94 Intra-uterine application 25 2 Injection of medicine 31 2 Intake of medicine' 17 1 Other 21 1
Total 1,484 100
* May include ergot preparation, quinine pills and extract of tongkui. It is improbable that an antimetabolite such as antifolic acid isdispensed as an abortifacient.
70 (3) Number of First and Last Abortion Cases Method of Termination All Cases (%) Method Seoul Urban Rural
Curettage 90 93 89 Aspiration 2 Herb Medicine o 1 Injection 2 1 2 Other 5 5 8
Total (N) 100(574) 100(608) 100(788)
Lessthan 0.5%.
(4) Termination Procedures for 1st Trimester Abortion Procedures Utilized Number Percent
D & C,Suction, MR 257 35.4 D&C 219 30.2 D & C,Suction 186 25.6 D &C, MR 27 3.7 Suction, MR 24 3.3 Suction 9 1.3 MR 2 0.3 D & C, Suction, MR, Prostaglandin 1 0.1 Other 1 0.1 Total 726 100.0
(5) Anesthetics Administered by Procedures MR Suction DEC % Anesthetics No. % No. % No. 431 62.4 Thiopenthal Sodium 109 35.0 261 54.6 50 16.1 67 14.0 84 12.1 Propanidid 24 3.5 Tricholoroethylene 12 3.9 14 2.9 2 0.4 2 0.4 2 0.3 Ketamine 12 1.7 Procain or Lidocaine 4 1.3 70 14.7 21 6.8 6 1.3 94 13.6 Multiple Agents 44 6.4 Not Administered 113 36.3 58 12.1 691 100.0 Total 311 100.0 478 100.0
(6) Analgesics Administered by Procedures MR Suction DeC % Analgesics No. % No. % No. 14.3 Pethidine HC1 46 14.8 75 15.7 99 14 4.5 20 4.2 36 5.2 Baralgin-amide 1.0 Diazepam 4 1.3 7 1.5 7 4 1.3 10 2.1 11 1.6 Hyosicine-nbutylbromide 1.2 HC1 6 1.9 9 1.9 8 Tilidine 4.7 Other* 7 2.3 13 2.6 33 24 7.7 43 9.0 50 7.3 Multiple Agents 64.7 Not Administered 206 66.2 301 63.0 447 100.0 Total 311 100.0 478 100.0 691
valenthamide * Other agents include valethamate bromide, sulpyrin, trospium chloride, papaverine HC1, acetyl salicylate, sodium phenyldimethyl bromide, phenobarbital sodium, mefenamic acid, morphine HC1, dihydrocoieine bitartrate, and pyrazolone-methyismine-methance sulfonate.
71 (7) Procedures for Mid-Trimester Abortion
Procedures Number Percent Metreurynter 322 36.2 Infusion of Oxytocics 251 28.2 Bougie 205 23.0 Laminaria 53 6.0 Prostaglandin, Intra or 31 3.5 Extra Amniotic Saline, Intra or 18 2.0 Extra Amnoitic Hysteretomy, Abdominal or 8 0.9 Vaginal D&C 2 0.2
Total 890 100.0 technique is utilized by two-thirds of practitioners (65.8%), vical injury are immediate complications and infection, spott and responsible for 30.3% of first trimester abortions. In ing, and continued pregnancy are delayed. majority of cases (99%), evacuation is preceded by dilatation of cervic in which laminaria tenting is often accompanied Kim 5 ) and Na 6) reported incomplete aspiration was de (77.6%). As to anesthetics, Thiopenthal Sodium (54.6%), Pro- tected in 21.6% 8 29.4% of 8 weeks group from the 8 LMP panidid (14.0%), and local anestheti..s (14.7%) are principal each otherand in 42.6% &48.3% of 9-12weeksgroup. drugs used but some practitioners ('2.1%) do not use any. About one-third (37%) uses analgesics and majority (97.1%) REFERENCE administer either antibiotics or oxytocics postoperatively. This technique has been practiced from the initiation of their prac- 1. Hong, S.B., Induced Abortion in Seoul, Korea, Dong-A tice in 18.4% and shifted from conventional procedure, D & C, Publishing Co., Seoul, Korea, 1966. in 81.6% and become popular since about 1968. D & C pro cedures is most widely used (95.0%) and isonly procedure for 2. , "Induced Abortion in Rural, Korea, Korean Jr. of the first trimester abortion in 30.1% of practitioners. Dull Ob &Gyn, 10(6): 1-30,1967. curette is utilized in 63.8%, sharp one in 21.9%, and the re mainder uses both types. The administration of drugs pre and 3. , Induced Abortion in Korea, The New Medical Jr. post operatively-differs not appreciably from that of suction Co., Korea, 1972. technique. 4. , "Studies in Providers of Induced Abortion in In midtrimester abortion the major procedures utilized are Seoul, Korea," Korean Jr. of Ob & Gyn, 21(11): 849 metreuryntor (36.2%), oxytocics infusion (28.2%), Bougie 867, 1978. (23.0%), Laminaria (6.0%), Prostaglandin (3.5%), saline solution (2%), and some of them are used frequently com- 5. Kim, S.Y., et al., "A Clinical Study on the Use of Karman bined. Cannula in the Termination of Early Pregnancy," Korean Jr. of Ob & Gyn, 18(6): 373-378, 1975. Table B-2 indicate the side effects in MR technique. Nausea & vomiting, faintness, uterine perforation, and cer- 6. Na, Keun Young, "Induced Abortion and its Complica-
TABLE B-2: - COMPLICATIONS OF INDUCED ABORTION
Complication Na 6) Whang 7 ) KIm 5)
Immediate (N = 1,830) (N = 695) Nausea & vomiting 1.4 1.4 1.4 Uterine perforation 0.050 0.1 Cervical injury 0.4 Yaimtness 0.3
Delayed (N = 1,339) Infection 1.0 0.4 1.1 Spotting 0.9 1.9 0.7 Continue pregnancy 0.19* 0.5 0.2** Retained products 0.1 of conception
* Cased by post-aspiration metal curettage.
Ectopic pregnancy.
72 tions," Korean Jr. of Fertility and Sterility, 3(2): 13-28, Shin15) performed the study on the size of the Lippes' 1976. loop (Table C-2). Cumulative pregnancy, expulsion and removal rates for the 1st 12 months after insertion by the size 7. Whang, M.C., et al., "A Clinical Study on Menstrual Re- of the loop. These were reported that the largest one, size gulation," Korean Jr. of Ob & Gyn, 16(8): 699-708, 30mm, seemed give better results in protection from preg 1975. nancy expulsion and removal. Side effects or complications noted in active users were less frequent with larger size than smaller one. The titles for the on-going research projects on induced abortion are as follows: A relatively high discontinuation rate caused by medical reasons was recorded in Korea. Major reasons for removal 1. A midtrimester abortion study during the first year appeared to be bleeding and pain (Table Objectives: C-3). immediate and delayed complica a) To document the 1 tion of midtrimester abortion by urea, PGF2 and Ahn and Kwak ), 10) examined the relationship between laminaria. position of IUD and side effects by the hysterographic examination (Table C-4). Position of IUD in uterine cavity b) To develop a methodology for the management of was divided into 3 groups; normal position, downward complications associated with induced abortion in position and distortion of shape. The complaints axpressed Korea. by the loop in abnormal position were slightly more than those wearing the IUD in normal position. clinical trial of flexible vs. rigid cannulas for the 2. Controlled 2 ) early termination of pregnancy by endometrial aspiration. Choe studied to compare the continuation ratas of IUD Objectives: acceptors recruited by volunteers workers and those recruited (a) To test the safety and effectiveless of different can- by government family planning workers. The results was nulas used for the early termination of pregnancy (up presented that there was no significant differences in the to 45 days since LMP) when cervical dilatation is not length of IUD retention between the acceptors by the volunteer required. Flexible with one hole, flexible with 2 holes, workers dnd the government family planning workers. rigid with one hole, and rigid with 2 holes cannulas are being used. In the comparative study on effectiveness and patient satisfaction for IUD insertion by physician and trained para C. IUD medical personnel such as a licensed nurse and midwife (Kong 6 )), no statistical difference was observed especially Various types of IUD was introduced in Korea, but Lippes' regarding side effects caused by insertion and total termina loop was only inserted by government programme and Lippes' tion rate. 3 ) byloop clinical and othertrials typesand self-supporting. such as cu-T, cu-7, Alza-T were inserted Kim performed a comparative study with cu-7, cu-T and Lippes' loop inserted immediately after the artificial termina There are several research findings on the cumulative tion of early pregnancy to compare their contraceptive effec expulsion, and removal rates in IUD inserted tiveness. Cumulative pregnancy rate obtained with cu-7 at the pregnancy, 2.2 (Table C- 1). Cumulative rates were compared by the type of end of first year was 1.7% 100 insertions, 2.1 in cu-T, and 3.7, IUD, time of insertion, and data collection method. In the in Lippes' loop. The expulsion rate obtained with cu-7 was national survey data cumulative rates were higher than clinical 2.2 in Lippes' loop, and no spontaneous expulsion was record trial data. ed with cu-T.
TABLE C-1: - NET CUMULATIVE PREGNANCY, EXPULSION AND REMOVAL RATES PER 1W AT THE END OF IST YEAR
Various Alza-T Cumulative Rate Llppes' Loop kinds cu-T cu-7 5) 3) 12) 8) 3) 14) 3) 4) 4)
2.0 Pregnancy 2.3 2.2 3.0 1.17 2.1 0.3 1.7 1.4 4.1 2.3 Expulsion 7.2 2.2 12.6 7.26 - 5.9 3.7 7.0 Removal 15.5 22.1 26.5 11.650 16.9 2.3 23.9 9.4 11.3 Total termination rate 24.5 26.5 42.1 20.08 19.0 29.2 27.3 14.9 193 No. of adopted 3,879 92 7,011 95 528 95 161
3) immediatl postabortion IUD insertion 8) includes lippes' loop, margulies coil, organon loop, and cu-T 12) gross rate in national survey removal for bleeding and or pain.
73 TABLE C-2: - CUMULATIVE DISCONTINUATION RATE AND SIDE EFFECTS BY THE SIZE OF LIPPES' LOOP
24mm 27'Amm 30mm
Cumulative rate Pregnancy 4.1 2.8 1.2 Expulsion 6.1 7.2 2.7 Removal (medical reasons) 13.2 15.0 8.0
Side effects Hypermenorrhea 18.5 20.3 15.9 Spotting 19.9 16.2 16.6 Bleeding 5.1 3.8 3.2 Abd. cramps, backache 17.8 12.8 13.3
TABLE C-3:- REMOVAL RATE FOR MEDICAL REASONS
Various Uppes'Loop Kinds cu-T cu-7 Alza-T 5) 3) 8) 14) 3) 9) 4) 3) 4)
Bleeding 3.9 1.1 5.7 3.0 2.1 3.2 3.1 5.3 4.2
Pain 5.5 5.4 14.7 17.2 2.1 9.1 1.9 1.1 1.0
Discharge 0.6 - 2.2 - - 1.1 -
Infection 0.7 - 0.7 - - 0.7 - -
Pregnancy - - 2.5 - - 0.4 - -
Others 0.2 - - 1.7 - - - 1.1 -
No. of examined 3,879 92 7,011 95 528 441 161 95 193
3) data in national survey. 4) immediate postabortion IUD insertion. 8) includes Lippes' Loop, Margulies Coil, Organon Loop, and Cu-T.
TABLE C-4: - RELATIONSHIP BETWEEN SIDE EFFECTS AND POSITION OF IUD
10 Ahn 1) Kwak bAhn ) Side Effect Normal Abnormal Normal Abnormal
Hypermenorrhea 21.5 26.7 19.5 26.1 Prolonged mens 13.8 33.3 - -
Intermenstrual bleeding 13.8 6.7 16.1 17.4
Dysmenorrhea 27.6 20.0 16.1 13.0
Abd. pain 7.7 13.3 5.9 13.0
Lumbago 6.1 6.7 5.9 8.7
Vaginal discharge 3.0 13.3 2.5 8.7
No. of examined 65 15 118 23
74 The major reasons for removal appeared to be bleeding Device Insertion by Physician and Paramedical Personnel, and pain and also the side effects observed on 48 hour follow- KIFP, 1976. up visit were bleeding and pain. 7. Kwak, H.M., "Studifs on the Effect of Intrauterine Con Kwak 7 ) reported that histologically the endometrium traceptive Device: with Particular Reference on the Endo showed essentially normal pattern except for hyperplasia. metrial Changes", Korean Jr. of Ob & Gyn, 8(6): 1-3, Hyperplasia observed may be in keeping with the Grafenber's 1965. idea of a "non-inflammatory hypertrophy which he believes is Intra the mechanism of action in preventing pregnancy. 8. Kwak, H.M. & C.H. Song, "A Clinical Study on uterine Contraceptive Device on Yonsei University Family Park Et Kim 13 ) performed a histopathologic study by Planning Clinic," Korean Jr. of Ob & Gyn, 15(11): 561 endometrial biopsies obtained from cu-7 users and Alza-T 586, 1972. (hormone releasing IUD) users on their. 12-month follow-up visit in order to observe the nature and the incidences of ab- 9. , "A Study on Intrauterine Contraceptive Device, normal endometrial findings. T Copper Model Tcu 200" Korean Jr. of Ob & Gyn, 16 (11): 737-748, 1973. Hyperplastic change was observed 15.4% of the cu-7 users and 2.9% in Alza-T users. Pseudodecidual reaction was 10. Kwak, H.M. & D.W. Ahn, "Hysterographic Study of not observed in cu-7 users, but 23.6% in Alza-T users. 59% of Intrauterine Contraceptive Device in Utero", Korean the cu-7 users and 73.5% of the Alza-T used exhibited signi- Central Jr. of Medicine, 22(5): 559-571. ficant degree of small round cell infiltration. 11. Lee, S.K. "Clinics - Radiographic Study on the Changes Kim 5 ) reported that 78.5% of the women who had their of Lippes' Loop by Use," Jr. of Korean Medical Associa devices (Lippes' loop) removed for planned pregnancy have tion, 14(4): 326-331, 1971. been followed up became pregnant within 1 year after re 12. MOHSA, National Intra-Uterine Contraception Report, moval. Korea, 1967. of poorly visible or invisiblo Lee11 ) reported the number loops radiographically was increased in the users of more than 13. Park, K.J. & S.W. Kim, "A Histological Study on the En thirty months, which was assumed to be due to the gradual dometrial Response to Copper- and Hormone-Releasing less of radiopaque material, barium sulfate, from the devices Intrauterine Devices," Korean Jr. of Ob & Gyn, 20(8): by use. 533-543,1977.
Ahn1 ) reported the heavier loops were the more elastic 14. Shin, J.H. "A Study on the Effectiveness of the New and there was no correlation between the duration of wearing Contraceptive Device, Copper-T," Kyungpook University and the elasticity of the IUD. Medicine Journal, 14(1):41-54,1973.
Kwak Et Song9 ) performed cervical cytologic study for 15. Shin, H.S., etal. "Results of the Clinical Research on IUD cancer before and after insertion of cu-T and was no evidence in Korea, Korean Jr. of Ob & Gyn, 9(5):1-12,1966. that the presence of device caused a progression of cytology toward cancer. The list of titles for the on-going research projects on IUD REFERENCE are as follows: 1. A comparative study on the effectiveness of immediate 1. Ahn, D.W. et al. "Hyterographic Study on the Uterine postabortion intrauterine contraceptive device insertion. Device in the Uterine Cavity," Korean Jr. of Ob & Gyn, Objectives: 16(7):447-454, 1973. a) To compare their contraceptive effectiveness and 2. Choi, Chi Hoon, Comparative Study on the Continuation acceptability of immediate postabortive insertion of Rates of IUD Acceptors Recruited by Volunteer Workers Lippes' loop, cu-7 and cu-T. and Government Family Planning Field Workers, Center for Population and Family Planning, Yonsei University, 2. Case-control study on the relative risk of ectopic preg Korea, 1975. nancy and pelvic inflammatory disease associated with IUD use. 3. Kim, Syng Wook, "A Comparative Study on the Effec tiveness of Immediate Postabortion Intrauterine Contra- Objectives: ceptive Device Insertion," Korean Jr. of Ob & Gyn, 20 a) To estimate the relative risk by type of device, age, (11):867-873, 1977. parity, marital status and past gynecological history.
4. , "A Clinical Study on the Contraceptive Effective- b) To assess whether there is interaction between the ness of Cooper-7 and Alza-T Intrauterine Device," Korean risk of PID and ectopic pregnancy. Jr. of Ob & Gyn, 19(12): 1-8, 1976. 3. Multi-center study of the microbiology and histology of 5. Kim,S.W., et al."A Study on the Long-Term Effective- the fallopian tube in IUD users. the Lippes' loop," Korean Central Jr. of Medicine, Objectives: ness of an 27(1):785-793, 1974. a) To determine ifintrauterine device users have increase likelihood of developing salpingitis. Whether, of 6. Kong, S.K., et al.A Comparative Study on Effectiveness - there isany microbiological contamination and Patient Satisfaction for Intra-Uterine Contraceptive the fallopian tube in IUD users vs. non-IUD
75 users. REFERENCE - there is any histological evidence of non bacterial or non-viral salpingitis in IUD users vs. 1. Choi, S.K. et al. "Clinical Characteristics of Trophoblastic non-IUD users. Disease in Korean Women,' Korean Jr. of Ob & Gyn, - if there is microbiological contamination of the 19(9), September 1976. fallopian tube in either IUD users of control or both, there is a commonly infecting organism 2. Lee, Y.H. "Clinical Study of the Trophoblastic Tumor," whether bacterial or viral. Korean Jr.of Ob & Gyn, 16(6), June 1973. - if there is microbiological contamination of the fallopian tube in either IUD users or controls or 3. Rhee, E.D. et al. "An Observation on Trophoblastic both, there is histological changes which corre- Tumor from Clinical Statistical Viewpoint," Korean Jr. of late with positive microbiology and, if there are, Ob & Gyn, 16(81, August 1973. the changes are more obvious in IUD users.
4. Hormone releasing vaginal rings. E. Traditional Medicine for Fertility Control Objectives: a) To evaluate the effectiveness of this new method of In Korea, numerous plant or animal preparation have been contraception, used for the purpose of fertility control. But these descriptions b) To determine its acceptability by evaluating what are based upon the experience of human trial for hundred degree of disturbance of menstruation occurs years. c) What the local tolerance of the form of contraception is. Kiml) studied the contraceptive effects of 6 kinds of herbal medicine: Bombyx Testa Ovum, Lithos'permi Radix, 5. Long-term effect of the IUD on the human endometrium. Woon Dae Ja, Yu Jun Mercury, Si Ja Dae, and Pteropi Ster Histologic, histochemical and ultrastructural studies. cus. Evaporated extract from individual herb medicine were Objectives: administered to female rats orally. Bombyx Testa Ovum, a) To search for morphologic evidence of possible anti- Lithospermi Radix, Woon Dae Ja, Yu Jun Mercury, and Si Ja fertility mechanisms and also side effects of long Dae were not entirely showed the contraceptive actions, but terms wearing of the IUD on the human endo- only the pteropi stercus was found 79% of contraceptive metrium by concomitant light microscopic, histo- effect. chemical and ultrastructural investigations. Lee2) surveyed literally the plants and the animals with fertility regulation activities which have been used in Korea. D. Trophoblastic Disease Lists of 110 plants and 17 animals covering most of the natural products with reputed antifertility effects in Korea are in Table Trophoblastic disease is a common disease in Korean E-1 and E-2. women. Here are some research findings on incidence of tro phoblastic disease. Studies were mostly undertaken for the clinical analysis and evaluation on the women with tropho- REFERENCE blastic disease who had been admitted and treated at hospital. The following features were the comparison of the result 1. Kim, Kwang Ho, "The Contraceptive Effects of the (Table D- 1). Several Herb Medicine," Bulletin of Kyung Hee Pharma ceutical Sciences, 4:51-54, Seoul, Kyung Hee Uni Rhee3) reported that the peak incidence of hydatidiform versity, College of Pharmnacy, 1976. mote was in the twenties (60.9%), that of destructive mole in the forties (44.4%), and that of choriocarcinoma in the thirties 2. Lee, E.B., et al. "Plants and Animals Used for Fertility (43.1%). Regulation in Korea," Korean Jr. of Pharmacognosy, 8121, June 1977. In cases of choriocarcinoma, hydatidiform mole as their previous pregnancy were reported above 30%1), 2), 3) Also antecedent pregnancy was abortion in 49.2% of hydatidiform In'Korea, the following title of the research is on-going. mole and 50.1% of choriocarcinoma. 1. A hex center c.)llnhorative approach fer the isolation of Inthe patient with chorioadenoma destruens,2) remission fertility reguladiiq .amponent from 246 plants. rate was 76%. In patient with choriocarcinoma remission rate Objective: was 51%, mortality rate was 26% and recurrence rate was a) To isolate fertility regulating component from 40 12% respectively, kinds of plants in Korea.
TABLE D-1: - COMPARISON THE INCIDENCE OFTROPHOBLASTIC DISEASE IN KOREAN WOMEN
Year of No. of Authora Data No. of Trophoblastic Hydatidlform Destructive Chorlo Collection Delivery Disease Mole Mole carcinoma 2 ) Lee 1961-1972 15,123 187 (1:81) 94 (1:161) 17 (1:889) 76 (1:199) 3 Rhee ) 1962-1971 11,996 163 (1: 74) 87 (1:137) 18 (1:667) 58 (1:207)
(: refers to the ratio occured once to all delivery.
76 TABLE E-1: - PLANTS USED FOR FERTILITY REGULATION IN KOREA Purpose Part Family Name Plant Name of Use In Use
Amarantaceae Achyranchesjaponica A rt Amarantaceae Amaranthus ascendens A h Amarantaceae Celosia cristata C Amaryllidaceae Narcissus tazetta var. chinensis C Araceae Arisaema sp. A rh Aristolochiaceae Asarun maculatum IM rt Auriculariaceae Auricularia polytricha C Balsaminaceae Impatiens balsamina C, IM h Bignoniaceae Campsis grandiflora IM f Borraginaceae Lithospermum erythrorhizom C(p) rh Campanulaceae Adenophora remotiflora A Caryophyllaceae Dianthus sinensis A, IM h, s Caryophyllaceae Melandium firmum IM h Celastraceae Euonymus alatus A Compositae Artemisia asiatica IM Compositae Artemisia keiskeana IM s Compositae Atractylodesjaponica IM rh Compositae Carthamus tinctorius A, C,IM f Compositae Chrysanthemum indicum IM f Compositae Chrysanthemum sitiricum IM Compositae Echinops setifer IM Compositae Helianthus annus IM Convolvulaceae Pharbitis Nil A s Cornaceae Macrocarpium officinale IM Cruciferae Brassica campetris var. nipooleifera C s Cruciferae Brassica juncea C(p) s Cucurbitaceae Cucurbita moschata var. toonas A, IM v Cucurbitaceae Trichosanthes cucumeroides A, C rt Cucurbitaceae Trichosanthes Kirilowii var. japonica C rt Cyperaceae Cyperus rotundus A, IM rh Cyperaceae Scirpus maritinus IM rh Ebenaceae Diospyros kaki C Eucommiaceae Eucommia ulmoides A Euphorbiaceae Croton tiglium A, IM s Euphorbiaceae Euphorbia pekinensis A, IM rt Euphorbiaceae Ricinus communis IL s Ginkgonaceae Ginkgo biloba IL Gramineae Coix Lacryma-Jobi var. mayuen A s Gramineae Hordeum sativum A, C sp Gramineae Imperata cylindrica var. koenigii IM rt Gramineae Phyllostachys edulis IM Gramineae Zea Mays A Irideae Crocus sativus IM f Labiatae Leonurus sibilicus IL, IM h Labiatae Mentha saccharinensis IM I Labiatae Ocimum sanctum C h Labiatae Perilla frustascens var. crispa A Labiatae Salvia multicorrhiza A, IM rt Lardizabalaceae Akebia quinata A, IM Lauraceae Cinnamomum cassia A, C (p), IM b Leguminosae Caesalpinia sappan IM Leguminosae Gleditschia japonica A Leguminosae Glycine Max IM s Leguminosae Glycyrrhiza glabra C rh Leguminosae Phaselous radiatus C d Leguminosae Pueraria thunbergiana A, C(P) rt, f Leguminosae Robinia pseudo-acacia C f Liliaceae Aloe sp. IM ex Liliaceae Hosta undulate A rh Liliaceae Smilax china C Loganiaceae Strychnos ignatii A, IL Loranthaceae Viscum coloratum IM Lythraceae Lagerstoemia indica IM Malvaceae Althaea rosea A, IL, IM h,s
77 Malvaceae Malva verticillata A, IL Moraceae Cannabis sativa A, IL, IM rt, s Musaceae Musa basjoo IM Oleaceae Forsythia koreana IM fr Palmae Trachycarpus fortwnei C(p) s Papaveraceae Cordatis sp. A, IM rh Pedaliaceae Sesamum indiucm IM s Phytolaccaceae Phytolacca esculenta A f, rt Plantaginaceae Plantago sp. A, IL S Polygonaceae Fagopyrum vulgare C Polygonaceae Reynoutria cuspidatum IM rt Polygonaceae Rheum unduratum IM rh Polyporaceae Poria cocos IM Ranunculaceae Aconitum japonicum A rh Ranunculaceae Clematis mandshurica A, IM rt Ranunculaceae Paeonia albiflora IM rh Ranunculaceae Paeonia suffruticosa A, IM rb Ranunculaceae Pulsatilla koreana C rt, f Rhamnaceae Zizyphusjujuba var. inermis IM fr Rosaceae Crataegus pinnatifida IM Rosaceae Duchesnea chrysantha IM fr Rosaceae Prunus persica A, IM s Rosaceae Rosa multiflora IM fr Rosaceae Sanquisorba officinalis var. carnea IM Rubiaceae Gardenia jasminoides C f Rubiaceae Rubia akane A, IM rh Rutaceae Zathoxyulm pipericum IM Scrophulariaceae Rehmannia gluticosa A Solanaceae Physalis francheti A, IL, IM h, rt Solanaceae Solanum melongena C f Solanaceae Solanum nigrum A Taxaceae Taxus cuspidata IM I Thymelaeaceae Aquitlaria agallocha IM Ulmace Ulmas japonica A, IL b Ulmaceae Celtis sinensis IM Umbelliferae Angelica dahurica IL, IM rt Umbelliferae Angelica gigas IM rt Umbelliferae Cnidium officinale A, IM rh Urticaceae Boehmeria frutescens A, IL Usneceae Usnea diffracta IM Valerianaceae Valeriana officinalis var latifolia IM Valerianaceae Patrinia scabiosaefolia IM Varbenaceae Verbena officinalis IM h Verbenaceae Vitex cannabifolia tM rt Zingiberaceae Curcuma longa IM rh Zingiberaceae Curcuma zedoaria IM rh
A: abortion, C: contraception; C(p): permanent contraception, IL: induction of labor, IM: induction of menstruation, br: bark, ex: extract, f: flower, fr: fruit, h: herb, 1:leaf, rb: root bark, rh: rhizome, rt: root, s: seed, v: vine, a: same species used in the other country, b: other plant in the same genus used in the other country, c: reported to have estrogenic activity, d: plants reported to show antifertili ,tivities in laboratory animals. TABLE E-2: - ANIMALS USED FOR FERTILITY REGULATION IN KOREA. Purpose Part In Use Family Name Animal Name of Use w Acridiidae Oxya velox IL Cervus sp. IL h Cervidae m Cervidae Moschus moschiferus sacchalinesis A, IL Chelonia japonica IL c Chelonidae w Cicindelidae Cicindela chinen,,s IM Oncotympana coreana IL C Cicodidae w Crustacea Percellio sp. IM Tabanus sp. A, IM w Diptera w Falsonidae Buteo burmanicus IM Grapsidae Eriocheir sp. A C w Hirudinea Hirudo nipponia A, IM Phrynocephalus frintatis IM w Lacertilia w Lepismadae Lepisma villosa A, IM Bombyx mori C(p), IL e Lepitoptera w Ranidae Rana nigromaculata C Scropendra rubiginosus AIM w Scropendridae w Trionychidae Amyda maackii A, IL,IM
of menstruation, c: A: abortion, C: contraception, C(p): permanent contraception, IL: induction of labor, IM: induction cortex, e: eggs, h: horn, m: musk, w: whole animal.
79 PAPER 16
TAIWAN
Country Paper
INTRODUCTION 2) research on socio-economic and demographic in terrelationships; and, The family planning programme in Taiwan Area, which has been carried out by some voluntary organizations or as the 3) prograrme-oriented research. study projects since 1959 was expanded as a national pro gramme in 1964. In 1968 the regulations governing the imple- This paper deals largely to the last category, particularly mentation of family planning was promulgated by the Exe- the medical aspect of contraceptive researches. cutive Yuan (Cabinet) and the Population Polfcy of the R.O.C. was announced in 1969. I. Systematic Analysis of Contraceptive Acceptors: All contraceptive acceptor data are compiled based on the Delivery of family planning services has been integrated results of analysis of returned coupons for all types of accep as part of overall health care. Todate, there are 363 public tors collected from the public, private and military hospitals health stations, 864 contracted physicians for IUD insertion and clinics as well as health stations where such services are and 635 physicians for surgical sterilization, 454 full time field provided. workers as well as 1,500 nurses and midwives are providing family planning services to the people. Four methods of con- The data are used as a mean to evaluate the workers per traception: Lippies Loop and Ota Ring, oral contraceptive, formance including work unit credits calculation for field condom and male and female sterilization are available to all workers, the auditing basis for payment to the physicians for married couples desirous of spacing, limiting or preventing service, and various findings obtained from the characteristics pregnancies. Annually, about 350,000 new acceptors are re- of the acceptors serve as a feedback for the operation of the cruited and of which about 50% accept IUD, 15% oral pill, family planning programme and are important director for pro 20% condom and 15% sterilization. The family planning prac- gramme planning. tice prevalence rate among married cou,'es iged 20-44 was estimated at 65% as of 1976. As of May 1979, the cumulativr number of acceptors in cluding 2,161,818IUD insertions, 654,538 pill and 548,963 con As of December 1978, the crude birth rate was 24.2 per dom users, 177,027 tubactomies and 15,658 vasectomies. As thousand, the crude death rate, 4.7 resulting in the natural in- far as the socio-demographic and reproductive characteristics crease rate of 19.5. In accordance with the third Three-Year of the acceptors are concerned, they have been becoming Reinforcement Famil7 Planning Programme, July 1979 - June younger, having fewer children, and higher proportion of con 1982, which set ata' get of reducing the crude birth rate to 22.1 traceptive practice has been for child birth spacing. For exam per thousand by 1';2. pIe, based on 1978 data analysis, 61.6% of the IUD acceptors were younger than 30, 72.3% of them had only three or fewer children at the time of insertion and about a quarter (26.7%) Contraceptive Research of the acceptors used the method for child birth spacing. The median age of pill and condom users were 26 and 27 respec- Research is a basic activities in the national programme tively and the median number of children for pill and condom from the start. Findings from studies undertaken enable us acceptors were both 2.2. The proportion accepting to space to adopt necessary policies and programme strategies that are childbirth for pill users was 40.5% and the corresponding deemed to help achieve the goals of population growth re- figure for condom acceptors was 40.8%. duction and improve the health status of the population. In regard to sterilization, almost half (49.9%) of couples Population/family planning related research activities in accepted sterilization at the wife's age below 29 and the Taiwan Area, R.O.C. can be categorized broadly into: average number of children was 3.4.
1) research on demographic levels, patterns and trends; II. Oral Contraceptives:
80 1. The first island-wide pill acceptor follow-up survey was (4 cases) and found that no jaundice and hepati conducted in 1968 by the Institute of Family Planning. tis was found among these tested. 2,217 pill acceptors were interviewed. The major finding from the study indicated as follows. The average months 3) 9 cases with abnormal EKG changes were found not of use of the pili for continuing cases was 10.3 months associated with the duiation of pill used. against 4.0 months for the terminated ones. The cumula- Il1 IUD tive termination rate was 49.8% for medical reasons, 9.2% for personal reasons and 8.6% for supply and other In 1962 Lippes Loop was introduced in Taiwan and has reasons. Nausea, vomitting and other G.I. disturbances, been adopted as the main method of contraception in the breakthrough bleedings and menstrual complication were national family planning programme. Ota Ring was used by the four major types of side-effects for those who ter- clinician even before loop was introduced and has also been minated for medical reasons. adopted by the programme since 1975. Other types of IUDs Cu-7, Cu-T, multiload were inserted by clinical trials 2. An experimental study was carried out in 1968-1969 in such as Each and self-supporting. three matching groups of townships in Taiwan. group of township, with 100,000-150,000 married Several researches have been conducted and the follow women 20-44, was offered only one type of pill; Ouvlen- ing summarize the findings which are more concerned with 21, Ouvlen-Fe-28 or Primovlar-21. The acceptors were medical aspects: followed-up four months later to compare the use-effec tiveness of each type of pill. The comparison between 1. Medical follow-up study for 1,500 women who accepted Ouvlen 21 and Primovlar 21 with Ouvlen-Fe-28 pills in- either loop or coil was carried out in 1962 by Taichung dicated that the Ouvlen-Fe-28 has slightly better continua- Study Center. The users were asked to return to a clinic tion rate than the other two types. The comparison be- for examination. Findings include data on termination tween the lower estrogen and the higher showed that the rates, reasons for termination and pregnancy rates. lower had higher continuation due to fewer side effects. 2. Histological Study of the Endometrium of IUD Users was 3. Medical follow-up of pill users was conducted for 26 conducted by Dr. Wei, P.Y. and others in 1967. Endo months by the OBGYN Department of Chung Shing metrial biopsies of 422 IUD users were studied. The in Municipal Hospital in Taipei City during 1974-1977. The cidence of abnormal endometrial changes among IUD study subjects were divided into groups; the A group in- users was determined. cluded 5 patients using Primovlar-ED for treating Endo metrities for more than two years, B1 group composed of 3. Several Taichung IUD medical follow-up studies were 675 cases taking pill for approximately one year and B2 conducted and the findings are summarized as follows: group including 228 cases used pill for more than 3 months. B.P., body weight and clinical signs and symp- 11 Ota ring and loop size No. 4 are no better than loop toms were recorded regularly. Laboratory examinations size No. 3 even if preferred by the inserting doctors; for blood (including blood routine, bleeding time and prothrombin), urine, pap smears and E.K.G. were carried 2) the use of loop does not seem to increase the inci out every 3months. dence of carcinoma; Three types of pills were used inthe study: 3) calcium deposition on the loop intensifies with dura seem to increase the inci 11 Primovlar-ED-28: Norgestral 0.5 mg., Ethinyl estra- tion of use but does not diol 0.05 mg.; dence of removal. of Coexist Neovlar-ED-28: d-Norgestral 0.25 mg., Ethinyl estra- 4. In 1971, astudy on Sonographic Visualization 2) a considera diol 0.05 mg.; ing Gestation Sac and IUD in the uteius and tion of causative factor of accidental pregnancy was con 107 women wearing 3) Ovral-28: Norgestral 0.5 mg., Ethinyl estradiol 0.05 ducted by Dr. Wei, P.Y. and others. using B scan at the mg. various types of IUD were studied OBGYN Dept. of the National Taiwan University Hospital. with satisfactory Major findings include: The position of IUD in suit was obtained result. Besides, other findings, such as complications of deve Complaints: associated with pregnEncy in the very early stage 1) gestation a. Reduced menstrual flow was found in almost lopment, myoma uteri, ad-nexal cyst, ectopic -O%of women who took pills for more than 6 and etc. This phenomenon has been one of the months. T-20 was conducted in 1972 irportant causes led to discontinuation of pill 5. A follow-up study of copper of arcceptors. by the Provincial Institute of Family Planning. 1,445 1,581 women accepted the device was covered in the b. 40% of women who used pills for more than 6 study. Important findings include: moinths complained increased luchorrhea. 1) 35% of women discontinued the device at the end of 2) Laboratory Examination: the fist year after insertion; a. Blood pictures, bleeding time, and prothrombin time were found tu be in normal range. 2) of the discontinued, 26% removed the device, 2.5% became pregnant and 6% expelled; b. Liver function tests were carried out to 6 cases with SGOT 40 SFU (2 cases) and SGPT 40 SFU 3) of the removed, 75.8% were due to side-effe
81 14.5% on personal reasons, and 9.7% were seeking County received tubal ligation during Jan. - May 1974 for pregnancy; were followed up in Sept. - Nov. of the same year by the Provincial Institute of Family Planning. In other words, 4) side-effects encountered were mainly bleeding, pain the cases were followed up between 6 - 11 months after and menstrual disorders. ligation. The study was conducted by interviewing of the women by well experienced public health nurses and IV. Sterilization family planning field workers and by reviewing of their medical records in the clinics where ligation was per formed. Since 1974, sterilization has been adopted as the pro- gramme method, the number of acceptors increased consider ably (mostly female) from 7,000 in 1974 to 50,000 in 1979. About 80% of the sterilizations were performed by the con- The socio-demographic data of the study revealed that tracred private physicians. The following summary describes the average age at the time of ligation was 30.4 for the studies conducted in sterilization, acceptors and 35.0 for their husbands. The educational levels for the cases were 22% below primary, 68% had 1. In 1974, the National Health Administration conducted a primary and about 15% had secondary education. The follow-up survey for 958 cases residing in Taoyuan Coun- corresponding figures for the husband were 10%, 60% ty and Taipei City received tubal ligation during 1957- and 30% respectively. 80% had 3 - 5 living children and 1973. Of these, 56% of them received ligation within three the mean was 4, onp child higher than the national figure. years. They were interviewed by a group of well trained 27% of the women have never used any contraception public health nurses. Questions asked to the women in- before ligation and among the used ones, 58% had ex cluded: socio-demographic characteristics, reproductive perience with loop, 28% with oral pills and 20% had con behavior, contraception experience before ligation, doms. The average number of pregnancy each woman psycho-sexual and physical health conditions after liga- had was 5 and 33% of them had experience of one or tion. more abortions. The important findings summarized are: Important findings obtained from the medical records were as follows: 86% of the operations were done 1) 84% of them received ligation soon after delivery and through laparatomy and 14% by vaginal route. Methods 16% during the interval, of ligation, 52% used Madlener technique and 34% used Pomeroy technique. Concerning length of hospitalization, 2) Only 16% had the surgery purely for ligation purpose 53% reported under 7 days and 25% were on the O.P.D. and the majority was carried out with other surgical basis. Concerning complications following ligation, due to procedures, incomplete recording, only 114 (22%) case records with notes. Of these records, 57 cases (50%) were found with 3) Concerning the procedures, 96% were through lapa- same complaint. The important ones were endometritis ratomy, 3% through virgina route and 0.63% bylapa- (9.6%) spotting (16.7%), lower abdominal pain (9.6%) rascopy. and some menstrual complication (15%).
4) In regard to anesthesia, they reported that 40% re- Comments regarding after ligation, 83% reported satis ceived general anesthesia, 38% by spinal anesthesia factory and 75% expressed that they will recommend the and 22% by local anesthesia. method to the others. 80% of the women reported no change in their sexual desire, 5% with increase but 10% 5) 83% of ligations were performed by the private prac- expressed decrease. ticing physicians and the rest by government hos pitals. 3. A follow up study jointly sponsored by the Maternal and Child Health Center, Taiwan Area, and the NHA for 200 6) Regarding menstrual history after ligation, 78% re- vasectomy cases with their spouses and a cor-nl ,-.-r ported no change and 22% observed some changes ws initiated in 1978 and expect to completc -i 19& "r, in the reduction of menstrual fluid but this seern programme is designed to follow up the !:'Lron-, .. related with age increases. aspect of the men currently received vasecton.,; t ICH Center and their spouses befora and after vasectomy, 7) Reporting of physical health condition, 65% men- their physical health conditions and complications after tioned no change and 17% said they feel better fit sterilization. then befor. The interview of the 200 cases and 150 of their spouses 8) More than 130%experienced no changes in their before vasectomy was conducted at the MCH Center by psycho-sex jal relations with their husband and other public health nurse. health educators and psychologists. family members. For the 17% with some changes, As of May 1979, psycho-sexual tests, using developed they expresied that they were happier, emotionally forms for 95 vasectomized cases, 44 of their wives for the more stable and became more interested in house- first (3 months after vasectomy) and the second time (one hold matters and etc. year after vasectomy) were carried out. The same tests were also conducted to 53 couples of the control group. 2. A study for 519 cases, residing in Taichung City and The project isstill ongoing.
82 PAPER 17
PRIMARY HEALTH CARE WITH SPECIAL REFERENCE TO NUTRITION, MCH AND FAMILY PLANNING
Dr. Somboon Vachrotai
Ministry of Health leaders in most countries of Asia have experience. For example: lorg recognized the need to strengthen the government health and utilization of 1 million village health care delivery system and extend basic health services to cover (1) Development volunteers and communicators; the majority of the population, over % of which reside in underserved rural areas. In Thailand, as the government health services searches for lternative methods for extending basic (2) Nw clinical care extenders including nurse and auxiliary of midwife practitioners; health services to the majority of rural villagers, a concept primary health care is evolving which builds on existing tradi- ( Community medicine departments for all provincial hos tional and indigenous patterns of health care, utilizes villages pitals; and, volunteers and available community resources for health deve lopment, and stresses the government role in helping the rural (4) Integration of health services and improved health sar people to help themselves. The primary health care approach v4 e ngeent for rural health development incorporates both modern know- vices management. ledge and traditional wisdom in evolving methods that are A high level of commitment by the government health simple, but effective, in meeting the dominant health needs of sarvice system to the implementation and the maintenance of the rural majority. primary health care workers is crucial to the success of the government this country, the Pitsunaloke Project, the Saraphi programme. A substantial change within the Here, in primary health now the Lampang Health Development Project health service isrequired for optimal support of Project, and of the government vanguard efforts which have helped to evolve the current care workers. Ideally, the reorganization are the selection and training of Primary Health Care approach to MCH, nutrition and family healto system should occur before but it can occur concomitantly as planning in Thailand. In 1974, the Ministry of Public Health primary health care workers, isin Thailand. inaugurated the Lampang Health Development Project to it health services and develop a provincial model for integrated effort for an cbre. The health development strategy of the The primary health manpower development primary health operate in concert involves four key features: extensive primary health care scheme to Lampang Project pla.e a heavy demand on primary health care workers for every village; w~th government health services will (a) developing available resources. The limitations of government training background of primary wechakorn, or community health paraphy- rescurces and the limited educational (b) developing methods and the for every hospital and rural health center; health care trainee require that the training sicians, technologies applied for primary health care work be low-cost, link be private sector involvement ani community simple, aopropriate and clearly speci the essential (c) developing and the government participation inprimary health care work; and, tween the primary hoalth care voluntee,s rural health workers. medical care, health promotion and disease (d) integrating the year 2000" still prevention services and developing improved manage- Clearly, inThait.nd, "health for all by however, recognized the ment practices from the provincial level to the health remains aformidable task. We have, that are waiting to be mobi center level, potential of the human resources lized. We are developing a "grass-roots" primary health care The Ministry of Public Health has drawn on the experience manpower force comprising traditional midwives, village promote Lampang Project in formulating the national health health post volunteers and communicators that will of the com policy and plan. The Ministry's most ambitious effort is the rural health and development efforts through organized modern national vlhage health volunteer and village health communica- munity effort. By combining traditional wisdom and and tor scheme for rural primary health care expansion. The technology we are forgoing a new health care system villages health plan includes several features which have been health technology appropriate for reaching 50,000 rural national people. developed, replicated and adapted from the Lampang Project and capable of serving 50 million Thai
83 ANNEX Training ACTIVITIES AND TRAINING OF WECHAKORN, The one-year training programme includes the following COMMUNITY HEALTH PARAPHYSICIANS topics: Activities 1. Core Skills: Wechakorn, formerly nurses, midwives and sanitarians, (a) History taking and medical terminology. 30 hours are trained in a one-year competency-based training pro- (b) Physical examination, anatomy gramme and deployed to all rural health centers and district and physiology 60 hours hospitals to extend competent clinical services to the sub- (c) Laboratory examination 30 hours district level, and to greatly expand the capacity of the entire (d) Use of a formulary 6 hours provincial health system to provide curative servicez and health (e) Iodealth care 6 hours promotion and disease prevention services. The trained (f) How to use protocol 6 hours Wechakorn is able to: 2. General Clinics 1. Provide medical care for patients suffering from common (a) Skin problems 30 hours illnesses and injuries, under the remote supervision of a (b) Ear, Eye, Nose and Throat problems 30 hours physician. (c) Chest problems 30 hours (d) Abdominal problems 30 hours 2. Provide first-aid and supportive care for serious or com- (e) Genito-Urinary/Kidney, Ureter, plicated cases, and refer these patients to a physician at Bladder problems 30 hours the district or provincial hospital. (f) Diarrhea/Vomiting/Dehydration 12 hours (g) General problems 30 hours 3. Supervise the health center personnel in providing simple medical care, health promotion services and disease pre- 3. Emergencies vention services. 4. Maternal and Child Health 4. Supervise and guide the work of village health post volun teers. (a) Maternal and Child Health Care 30 hours (b) Family Planning 24hours 5. Administer health center work and assist in clinical and administrative work of the district and provincial hos- 5. Community Health and Field Supervision pitals. (a) Nutrition problems 30 hours (b) Prevention 30 hours 6. Promotd and guioe community health development pro- (c) Vital Statistics 18 hours grammes such as nutritional surveillance and community (d) Community Health Education 18 hours nutrition improvement programmes. (e) Supervision 12 hours
84 PAPER 18
PRIMARY HEALTH CARE WITH SPECIAL REFERENCE TO NUTRITION, MCH AND FAMILY PLANNING
Jae-Mo Yang, M.D.
CHAPTER I. INTRODUCTION AND OBJECTIVES When the Kangwha Community Health (Teaching) Pro ject of Yonsei University was started in 1973 the problems health care delivery system suffered from There is no doubt that during the 20th century, particular- which the Korean and medical were typical of developing countries. Health care was uneven ly since the 2nd World War, medical knowledge to unprecedent in ly distributed among the people, too costly for the majority technology made remarkable development disease such highly developed afford, disease and hospital-oriented although most human history. But, unfortunately, were caused by preventable conditions. Number, education modern medical care services are mostly provided by highly and distribution of health manpower were inappropriate to qualified specialist at urbasn hospital at high cost that hardly actual needs of the population. Health problems remained un accessible to the masses, and medical education also has been recognized and unattended to in the face of abundant need grossly mislead to such direction. because of poverty, but equally so because of lack of health knowledge, health consciousness and health concern among From the 4th Five-year Development Planning period the people and the government. (1977-1981) the government of Korea firmly decided to pay attention to the health and welfare aspect of her people and Even though nowadays the health service scene in Korea began to put as much emphasis on social development as has changed greatly from the initial period of the project due economic development. But the immediate question encoun- to rapid economic growth, and even though the general out tered was how to achieve such goal. Compared with the na- line of the national health plan for the next 5 years has been tional education service, which made the primary education formulated, the major health problems are still similar to that compulsary decades ago and now planning to extend it to the of 5 years ago. The most striking change that has occured in secondary (high school) education, unfortunately, in the the last five years is the development of the rural community health care field the need of utmost priority of primary health itself led by "Saemaul undurig". Health is again left behind care has been recognized only recently. even in the "Saemaul undong". With this rapid community development the income and the health status of farmers have much improved; however, the health care delivery system has Now that such problem is well recognized, the challenge not been significantly improved yet. and task vested in modern medical education and health care service planning is to ensure a comprehensive health care of Up to the present time, the health care delivery system in adequate quality to every body, regardless of old or young, rural Korea has been based on a centrally controlled system rich or poor, through the development of ideal and efficient offering mainly public health and preventive medicine pro health care delivery system with the utmost priority in primary grammes, and having very poor infrastructures connecting health care. grass root activities. Each gun (county) has one health center with one public health officer whose major role is inevitably Yonsei University has three projects in the area of primary public health administration. Many of the health centers have health care: namely, langwha Community Health Project been unable to recruit the public health officer. started from 1975, A Study on New Approach in Maximization of Family Planning and Health Services in Rural Korea: Com- The major portion of the subsidy to add to the salary of parison between New Village Health Worker and New Village the health officer isfrom the central government. Major health Movement Leader started from 1977, An Experimental Study programs of the local health center are assigned and directed on the Integration of Health and Family Planning with the by the central government. The health center is usually built "Saemaul" Movement started from 1978. Following descrip- with support from the central government. Additional facilities tion is primarily the experience of the Kangwha Community and equipment are mostly supplied by the central government. Health Project. Therefore, the community voice has not much input in the
85 decisicn making process for its own health programme. The services in response to community demands and to ensure the community is simply a passive receiver of health services. It is best utilization of existing facilities and services. necessary to establish a certain mechanism so that the com munity can participate actively in the health programmes for At the myun area, a comprehensive primary health care its own people, if a new system isto be designed. center (myun health subcenter) with referral channel to a hospital was designed and organized in order to function as Administratively, the myun (township), where the majo- a nucleus or center for the health care services to the rural rity of the rural population reside, is the official terminal unit population. A financing mechanism to make the system viable for comprehensive public administration. Each myun has a was also developed in the project. government health subcenter building which is supposed to provide primary health care service to the rural r.Jpulation. The project was developed as a field area for community One midwife is sometimes provided for MCH services, and based medical and nursing education in rural community two nurse aides for T.B. and F.P. care are dispatched by the health, and for the provision of necessary statistical and obser health center to provide preventive health services to the myun vational data for classroom teaching. area. But the functions of these health workers have not been integrated into the health subcenter; they are supervised by A project planning, implementing and coordinating team, the township chief and work in the myun office instead of the which had already been established 5 months before funds health subcenter building. became available, concerned itself first with development of the necessary concepts and strategies for planning. In addition, afew experiments on the improvement of the health care delivery system in rural Korea revealed that the This mea,it, before other considerations, to identify those present myun health workers, usually three nurse aides with problems which the project should try to solve conceptually nine months training, are not enough to cover the basic needs and pragmatically, and those problems which would come up of primary health care in their entire target population, during implementation of a basic care project into a specific community. These considerations included the fact that mo Another weak point of the health care delivery system in dern health services often have difficulties in relating their ad rural Korea is the dual system of health services. The preven- vantages effectively to non-Western communities. This diffi tive medicine and public health programme are under the culty of introducing modern health services into traditional government's jurisdiction and the curative service is mostly in non-Western communities is a result of the fact that a tradi the hands of local practitioners. No integrated programmes of tional culture and woridview of the people in the region has efforts have ever been attempted. Even though it is not suffi- existed for millenia, and that the health and illness behaviour cient, the government preventive service system usually of the people are different from what they are in the West. reaches the village people; however, the curative service is Although modernization changes almost every aspect of social available only for those who seek it and are able to afford it, life in Korea with breath taking speed, health and illness be and is generally rendered by the private practitioners. In addi- haviour are less easily affected. Modern medicine in Korea has tion, the curative service is often beyond geographical reach not yet sufficiently taken this behaviour into account. of the rural residents. Furthermore, the inability of health services to adequately In short, the health care services for the rural population cover health needs with the existing health professional such are totally inadequate. Therefore, it was strongly felt that a as physicians and nurse alone, is a proven fact, documented new more effective and feasible comprehensive health care by literature from almost every country, Korea being no excep delivery system should be developed and organized in order tion. to provide adequate health care services for the rural popula tion. The integration of preventive and curative services with Finally there is the fact that no new community service agood channel of referral from the grass roots upward should can be established independently of other community orga be an essential part of the new system, in order that the health nizations. It can never exist in a vacuum. To become success care system can effectively respond to actual community ful it must always beconie integrated with already established health needs. institutions and must interrelate its functions with those of other community institutions. A strong project may become Yonsei University Medical Center recognized this successful in itself but it may become counter productive in challenge early and planned to develop a demonstration pro- the total context of community lii':. A weak project may be ject through which the medical and nursing students could come marginal, unsuccessful and totally rejected by the com be educated in the principles of community health. A grant munity it intended to serve. became available for this purpose in May 1974, from the Cen tral Agency for Protestantic Developmenv Aid in Bonn, West After identifying these problems the project team evolved Germany (75%) and the United Board for Christian Higher a philosophy and strategies which would guide the planned Education inAsia, New York, U.S.A. (25%). change process in the com -nunities and the implementation of the project in a manner that would solve all of them to the The project includes introduction of a new category of degree possible under existing in'mstances. heal-th personnel at the grass-root level, based on successful experiences in other countries. In this project a new type of health worker called Family Health Worker (FHW) is being The Goal introduced into the village. This new frontline worker is a housewife from the village, chosen by the village, integrated The goal of this strategic plan was: To establish a func into the community power structure and acting as village tioning, effective basic care system that utilizes all existing re health representative. sources efficiently a, 7affectively, that is itself an organic part of community life, umat successfully improves community Through such an approach it will become possible to health status, and that is suitable for research and for educa streamline, with the help of community input, the offered tion of students in basic community health care. At the heart
86 of this strategic plan were the following broad objectives: The production of rice in the island is sufficient to be self supporting and ginseng production is one of the largest cash this island has 1. To develop functional community health services at village crops of the islanders. Other than agriculture, and township levels in adequate relation to community been famous for it's small-scale textile industry. life and structure, with adequate community cooperation, per family was with a community health team in which roles and func- The average annual income per year tions of each worker are defined in relation to the services W780,000 ($1,510) in 1975 and W1,300,000 ($2,700) in 1977. and in relation to each other. The rate of families owning a T.V. was 45.1% and the rate owning aradio was close to 100% in 1977. stimulate and foster community self-help activity, 2. To high awareness, interest in improving health conditions 10.9% of the heads of households are graduates of health elemen and willingness to cooperate with the health services. school and above, 11.9% junior high school, 55.1% tary school and 22.7% had no schooling. Most of the un There has 3. To develop a data base for demographic, morbidity and schooled however are those whose age is over 60. among the health services data which allows the health status of the been a very rapid trend toward college education community to be determined and to follow its develop- younger generation. ment over time, and which allows for development and before the of educational material and research pro- No physician was practicing in the project area structure practicing privately grammes for students in basic health care. project began. 7 physicians, however, are in the eup area where the local government office is located. 2 and 7 4. To produce new medical leadership with the necessary dentists and 6 herb doctors are practicing on the island, critical view of health services and the skills to conduct drug stores are functioning in the project area. them; persons familiar with the broad and complicated of basic health care in this country, with the poten- Each myun has a health sub-center building as is typical issues and tial to find and contribute to adequate solutions, and with for rural townships, plus one midwife for MCH services desire and ability to rehabilitate the efficiency and effec- two nurse aides for TB and FP care are dispatched by the tiveness of the medical profession inthe rapidly changing health center to cover township preventive health services. socio-economic and cultural environment of the Korean But these health workers do not work in the health subcenter community. buildiing and they are supervised by the township chief. The availability ofta midwive was not typical, but because of their long experience in the community great support for the project was expected. CHAPTER II. DESCRIPTION OF THE STUDY AREA There were no public health nurses available and equip ment amounted to a bare minimum allowing some preventive to pro The Project is located in Kangwha gun, an island 421.4 care in MCH, TB and FP services. In other words, prior services, in in size, Gyeonggi Province, approximately 58 km distant ject implementation the services, or rather lack of km2 typical rural area. from Yonsei University campus in Seoul. The rural island health care were comparable with any other has been chosen because of its proximity, its rural district to the characteristics and the unlikeliness that it will be absorbed into Villages are classified into three groups according the rapid urbanization process around the capital. It can be criteria set by the Saemaul Undong (New Village Campaign). in a one hour fifteen minutes, drive by car, passing They are: completely independent village, partially indepen reached there over abridge which connects the island with the mainland, dent village and dependent village. In the entire country, were only 12 independent villages out of 159 villages in 1973; villages The Project is being developed in two out of thirteen however, it increased to 51 in 1977. The dependent area as myuns as the first activity of a long range programme to deve- decreased from 61 in 1973 to 12 in 1977. In the project lop the entire island district into a teaching demonstration and of 1977 there were no dependent villages out of 20 villages. research area for delivery of comprehensive health care to rural 1977 had a Korean people. The two myunsareSunwonand Naega myuns. 0.56% of 2,376 house in the project area in toilet made of cement concrete and 34% used traditional The total population in the target area was 12,306 in 1975 toilets. 10% of houses were improving their toilets. in 1977. During the three years of the project period and 11,262 piped water, total population has decreased. The popula.ion structure 41% of total households was receiving the spring water. that of pyramid shape with guitar appearanco which is the 18.5% used their own wells and 40.4% used was in terms of sanitation typical shape of the rural population in Korea. 31 % of wells were clas:;ified as perfect ,:tandard, 34.3% as acc,3ptable and rest of them as unaccept fast along The gross migration rate in 1977 was 190.2 per 1,000 able. This situation was, however, improving very with 49.5 in-migration and 149.4 out-migration rates. There- with Saemaul Undong. net migration was done by people under 30 years of fo'e, the of 12 age. Administratively, Kangwha country is composed myuns (townships) and 1eup (smallest city). Each myun has a by the The crude birth rates were 24.4 in 1975, 19.3 in 1976 and myun chief who isconnected, supervised and directed 20.3 per 1,000 in 1977. The crude death rates were 9.5 in 1975, county chief. 9.6 in 1976 and 8.1 per 1,000 in 77 Therefore, the natural increases were 14.9 i9-, id 12.2 per 1,000 in In the county there are 96 legal villages and 159 adminis population one officially re 1977. trative villages. In each administrative village cognized village chief is nominated by the government. The village is divided 70% of total population wi,. , ;.jdin farming, 6.8% in total number of natural villages is 311. Each unit of the community. commerce, 4.2% in fishery and Z.7% in public offices, into 7-8 bans which is the terminal
87 There were 1,112 bans in the entire county. The ban meets has been good and this enabled us to plan the 50 bed com at least once in every month at the same time nation wide. munity hospital together.
The center of the local administration is the county B. Health Care Delivery System of the Project government. The policy office and the education council were independent from the county office, but with good coopera- 1. General outline of basic health care delivery model tion. The health care delivery system in Korea had been mainly Public health is administered by the health center, and the based on free enterprise without a national health plan when health center director isnominated by the county chief, the Kangwha Community Health Project was planned. A basic concept of the organization of a comprehensive health care In myun areas, other than the myun office, the agriculture delivery system was never formulated. The community health guidance office, police branch, a company of home guards, concept was only starting to be appreciated by afew concern agriculture cooperatives and post office are considered to be cd health protessionals. the important power groups. In the planning stage of our project, the general outline of Ina myun, usually 2-3 elementary schools and one junior the basic health care delivery model for the rural area was high school or high school are located depending on the size developed. In formulating this model, basic philosophy and of myuns. principles of community health, health status of the com munity, existing and available health resources and systems, Christianity was introduced 80 years ago in this country. the official administrative system, community character:stics Therefore, the ministers have been very much influential in the and past experiences were all taken into consideration. community affairs. At the beginning of the project, the concept of the orga nization of health care services at the grass roots level (health CHAPTER III. SYSTEM AND PROGRAMME INPUT post) was written in detail in terms of selecting village health workers, their role and functions, and necessary training and equipment. In this Chapter the system and programme input of the project excluding the educational part, the planning manage- The detailed plan of the organization of Myun level and ment part are summarized briefly, above health care services, however, was not clearly establish ed because of lack of information, budget and experience. Therefore, the entire model was to be completed with the A. Relation of the Project with the Existing Health growth of the project. Fortunately, the organization of Myun Systems level health care services was completed by the end of 1976 after a series of surveys and studies. 1. The Government system The entire model turned out not to be very innovative. Even though the Kangwha Community Health Project The new model was largely an expanded and strengthened was planned and initiated by the professors of Yonsei Uni- form of the existing system with little modification. versity College of Medicine, the plan was implemented through the existing government system. Therefore, before the project A health post is placed in each village (average popula started, a contract was entered between the County Chief tion: 500-600) and simple health service is handled by the and Yonsei University College of Medicine. The health center family health worker (see following details). A Myun health director was the most important person in implementing the subcenter is placed in each Myun and serves a population of plan. 10,000 on the average. The Myun health subcenter plays the role of the comprehensive rural health care service center Yonsei University College of Medicine supplied three phy- which is the official terminal unit for the primary health care sicians to cover the two target townships and the health cen- service. This center is staffed with a community physician, a ter. These physicians were on the government payrolls. The midwife, a public health nurse and other health workers (see project itself recruited two nursing supervisors to help govern- following details). An existing Gun health center was streng ment health workers and FHW technically. These two nurses thened without modifying its role in the model. were paid by the project. Community health care, in order to be comprehensive, 2. Private practitioners must include hospital services. Five to ten percent of the patients in the townships will need the sophisticated services Inthe project area, there was no private practitioner; how- of a community hospital. Kangwha does not have such ser ever, in the Eup area 6- 7physicians practiced privately, vices available. Patients who need them must be sent to Seoul.
It was true that most of the innovative community health Approximately a 50-bed community hospital, staffed with projects had conflicts with the existing private practitioners. mostly experienced general practitioners and a few specialists, At the planning stage aprinciple was set to maintain mutually would be needed to cover the approximate 100,000 population complementing relationships with the existing physician, in Kangwha setting. The hospital has been planned and is about to be approved by adonor agency incollaboration with Based on this principle, the project was introduced to acommunity fund raising group. them first and their participation was asked in the project. The project referred patients to their offices and they were con- 2. Development and organization of grass roots health tracted as insurance physicians. They participated particularly services through a village-based family health in the student teaching with much interest. The relationship worker
88 Lack of health consciousness in the communities is one 3) Functions of the family health worker of the most serious drawbacks in the attempt to provide effec tive health care to the rural population. Likewise, entirely hos- The FHW functions include activities at the household pital-based education of key health manpower hinders them and health post level. Bi-monthly household visits are made to in becoming familiar with community health conditions and every household in the community, and weekly health post problems. But it is here where the sources of disease are, consultations, usually at the worker's own home, are being where its impact is felt, and where not only the physical as- held at hours most convenient for village mothers. The func pects of illness in an individual are of importance, but also the tions of the FHW include case finding, simple service, referral, mental and social impliuations and the impact on the family follow-up and health education in MCH, FP and TB care. One and community. What is known and practiced in an urban additional major function is the collection and recording of hospital with wealthy, westernized, well-motivated clientele, vital statistics, morbidity and other activity data. where the physician is the highest authority on health, must be put into the perspective of the rural, traditional home, 4) Selection of family health workers where education and economy are poor, where cultural taboos are powerful, where motivation and knowledge of health The country health center director, together with the issues are lacking, where preventable and easily curable township administrator, invited the village chiefs to support diseases lead for too often to misery and disaster and where the new programme by suggesting two FHW applicants from the physician's authority does not necessarily outweigh a each village, giving on a printed form the social and family mother-in-law's impact on health practices in the family. The background, suitability according to the established criteria, best approach to grass-roots level health care is not through and reasons for suggesting the applicant. The township health the physician but through the people themselves. However, workers, together with the project public health nurse super the physician can help them to get there, and his education visor, interviewed the two applicants and made the final de should prepare him to do so. In the project, the village-based cision on selection of the trainee. The staff attached more family health worker now has the most important role in bring- imDortance to personal communicational ability than to in ing about change both in community health and in enhancing tellectual ability and also gave due consideration to the health community-based education of health manpower. The crucial worker's preference. aspects of this new worker are concept, objectives for imple mentation, functions, service package and training. They were 5) Family health worker training developed by the project staff well in advance of the actual project and will be described briefly. Basic training of FHWs lasted 4 week3. Guidelines for teaching and behavioral objectives had been developed in concept, function and implementa 1) The concept of the family health worker advance according to the tion plan of the FHW, and they proved eventually to be ade implementation and evalua Family Health Worker (FHW) is a married village quate and successful in teaching, The township health workers, 20-45 years old, healthy, in good community tion. The teaching staff consisted of housewife, members and project nursing super standing with at least primary school education, a history of county health center staff invite teachers from outside and tried to social activity in her community and interest in the challenge visor. We tried not to environment as realistic as possible. Con of the offered work. She is the village health representative, maintain a teaching and technically tent of instruction focused on the bare minimum of facts and supported by village leaders and committees imple health workers in the township. skills the FHW had to master for effective programme supervised by the government made as interesting and as salary (W8,500-$18) per month, and mentation, and the instruction was She is given a nominal It started with within 2 years she is expected to be sup- rewarding a learning experience as possible. it was planned that level health related in by the village, three days of orientation at the county ported financially stitutions. Thereafter, training continued at the local health subcenter focusing on child care, maternity care, family plan 2) Objectives in family health worker implementation ning, TB care and record keeping based on predeveloped be havioural specific objectives. In addition, skills in home visiting The FHWs are now well established in their villages, and handling the contents of the FHW bag (first aid and rou strongly motivated and convinced that their activity makes a tine MCH care equipment) were taught. The FHW learned to difference in the healtlh of the community. They appear to be understand her role as village health representative, and to able to fulfill the objectives set forth for their implementation anticipate that students and project staff hoped to learn from which were: and with her how health problems in her community could most satisfactorily be solved using existing resources. - to bridge health manpower shortages at the grass-level through simple service in MCH, FP and TB care, Systems implementation and 2 months on-the-job train - to enhance community health consciousness through ing proceeded simultanecusly. Retrriining profit.ed from the health education, gained experiences. Retraining lasted 10 days concentrating - to serve as a communication channel for reciprocal on the questions that were raised by the FHWs. An under understanding of health issues and problems between standing of the health care system and how the worker and traditional villagers and city-educated faculty and the patient relate to it at specific points was stressed for each students, area. It also emphasized the workers' obligations in case find - to protect the communities from dependency on uni- ing, prevention, service, referral, follow up, and health educa versity input, tion. - to collect essential data on health, - to create in the communities an atmosphere for co- 3. Development Et organization of Myun (township) operation with the teaching project that stimulates level health care services. students to creatively think of how health problems can be solved through exploitation of community re- Administratively, the next level above the village is the sources. Myun where the majority of the rural population resides.
89 To organize the Myun health service, a health subcenter ii) Public physicians was built in early 1970s by the government. However, its func tion Et role have never been determined: consequently, types The original government plan was to invite a physician to of health personnel, necessary facilities and equipment were the health subcenter and let him practice there with a small not standardized. The Gun health center dispatched three government subsidy. They are called public physicians. About health workers-namely MCH, FP Er TB workers to the Myun one third of Myun health subcenters in Korea have been staff area. Because of the insufficient supervisory system of the ed with a physician from this programme. They are only res. local health center, these three health workers were dispatch- ponsible for medical care. No role for supervision of preventive ed under the direct supervision of Myun chief. services was assigned. They are not part of an official health care delivery system. Naturally, these health workers were using Myun adminis trative offices as their working center instead of a Myun health In the new model, the public physician is appointed as a subcenter. Therefore, some of the Myun health subcenter director of the health subcenter and is responsible for the en buildings were empty and deserted. The situation of Kangwha tire primary comprehensive health care services rendered at health subcenter was no better than others. the health subcenter. He supervises and trains health per sonnel. He plans health programmes and represents the health How the subcenter should be developed and organized in subcenter. order to provide basic health care to the entire township popu lation was the next task for the project staff. This was also To assume these roles he should be well-oriented toward what concerned the government deeply in regards to the community health. future health plan. 2) Additional manpower A series of studies such as health interview surveys, health care pattern surveys, time-activity studies with the health In the new health subcenter model one public health workers, morbidity studies, establishing priorities for the solu- nurse (or community health nurse) is being added to provide tion of health problems, determining basic health require- and supervise preventive health services other than maternity ments, patient flow, and breakdown of programmes into care. operational terms were performed. They were used to identify community health needs and demands, health care patterns, The public health nurse who has been appointed by the types of diseases, necessary manpower, necessary space, project is being assigned to each Myun. She will be playing a facilities, equipment, capital costs, operation costs, other very important role in coordinating supervising and planning material, etc. at the health subcenter. She is a member of the project deve lopment committee together with the public doctor. Based on the results from those studies and surveys, a model comprehensive health subcenter for rural population 3) Functions Et logisticsof the new health subcenter was developed quantitatively and has been implemented for the past three years to prove its feasibility in real situations. The functions of the health subcenter were determined quantitatively after identifying health needs, demand, priority, The model of the comprehensive health subcenter will and basic health requirements. be described briefly below. The proposed 10 functions of the health subcenter were: 1) Reorganization of the existing government health medical care, MCH care, family planning, tuberculosis control, system erc:ironmental sanitation, general health education, com munity & government relations, internal management and iD The township health workers planning, training and supervision, and others.
All three Myun government health workers are brought The necessary number and types of manpower to perform to the health subcenter from administrative office, the predetermine6 functions of the health subcenter, which covers a population of about 10,000, were calculated and their In the proji.ct area the existing MCH workers are qualified role and job desciptions were also developed in detail. The midwives. They are of great value of the project since they are proposed manpower at the health subcenter consists of one already well accepted leaders in community health. Therefore,. community health physician, one public health nurse, one their roles are not changed in the new system. The TB and FP midwife, one MPW per 2,000 population, and one clinical aide. workers are nurse aides and uni-purpose health workers. In the new model they are called multi-purpose workers I & II (MPW The proposed size of space was 165m2 with 9 rooms (one I Er II)and change their roles from uni-purpose to multi-pur- examination room, one treatment room, one counselling pose. The towns.-.ip is divided between the two into areas A room, one maternity care room, one two-bed room, one room and B. MPW I and IIhave the new function of supervising and for laboratory and pharmacy, for reception and record keep supporting the services and activities of the FHWs in the field. ing, and one waiting rooni). Necessary facilities, equipment, drugs and other materials were also calculated and stand The Myun hea th workers (MPW) had to become ardized. thoroughly familiar wth the community health concept and the FHW role and function. They had to comprehend their These new models were actually organized in real situa own changing role and function, their new relations with each tions and implemented for the last three years. other, with the FHWs at the village and their supervisors at the county level. Therefore, the new job descriptions and C. Mechanism of Community Participation functions were handed to them in print, and they were given an opportunity to grow into their new role by actively parti- As stated previously, one of the project's characteristics cipating in the selection and training of the FHWs. was emphasis on community participation. In the project 3
90 members of the insurance programme itself, was selected. mechanisms were developed together with the community and the end of 1976 about 300 families enrolled in the coopera people for participating actively and voluntarily in the health At tive and at the end of 1977 about 800 families enrolled in the system. cooperative. The number is slowly growing. Family health worker 1. The monthly premium per person was W200 ($0.42) and annual average premium per family was about W12,000 The FHWs were selected by the community and they are ($25.00) initially and it was raised to W300 per person per community representatives who participated directly in all the month. health systems and programmes at the grass-roots level. The as an entry most important role of the FHWs was functioning for the past and the The cooperative has been self-supporting point or bridging the gap between the community 50% of of two years. 80% of primary health care expenses and formal health care delivery system. Detailed descriptions secondary care expenses are being paid by the cooperative. the FHW have already been presented in the previous sections. S'till the number of enrollees are small (only 20% of the 2. Community health council target population). Most people in rural areas of Korea have insurance until an unexpected was established in each little knowledge about health The Community Health Council it is difficult to con in the health illness occurs in their family. Furthermore, Myun in order to reflect the community's voice of health support vince them that they should pay for the priviledge project and government health system and also to are services which they apparently do not need when they FHW's activities, healthy, and unfortunately cooperatives have a bad reputation in rural Korea. The project staff members motivated the community or in groups, and by leaders by contacting them individually these barriers. The of an opinion- It would take a long time to overcome explaining to them the necessity of the formation to show an interest was proposed government, however, has already started leading body. The Community Health Council insurance pro which in the development of national-scale health and formed out of the Community Defence Committee, coverage of formal gramme. Therefore, in the near future, complete was the largest official Myun meeting comprising all by rural population could be realized. and informal leaders. 12 council members were selected vote at the meeting. D. The Health Services at the Village and Myun Level The council met once a month regularly. The major roles Services are being delivered at household, village and were; building of health subcenters, provision of lands for the myun level, in child care, maternity care, family planning and building, organization of health insurance cooperatives, credit care. union to support FHW incentives, and other various suppor- TP activities for the project's health programmes. tive essentially build around a The child care programme is continuous weight survey conducted by the FHW. For this 3. Health insurance plan purpose she is given a scale and the necessary records. The is filled out at birth and handed to the mother. Weight, establishment of the new health care delivery record After the and incidence of disease are recorded on this level, it has become apparent that a vaccinations model up to the Myun history of growth, development, vacci to make the system func- chart. Through this a financing mechanism is necessary becomes available at each contact The present system, in nations and previous illness tional and to distribute its benefits. All children under age two health subcenters of the child with the health services. which the government assigns physicians to quarterly, and mec- are weighed monthly, two-to four-year-olds compulsorily in the abscence of an efficient financing "under five-to six-year-olds twice a year. Experiences with the the community, is inadequate, hanism by fives" programme and "road to health chart" in Nigeria served the health of all pre that rural people as a blue-print in Kangwha to supervise It has been the general understanding through village auxilliaries and that the government school children in the community are too poor to afford health services, The contacts are used to A survey o 1Kang having only rudimentary training. mu!-t support financially the entire system. the mother on not identify and refer sick children and to educate wha as well as in other rural areas of Korea has shown growth and development of her child with regard to nutrition, only the annual income of rural families; has recent;y increased health vaccination and hygiene. Vaccinations are given at the remarkably but that fairly large sums are soent to obtain health subcenter and village on the occasion of the regular MPW care. visit. Regular home visits help to identify sick children and weight and vaccination programme defaulters by means of the In Kangwha, the average health expenditure of a rural "road to health chart". family in 1975 was W25,000 per annum 0$52). This indicated that if we are able to mobilize the health o-xpeuises in a more Maternity care starts with identification of a possibly preg systemic way it would probably cover health services more nant woman at her home through inquiry about menstruation efficiently and effectively. history, which is made of all eligible women. If the menstrua of last tion is delayed more than six weeks from the first day Consequently the community leaders and the project staff menstruation the women is referred to the midwife (MCH discussed suitable ways to mobilize local financial resources worker) for diagnosis and counselling. and agreed upon the development of a health insurance pro- gramme. In April 1976, two years after the project, a few The consultation includes history, diagnosis, lab. tests, months after the implementation of the new primary health and an inquiry of whether the pregnancy is desired. If the preg care center, community leaders, through the community nancy is not desired, and the patient is still within the first tri health council, organized the health insurance cooperative. An mester, she is immediately referred to an OB/GYN at the eleven-member board of trustees for the insurance pro- county level for possible pregnancy termination. gramme, consisting of community leaders, interested persons
91 Otherwise, the maternity record is filled out with a carbon Traditionally mortality statistics are one of the most corn copy to be handed to the FHW in charge. The patient is given monlV used health indicators. The crude death rate of the pro printed and verbal instructions about pregnancy, childbirth, ject area in 1975 was 9.5 per 1,000 population and was de newborn and child care. creased to 8.7 in 1977. Age standardized crude death rates showed a more obvious decreasing trend. Leading causes of These instructions were developed to build her motivation death in the project area were cerebrovascular diseases, mali and provide essential knowledge taking into account attitudes gnancies, senile and ill defined diseases, suicide, and liver cirr and conditions in her home environment. Major emphasis is hosis which are all non infectious origins. It is note worthy that on regular prenatal care, preparation for safe home delivery deaths due to pulmonary tuberculosis and other infectious and child spacing, and instruction for the attendant. The diseases ranked below fifth and it was an interesting finding patient is seen monthly by the FHW during the second tri- that suicide ranked 4th through the period of 1975-1977. mester; there-after, bi-weekly; and during the last six weeks of pregnancy, weekly. On each occasion she examines the Infant death rate decreased from 30.1 per 1,000 live births urine for albumin and sugar, screens for edema, inquiries for in 1975 to 21.8 in 1977, The number of deaths, however, was problems and records her findings in her copy of the maternity too small to obtain a meaningful rate. record which is presented to the MCH worker at the weekly meeting. Four to six weeks prior to delivery the patient is seen It is also a valuable finding that no neonatal tetanus was again by the MCH worker at the clinic for another thorough developed since 1975 when two infants had died due to neo examination and instructions related to safe home delivery, natal tetanus. The death rates for the 1-4 year age bracket This approach is maternity care allows the MCH worker to be can be valuable health indicators but the numberator was too aware at any point in time about the health condition of all small to calculate a meaningful rate. pregnant women in her target area, to concentrate her atten tion on the high risk group and to attend all deliveries. Proportional mortality indicator (P.M.I.) in the project area showed no apparent trend. It seems that the P.M.I. is a Many hazards from childbearing and for the new-born in relatively insensitive indicator to show any change of health the community can thus be more readily identified and eli- status in a small population. minated. Moreover, motivation of expecting mothers to learn about healthy birth and upbringing of the expected child can Morbidity statistics are a more direct measure of health be most effectively continued in the child care programme. status of the population. Morbidity information which was Within five years the community will have in its mothers of pre- obtained through health interview surveys showed a decrease school children a core of individuals knowledgeable in basic in rates for chronic conditions in the project area compared issues concerning MCH who will be able to make intelligent with the control area from 1975 to 1977. But it needs careful demands of service providers, as well as assist in influencing interpretation because of the limitations of the health interview the health behavior of new mothers, survey.
The regular household visits also include identification of Measles infection rates were selected as tracer indicators family planning needs, inquiry into family planning practice, and were observed by birth cohort since the beginning of the family planning education, provision of supplies (condom, project and for three years thereafter. The cumulative ex foam, pill), referral for loop insertion, vasectomy, and tubal perience rates of measles in birth cohort 1971 through 1975 ligation and follow-up of acceptors. Family Planning is so showed that there were marked decrease (60%) in the measles closely related to MCH that it can become quite naturally inte- infection rates through all ages during the period. grated with the MCH service packages of the different workers. Good rapport and communication with the clients on issues Other possible health indicators other than mortality and relating to child health, family welfare and maternal health can morbidity, such as physical and physiological status of the foster internal motivation for spacing and reduction of family people, was not possible to obtain because of either too short size. It can be expected that the family planning programme project period or too small target population. will improve without additional input. B. Evaluation of Integrated Programmes for Maternal The TB programme is the only programme area involving and Child Health and Family Planning Programme a different target group, different knowledge and somewhat different activities. It can, however, be incorporated without In the Kangwha Project the MCH programme integrated too much difliculty. The FHW identifies suspects of her regular with the Family Planning Programme was considered to be the home visits, -efers them and follows up on patients. She dis- most basic and central programme. Therefore, the evaluation tributes drugs, identifies drug defaulters, educates patients of this programme is of utmost importance. and their families on home hygiene and ensures that all child- Such indices of the programme output as maternal death ren in her cory munity are properly BCG vaccinated, rate, infant death rate, birth rate and natural population in creases have already been described in Chapter IIand the pre vious section. Therefore, in this Chapter, the indices and pro CHAPTER IV. CHANGES OF HEALTH STATUS Et cess indices were used as indices for the programme evalja PROGRAMME EVALUATION tion.
Since the baseline indices before the programme were not A. Changes of Health Status available, the annual changes of the indices after the imple mentation of the project were focused on. The sources of data The ultimate goal of a health demonstration project is to used here were mostly household records, infant weight improve the health status of the people. To see any effect of charts, vaccination records and pregnancy record of the pro the project on the health of target community people, several ject. These records were linked in one format made for each health indicators were selected and compared, before and of all families with eligible couples. The indices of MCH pro after the project or occasionally, with the control area. grammes were observed by birth cohort. The following is a
92 summary of results, annually. The rate, particularly, jumped from in 1974 to in 1975, which was the initial year of the project. 1. Maternity care 3. Family planning 1) The prcnancy outcome of the project period showed that 78.8% terminated as full term live-birth, 2.9% as In 1974, before the project started, only 38% of the eli spontaneous abortion, 17.1% as artificial abortion and gible women had practiced family planning. In 1977 three 1.2% as still birth. The rate for full term live birth was 7% years after the project the experience rates of F.P. practice higher than that of other studies and the rate for the spon- showed 72% and about 50% eligible women were current taneous abortion and still birth were slightly lower than users of one of the F.P. methods. Permanent sterilization was other studies. performed on 14.3% of the eligible women.
2) The prenatal care rates were improved annually. Only All these input and process indices showed extremely 1.1% of total pregnant women in 1977 did not receive any high rates in the project area and in the project period com prenatal care. pared with that of other areas. We conclude without hesitation that the good results were mainly contributed by the activities 70% of pregnancies registered in the first trimester and of FHWs. received a satisfactory level of prenatal care in 1977. 4. Tuberculosis control programme 3) 7.5% of total delive:ies in 1975 and 12.1% in 1977 were institutional delivries. More than 50% of deliveries were The ultimate objectives of the tuberculosis control pro assisted by professionals either by midwife or physician. gramme would be reduce the incidence, prevalence, and mor The same rates in average rural Korea are said to be 5- tality rates of tuberculosis in the community. 10%. The incidence and prevalence surveys of tuberculosis are 4) 80% of pregnant mothers received postnatal care and all too costly and too complicated. Such a survey also needs to risk cases detected through the prenatal and postnatal observe large number of population for a long time, because care referred and successfully managed. T.B. incidence and prevalence rates are not a very sensitive indicator for a short period of a programme. The annual T.B. 5) No maternity deaths or serious complications were ob- mortality rates, however, were possible to obtain in the pro served during the 3 years of the project period.. ject.
2. Child care The tuberculosis specific death rates decreased from 56.2 per 1,000 population in 1975 to 35.5 in 1977. The total number 1) Vaccination rates of deaths due to tuberculosis in the target area were only 7 in 1975 and 4 in 1977. Therefore, this together with the absence D 90% of birth cohort born in the project period re- of the control data has to be carefully interpreted. ceived BCG vaccination. In 1977, 85.9% of children received BCG vaccination within 3 months as re- The evaluation of the tuberculosis control programme quired by the T.B. Control Law. was centered more on lower level objectives: stage of registra tion, regularity of follow up, and improvement of cure rates. ii) 60% of birth cohort received small pox- vaccination. This was because the project did not strongly en- The registration rates of new patients in the project area courage the small pox vaccination, were higher than that of the control area through all 4 years.
iii) About 70% of children received three DPT vaccina- Slightly earlier cases of tuberculosis assessed by sputum tions within one year and 90% received at least one test were registered from the project area than the control or more. area througl the period of 1974 to 19-7.
iv) The measles vacciiation was not considered as a In order to evaluate regularity of follow up of the register basic vaccination required by the law in Korea. It is a ed patients, regular X-ray check ups and sputum tests were recommended vaccination for which the beneficiary analyzed. It was found that those who obtained regular follow should pay. As shown in figure 6-3 the measles, up went up from 49% in 1974 to 59.6% in 1976 in the project vaccination rates observed by birth cohort 3howed a area, while the same rate declined from 56.6% in 1974 to 5.6% beautiful gradual increase in the earlier age annually. in 1976 in the control area.
This was considered to be a 2 to 3 times higher rate than The complete cute rates of the registered patients in 1976 that of other rural areas. This proves that the consciousness of viere 15.6% in the project area and only 3.8% in the control the health of the community people substantially increased area. after the project. 5. Medical care programme 2) The weight measurement of children In evaluating the medical care programme, care is riceded Those who were born during the three years of tho project to observe quantitative aspects such as utilization of medical period received 5 times the weight measurements on the aver- care institutes as well as qualitative aspects such as content, age within 12 months after birth. Less than 20% did not re- zontinuity, satisfaction of clients and the costs of the pro ceive any measurement. gramme. But in this paper, only the quantitative aspect of medical care was assessed, and the subject of the qualitative 3) The health subcenter visit rates for child care increased portion is treated in chapter IX.
93 Increasing utilization of medical care implies two opposite 3) After delivery all Korean women take seaweed soup and meanings: increasing morbidity and decreasing unmet need of rice, to the exclusion or practically anything else, for at the population. least three to seven days and some times longer even though on occasion they were not able to stand the sight Considering an extremely low utilization of medical care of it. This custom of eating seaweed soup after birth in institutes among rural people in Korea, one of the aims of the Korea is so old and ubiquitous among all classes and establishment of a health care delivery system would be an walks of society that nobody appears to be able to give a improvement of utilization rates. satisfactory reason for it any more.
The health subcenter utilization rates increased from 2.0 Such culture oriented behaviour is hard to change. per 100 persons between July 1974 - June 1975, to 13.3 be tween July 1976 - June 1975, which is a sixfold increase. CHAPTER V. EVALUATION OF THE PERFORMANCE OF In order to obtain the medical care utilization rates of the HEALTH WORKERS general population, two household health interview surveys were conducted. The utilization rates for acute conditions within the last two weeks and for chronic conditions within Inthis chapter, activities of each health worker as a mem the last month showed not much difference between 1975 and ber of the team in the project were analyzed in order to identify 1977. The physician utilization rates, however, increased mark- work content, to measure work load and to determine ade edly from 0.15 per 100 population per year in 1975 to 1.63 in quacyof their functions and roles. 1977, which is almost a ten-fold jump. For the analysis of Family Health Worker's activity the This means that by the establishment of a health care monthly activity reports, daily activity records and the results delivery system the health care patterns have been much of the interview survey of the residents were used. For the changed. Multipurpose Health Worker, the time-activity studies of 6 Multipurpose Health Workers was performed with Health Workers in non-project areas in Kangwha gun as acontrol. 6. Nutrition The analysis of the Public Health Nurse activities was According to the data of 1977 National Survey conducted based on their own experiences and the observation by the by the Ministry of Health & Social Affairs, average calorie in staff members of the project. take per day per adult in rural side 2,778 cal. is much more than that of national average 2,668 cal. and the average amount of The physician's performance was excluded because their protein consumption is about the same (rural 85g, national roles are versatile. 84g), rural people have poorer nutritional status in following aspects: The performance of each health worker obtained from the analysis is summarized below. 1) Lower proportion of animal protein to total protein intake in rural area (20.9%) than urban average (27.5%). A. Family Health Worker 2) Average fat intake in rural area is 32g versus urban aver age of 38g. The amount in terms of number of F.H.Ws activities start ed to increased in the initial 6 months and thereafter it main 3) 88% of average iron intake is from vegetable food which tained a fairly constant level with seasonal fluctuations. The has poor utilization than animal food. home visiting slowed down in the cold winter and busy plant ing and harvesting ,;easons. Therefore 15mg as average iron intake per day per person in rural area is not sufficient for intake of Vitamin A, B1, B2, The average work hours of F.H.W. was 3 hours per day Niacin, and Vitamin C are, taking account of their cooking to perform their roles adequately. loss, grossly inadequate to meet the recommended allowances. The average number of visits to a single home by F.H.W. In addition to above mentioned inadequate intake of are 14.7 times per year and the average number of visits to essential nutrients in general, the nutritional status of rural F.H Ws made by asingle resident was 8.2 times per year. The women, particularly during the period of pregnancy and con- average number of total contacts between F.H.W. and a parti finement are further aggravated due to certain traditional be- cular resident, therefore, totalled 23 times per year. This num haviours: ber is more than the expected or assigned number of contacts. This means that F.H.W's function is one of acommunity com 1) During pregnancy, there are numerous foods to be avoid- munication center. ed.,Every client in the study area had heard of at least some of them and many adhered to one or the other 70% of homes in a village visited regularly by F.H.W., taboo. Chicken, duck, eggs, and octopus are among the 15% irregularly and 15% of households have never been visit foods to be avoided. Most frequently they are believed to ed by the F.H.W. This indicates that F.HWs have not visited cause fetal malformation or danger of some spiritual kind. a certain group of households with might be considered as households without problems or not visited for other private 2) On the other hand there are practically no awareness of reasons. the need for good nutrition in pregnancy. A woman's diet generally is bland - rice, soup, and kimchi three times a F.H.Ws shared most of their time among child health, day. Pregnant or not, she serves the better things to family planning and maternity care, which reflects the pro husband and children. gramme priority of the project itself.
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-aamaw wd am Po 00Pa of $d*si ov* A j (Te 53a S.aamPdmi*"vkt* wri Kong, the incidence is approximately 1 in 1300 hospital de- and breathlessness. A pelvic examination is performed to ex liveries. clude vaginal secondaries, subinvolution of uterus and the calutein cysts. A chest X-ray is performed at diagnosis of b) Age (Table 4) molar pregnancy and repeated monthly until HCG disappears.
The mean age is 30.6 years with a range of 15 to 53 years. Measurementc; of HCG levels of serum are carried out at There is a four-fold increase between 41 and 44 and a 24-fold each visit by haemagglutination inhibition (HI) tests. Once the increase after 45 years. It is also slightly more common among HI test becomes negative, HCG level is measured by the radio teenagers. This is in agreement with observations by other immunoassay technique at each subsequent visit. workers. It is our policy to repeat a curettage if irregular bleeding c) Parity ITable 5) persists after four weeks or if the HI test remains positive after six weeks. The HCG levels are expected to be negative by HI The incidence of chorionic malignancy rose from 1 in 7680 test after six weeks and by RIA by nine weeks (Curry et al, deliveries in para 0 to 1 in 2285 deliveries in para 5 and above. 1975) or twelve weeks (Goldstein, 1976). In general, if there is a sustained progressive fall with normal chest X-rays and nor d) Race mal clinical findings, we would allow the HCG level to remain above 3 m IU/mi until twelve weeks. After which, an effort The Malays have a higher incidence of choriocarcinoma should be made to look for possible malignancy. A pelvic arte compared with the Chinese. This difference was found to be riogram may then be indicated. statistically significant (p < 0.02). C. Contraceptive Practice el Preceding gestation It has been customary to defer pregnancies after a mole See Table 6 for at least one vear because any rise in HCG levels would be difficult to interpret. However, with the advent of ultrasound, f) Malignant sequelae of moles (Table 7) gestation sacs may be seen as early as five to six weeks. Per haps, it is unnecessary now to restrict pregnancy beyond six Tow 1966 showed that the incidence of malignancy among months, provided the HCG levels had fallen satisfactorily. moles was 13.5%. However, for those aged 40 and above and those aged 39 and under but para 3 and above, the risk of mali gnancy is much higher. CONCLUSION
Malignant changes in molar pregnancy are more common Epidemiological studies have shown that several factors in blood group A women lScott 1962, Llewellyn-Jones 1965, such as age, parity, socioeconomic status predispose to molar ')awood et al 1971). pregnancies. These risk factors may all be related. Larger scale epidemiological studies are necessary to elucidate the relative g) Mole/recognition of malignancy interval and importance and the relationship of the risk factors. The finding mortality rate of apparent occurrence of epidemics of moles is important as it suggests an infective etiology. Again, this requires confirma See Table 8 tion.
II. Follow-up of Moles Great importance should be put on follow-up of mole cases for two reasons. Firstly, ,.2% of choriocarcinomas are From our results, it is quite obvious that the mortality rate preceded by a molar pregnancy and secondly, the mortality of choriocarcinoma increases significantly with increase in rate of choriocarcinoma increases sharply with increase in interval between the occurrence of mole and detection of interval between the occurrence of mole and detection of choriocarcinoma. It has also been shown that 82% of chorio- choriocarcinoma. In my opinion, it is logical to follow-up mole carcinoma are preceded by a molar pregnancy. Therefore, it cases for up to four years because 95% of our choriocarci is only logical that great emphasis is placed on close follow- nomas are detected within four years. v, f mole patient.
A. Follow-up Visits Schedules REFERENCES
The follow-up fisit schedules adopted in Singapore are as 1. Curry S L et al (1975): Obstetrics & Gynaecology. 45:1 follows: 2. Dawood M Y, Teoh E S, Ratnam S S (1971): ABO Blood - weekly for 8 weeks, then Group in Trophoblastic Disease, Journal of 0 & G', British C' wIth. 78:918 - monthly for 10 months, then 3. Llewellyn-Jones (1965): Journal of 0 & G, British C'wlth. - three monthly for 2 years, then 72:242
- six monthly for life 4. Ratnam S S and Chew S C (1975): Trophoblastic Disease in Singapore. Journal of Obstet and Gynaec of India. B. Follow-up Visit Procedures 1:127
At each visit, a history is taken to elicit irregular vaginal 5. Scott J S (1962): Observations on Etiology. Amer J of bleeding, central nervous system disturbances and hemoptysis Obstet and Gynaec. 83:185
193 and 6. Teoh E S, Dawood M Y, Ratnam S S (1971): Epidemio- tions on Choriocarcinoma in Singapore. Obstetrics logy of Hydatidiform Mole in Singapore. Amer J of Obstet Gynaecotogy. 40:519-524 and Gynaec. 110:415-420 8. Tow W S H (1966): The Influence of the Primary Treat ment of Hydatidiform Moles on its Subsequent Courue. 7. Teoh E S, Dawood M Y, Ratnam S S (1972): Observa- Journal of 0 E G, British C'wlth. 73:544-552
194 PAPER 34
INCIDENCE AND FOLLOW-UP OF TROPHOBLASTIC DISEASES
Prof.Ho Kei Ma
easier is a discussion on the objectives, the Centralized laboratory is economic3l and probably This presentation transportation of and the problems of a regional-wise or for quality control, but the problem of possible achievements need to be overcome. national-wise follow-up programme for patients with molar specimens and communication The Hcng Kong follow-up programme is an on pregnancy. patients who show evidence of tropho going programme and will be used in this discussion only as 4. Management of an example. The data presented are not finalized, and there- blastic disease. fore, should not be quoted.
OBJECTIVES OF A FOLLOW-UP PROGRAMME FOR MOLE PATIENTS PROBLEMS OF A MULTICENTER FOLLOW-UP PROGRAMME 1) To study the post-abortal H.C.G. pattern. 1) Wrong diagnosis 2) To correlate the H.C.G. regression pattern with the of the disease. course 2) Incomplete laboratory study early diagnosis of residual or malignant tropho 3) To make a) Nosample blastic disease in mole patients b) Non-delivery of samples Protocol 3) Loss to follow-up 1. Duration of follow-up: Minimum : 6months. Communication Maximum : 24months. 4) Achievements 2. Clinical follow-up: The Possible History of high risk mole patients for chemotherapy. Examination 1. Selection for localization of tumour and Investigations higher than 95% of patients with gesta its metastasis 2. A survival rate of tional trophoblastic diseases. follow: 3. Laboratory of health care in a national orogramme. H.C.G. estimation. 3. Reduction of cost
195 PAPER 35
INCIDENCE AND FOLLOW-UP OF TROPHOBLASTIC DISEASES
Takashi Wagatsuma, M.D.
INTRODUCTION ment (real.time electronic scanning) and the bvailability of immunological titration kits for urinary HCG determination In 1971, the Ministry of Health and Welfare of Japan orga- have made early diagnosis of the hydatidiform mole simple and nized a task force for the research of trophoblastic diseases. possible. Since then, both basic and clinical research on trophoblastic diseases have been carried out in more than thirty Japanese 2) Differential diagnosis and evaluation of prognosis In Univers hospitals and medical ipr.tutions. the case of the Invasive mole Presently, no precise diagnostic method to differentiate BASIC RESEARCH invasive moles from simple (non-invasive) moles is available. Recently, pelvic anqiography has been widely utilized to diag It is impossible to describe every detail of the extensive nose the invasive mole and was found to be useful in those research that is currently being conducted. The following is cases in which following pregnancy and childbirth were de the summary of some interesting findings, sired. At present, it is considered that only precise and inten sive follow-up of individual cases after evacuation of the hy 1) Androgenesis of the hydatidiform mole datidiform mole can diagnose or prevent the development of both the invasive mole and choriocarcinoma. The standard Chromosome analyses of the hydatidiform mole have follow-up formula will be discussed in a following section. shown that in most cases (90%), their aryotypes were 46XX. Recently, it was found that in these caseb a;ichromosume., were homozygous and of paternal origin; there were no The Incidence of Trophoblastic Disease In Japan chromosomes originating from the mother. This would sug gest that the hydatidiform mole develops either from an ovum In 1974, the Trophoblastic Diseases Committee of the fertilized with diploid sperm or from the duplication of an ovum Japan Society of Obstetrics and Gynaecology started a regis fertilized with 23X sperm. Detailed mechnisms of this are yet tration system of the incidence of tropholastic deseases in to be clarified. limited areas of Japan. The area has been gradually expanded and now the system covers 14 prefectures (Japan consists of 2) Immunoselection theory as a mechanism for the 47 prefectures) where approximately 42.9 million people reside development of the hydatidiform mole corresponding to athird of the entire population. Most embryos with various chromo3omal abnormatities The following tables show the incidence of the hydatidi fail to develop in utero and die at an early stage of pregnancy. form mole, invasive mole, and choriocarcinoma in these se Most of the dead embryo are rejected as spontaneous abor- lected v"fecturos. (These prefectures were selected accord tions probably because of the disappearance of a specific ing to the interests of researchers working in the large medical immunological condition during gestation. institutions located in these particular prefecm.res.) These results sho,- that the incidence of the hydatidifo,'m mole with Incases of the hydatidiform mole, such an immunological in these different prefectures is fairly constant at a rate of 5 to condition (not yet clarified) continues due to some unknown 6 per 100,000 population and 3.5 per 1000 live births. On the reason resulting in the development of a mole from the ern- other hand, the incidences of the invasive mole and that ot bryo. choriocarcinoma vary considerably in different prefectures. Japan's population in 1977 was 113,499,000 and the number CLINICAL RESEARCH of live births was 1,755,032, therefore, it is estimated that we have 5000 to 7000 cases of hydatidiform mole annually in 1) Diagnosis of the hydatidiform mole Japan. The increasing utilization of ultrasound scanning equip- Follow-up for the Hydatidiform Mole
196 As mentioned previoiisly, an intensive follow-up of in- nancies following molar pregnancies. Two hundred forty-nine (13.4%) had either dividual cases after the evacuation of the mole from the uterine cases (73.6%) had normal pregnancies, 45 12 (3.6%) cavity is the only way to prevent or to detect the development spontaneous abortions or premature deliveries, (9.2%) terminated their of the invasive mole or choriocarcinoma in the early stages. repeated hydatidiform moles, and 31 There are several different follow-up formulae recommended pregnancies. by various university hospitals, one of which is shown in the abortions, pre following figure. Although the incidence of spontaneous mature deliveries, and repeated moles was high among these significant difference in the Previously, the patient with a hydatidiform mole was cases, there was no statistically between those who be strongly urged to defer following pregnanLes for at least two incidence of abnormal pregnancies those who conceived years after the evacuation. The main reasons for this are as came pregnant less than one year and pregnancy. follows: more than one year after the molar a molar pregnancy who wishes 1 Previously, it was difficult to differentiate normal preg- Therefore, the patient with proceed to plan the next nancy from the development of choriocarcinoma. to have a child in the near future may pregnancy provided that the following conditions are fulfilled. the evacuation to a 2) It was belirved that the possibility of malignant change of The urinary HCG level must decrease after stay at that the previous hydatidiform mole became higher if the level below normal LH (less that 20 IU/ L) and must cycles. patient became pregnant soon after the evacuation of the level for at least three normal ovulatory mole. THE EFFECTIVENESS OF CHEMOTHERAPY AND 3) It was considered that the incidence of abnormal preg- RATE OF CHORIOCARCINOMA nancy would increase when the patient became pregnant THE MORTALITY today is a soon after a molar pregnancy. The standard therapy against choriocarcinoma Both MTX (0.4 Recently, however, Jifferential diagnosis between normal hysterectomy combined with chemotherapy. repeated for three courses) and intrauterine pregnancy at 6 - 7 weeks arid the malignant mg/kg/day for five days, for five days) improved the change of the previous mole became possible due to the avail- Actinomycin-D (10 ug/Kg/day significantly compared to other ability of the ultrasonic scenner. Furthermore, the possibility prognosis of choriocarcinoma agents such as Nitrogenmustard or Chlo cf the enhancement of malignant change due to a shoit preg- chemotherapeutic in the following table, the prognosis of nancy interval was refuted. rambucil. As shown choriocarcinoma is still much higher than that of the invasive In 1978, Y. Kawashima studied the outcome of 337 preg- mole.
FIGURE I - FOLLOW-UP FORMULA OF HYDATIDIFORM MOLE
Evacuation of Hydatidiform Mole
of Basal Body Temperature days Recording 10-14 01aImmunoassay of urinary HCG, once a week. Chest X-ray
Repeat D. & C.
7 Weeks s
Urinary HCG P TV* NEGATIVE POSITIVE up with periodical Change Follow Risk of Malignant immunoassay of urinary HCG, recording of BBT, Admission and detailed examination Chest X-ray. including Pelvic Angiography
Diagnosis established.
Invasive Mole or Choriocorcinoma Diagnosis not established
Treatment
197 TABLE I
INCIDENCE OF TROPHOBLASTIC DISEASES IN SELECTED PREFECTURES IN JAPAN (1974)
Mole+ Chorlo 4 Pop. Live Inv. Chorlo- Unclassified Mole/Pop. 1) Mole/Birth2) Inv. Ca./Birth ) Prefecture x 1,000 Birth Mole Mole Carcinoma Mole/Birth 3)
Hokkaido 5,271 94,356 217 9 6 8 4.12 2.30 2.40 0.064
Fukushima 1,946 32,884 88 4 2 4 4.52 2.68 2.80 0.061 Niigata 2,365 38,905 124 9 7 0 5.24 3.19 3.42 0.179
Gumma 1,746 31,939 112 3 6 3 6.41 3.51 3.60 0.188 Chiba 3,990 82,080 205 7 5 14 5.14 2.50 2.58 0.061 Kanagawa 6,276 116,675 286 8 4 38 4.56 2.15 2.52 0.034
Hyogo 4,952 93,347 292 29 14 14 5.90 3.13 3.44 0.150 Shimane 769 11,338 33 4 1 2 4.29 2.91 3.26 0.088
Tottori 577 8,778 29 1 0 0 5.02 3.30 3.42 0 Kumamoto 1,682 26,144 45 1 1 11 2.68 1.72 1.76 0.038
Fukuoka 1,374 19,628 49 2 3 0 3.57 2.49 2.59 0.015 Aichi 5,863 120,763 349 12 9 22 5.95 2.89 2.99 0.075
Total 36,811 676,837 1,829 89 58 116 4.70 2.55 2.69 0.086
Trophoblastic Diseases Committee, . Gociety of Obstet. & Gynec. 1) Incidence of Moles/100,000 Population 2) Incidence of Moles/1,000 Live Births 3) Moles + Inv. Moles/1,000 Live Births 4) Incidence of Chorio Ca./1,000 Live Births TABLE II
INCIDENCE OF TROPHOBLASTIC DISEASES IN SELECTED PREFECTURES IN JAPAN (1975)
Mole + Unv. Chorlo Pop. Live Inv. Chorio- 2 3 4 Mols/Pcp. 1) Mole/Birth ) Mole/Birth ) Ca./Birth ) Prefecture xl.G00 Birth Mole Mole Carcinoma Unclassified
1.84 1.90 0.100 Hokkaido 5,329 89,631 165 5 9 8 3.10 5.72 3.64 3.77 0.129 Fukushima 1,974 31,013 113 4 4 1 6.39 4.08 4.45 0.187 Niigata 2,392 37,524 153 14 7 0 3.71 3.78 0.236 Gumma 1,761 29,616 110 2 7 5 6.25 4.72 2.53 2.62 0.026 Chiba 4,149 77,415 196 7 2 15 4.56 2.50 2.58 0.068 Kanagawa 6,423 117,269 293 10 8 33 5.93 3.41 3.73 0.161 Hyogo 4,992 86,839 296 28 14 14 2.94 3.13 0.368 Shimane 770 10,870 32 2 4 1 4.16 3.61 4.08 0.117 Tottori 583 8,581 31 4 1 1 5.32 3.14 0.080 Kumamoto 1,717 25,146 75 4 2 8 4.37 2.98 1.69 1.73 0.173 Fukuoka 1,515 28,982 49 1 5 5 3.23 2.74 2.86 0.099 Aichi 5,939 111,535 306 13 11 21 5.16 3.62 3.91 0 Wakayama 1,072 17,140 62 5 0 2 5.79
2.80 2.9r5 0.110 Total 38,617 671,561 1,881 99 74 114 4.87
Trophoblastic Diseases Committee, Japan Society of Obstet. & Gynec. 1) Incidence of Moles/100,000 Population 2) Indicence of Moles/I,000 Live Births 3) Moles + Inv. Moles/1,000 Live Births 4) Incidence of Chorio Ca./1,000 Live Births TABLE III
INCIDENCE OFTROPHOBLASTIC DISEASES IN SELECTED PREFECTURES IN JAPAN (1976)
Population Live Inv. Chorlo- Mole + Inv. Chorio 2 Prefecture x 1.000 Birth Mole Mole Carcinoma Unclassified Mole/Pop. 1) Mole/Birth ) Mone/Birth3) Ca./Birth 4)
Hokkaido 5,386 86,335 121 3 4 11 2.25 1.40 1.44 0.046
Fukushima 1,988 31,287 92 1 5 0 4.63 2.94 2.97 0.159
Niigata 2,404 37,602 130 e 6 0 5.41 3.46 3.70 0.160
Gumma 1,782 29,356 107 5 1 6 6.00 3.6-4 3.82 0.034 Chiba 4,268 75,601 195 3 5 14 4.57 2.58 2.62 0.066
Kanagawa 6,522 119,438 272 10 5 38 4.17 2.28 2.36 0.042 Hyogo 5,034 82,405 275 19 7 18 5.46 3.34 3.57 0.085 Shimane 773 10,480 39 1 1 0 5.04 3.72 3.82 0.095 Tottori 587 8,657 38 1 1 2 6.47 4.39 4.51 0.116 Kumamoto 1,734 29,285 58 6 1 2 3.35 1.98 2.19 0.034 Fukuoka 1,395 18,021 50 5 1 2 3.59 2.77 3.05 0.055 Aichi 5,988 106,353 280 7 1 31 4.68 2.63 2.69 0.099 Wakayama 1,074 16,576 50 8 6 0 4.66 3.02 3.49 0.362
Total 38,935 651,396 1,707 78 44 124 4.38 2.62 2.74 0.068
Trophoblastic Diseases Committee, Japan Society of Obstet. Et Gynec. 1) Incidence of Mo:es/100,000 Population 2) Incidence of Moles/1,000 Live Births 3) Moles + Inv. Moles/1,000 Live Births 4) Incidence of Ch%.rio Ca./I,000 Live Births TABLE IV PROGNOSIS OF TROPHOBLASTIC DISEASES
No. of Cases Died (%) Alive and Well %)
Choriocarcinoma Histologically 87 33(37.9%) 54(62.1%) Confirmed Diagnosed by 35 7 (20.0%) 28(80.0%) Clinical symptoms Total 122 40 (32.8%) 82 (67.2%)
Invasive Mole Histologically 88 1( 1.1%) 87 (98.9%1 Confirmed Diagnosed by 172 0 172(100 %) Clinical symptoms Total 260 11 0.4%) 259 (99.6%)
Y. TOMODA et al. Nagoya University Hospital 1965 - 1977.
201 PAPER 36
INCIDENCE AND FOLLOW-UP
OF TROPHOBLASTIC DISEASES IN TAIWAN
Pei-ChuanOuyang,M.D.
It is well known that gestalional trophoblastic diseases year period from 1971 to 1978. The incidence in each period have a striking geographical distribution. They occur most fre- was compared to see any variation in its occurrence according quently in nearly all of Asia(1 ). Taiwan has an apparently high to the change of time. incidence of gestational trophoblast;c diseases, like other Oriental countries (2 ). The prognosis for patients with choriocarcinoma and re lated gestational trophoblastic neoplasms has markedly im- As 457 cases have been accumulated in the year 1951 proved since the institution of chemotherapy in 1956(5). Me through 1978 in National Taiwan University Hospital, it seems thotrexate was introduced in Taiwan since 1962(6). In this appropriate to evaluate the variation in incidence according to study the outcome of 60 destructive moles and 89 choriocarci the changes of period and a comparison of the therapeutic nomas was examined according to the group of use or non re!:ults of destructive mole and choriocarcinoma either with or use of methotrexate and a comparison of the results between without chemotherapy is attempted in this study. the groups was made.
Materials and Methods Results In the 28-year period from 1951 through 1978, 457 patients. wih gestational trophoblastic diseases among 56,727 de- The material studied here represents 457 patients with iiveries were investigated and treated in the Department of gestational trophoblastic diseases among 56,727 deliveries Obstetrics and Gynaecology, National Taiwan Univers;ty Hcs- admitted to National Taiwan University Hospital from 1951 to pital. The surgical specimens of the patients were classified 1978. The classification and incidence are shown in Table I. into three categories, i.e., hydatidiform mole, destructive mole and choriocarcinoma according to Novak's histologic criteria The over-all incidence of gestational trophoblastic diseases by our pathologists(3, 4). However, in a part of the patients to deliveries was 1:124. This figure is higher than that in any who did not permit positive identification of the lesion, the Western country. The incidence in the 1950's was 1:82, in the diagnosis was based on unequivocally positive clinical, hor- 1960' was 1:157 and 1:136 in the 1970's. The incidence to monal and radiologic evidence, deliveries somewhat decreased with advancing period due to the increase in hospital "eliveries. But the actual number of the All of the patients were divided into three groups, i.e., a patients slightly increased in the 1970's. The ratio of destruc 10-year period from 1951 to 1960 and 1961 to 1970 and an 8- tive mole to choriocarcinoma was 1:1.5. TABLE I CLASSIFICATION AND INCIDENCE OF TROPHOBLASTIC DISEASE INNATIONAL TAIWAN UNIVERSITY HOSPITAL, 1961 THROUGH 1978
1951 - 1960 1961 - 170 1971 - 1978 OveIll Incklen . Type of No. of Incidence to No. of Inckence to No. of Incidence to No. of Incidence to Trophoblastlc cases deilvedee ceS dellverle coes. dellvee can delfvedel dises [12,9031 (22,176) (21,648) (M%72") Hydatldlform mole 103 1:125 84 1:264 114 1:190 301 1:189 Destructive mole 23 1:561 20 1:1,109 17 1:1,273 60 1:94 Chorlocarclnom- 26 1:496 35 1:634 28 1:773 89 1:637 Syncytial endometrltis 3 1:4,301 2 1:11.088 5 1:11,345 Unclassified 2 1:6,451 2 1:28,364
Total 157 1:82 141 1:157 159 1:136 457 1:124
202 The age distribution and incidence according to parity of gestational trophoblastic diseases relative to deliveries was dis hydatidiform mole, destructive mole and choriocarcinoma are proportionately high in the age group of over-40 and in the Number of deliveries shown in Tables II,III and IV respectively, parity of 5 or more in all categories. of teens and over-40 decreased markedly in the 1970's, so did It can be seen from these tables that the incidence of that of parity of 3or more.
TABLE II AGE DISTRIBUTION AND INCIDENCE ACCORDING TO PARITY INHYDATIDIFORM MOLE 1961 -190 1961 - 1170 1971 -1978 Per cant of No. of Per cnt of No. of Par cant of No. of cas % Age dliveekle as % deliveres Cae % deve 1.8 Under 19 64 6 5.8 1.7 3 3.6 0.8 2 78.1 20.-29 61.8 65 63.1 61.6 48 54.7 86.5 89 20 17.5 30-39 29.3 27 28.2 34.3 22 26.2 31.3 3 2.6 Over 40 2.5 6 4.9 2.4 13 15.5 1.4 Parity 43 37.7 0 27.2 23 22.3 33.2 30 35.7 44.5 40 35.1 1 21.8 19 18.4 28.1 15 17.9 32.4 14.0 2 17.1 15 14.6 19.4 8 9.5 14.5 16 5.3 3 12.3 14 13.6 9.6 6 7.2 5.2 6 2 1.8 4 8.6 11 10.7 4.8 7 8.3 1.9 7 6.1 5or more 13.0 21 20.4 4.9 18 21.4 1.5 114 Total 103 84
TABLE III
AGE DISTRIBUTION AND INCIDENCE ACCORDING TO PARITY IN DESTRUCTIVE MOLE
1961 - 1960 1981 - 1970 1971 - 1978 Per cent of No. of Per cant of No. of Per cent of M~o.of Age delvedN cas % dlIvedes cases % delhveie caes
1 5.9 Under 19 6.4 1 4.3 1.7 0.8 66.5 10 58.8 20-29 61.8 14 60.9 61.6 6 30.0 2 11.8 30-39 29.3 4 17.4 34.3 8 40.0 31.3 4 23.5 Over 40 2.5 4 17.4 2.4 6 30.0 1.4
Parity 7 41.1 0 27.2 7 30.4 33.2 2 10.0 44.5 6 35.3 1 21.8 3 13.1 28.1 1 5.0 32.4 5.9 2 17.1 2 8.7 19.4 5 25.0 14.5 1 1 5.9 3 12.3 3 13.1 9.6 1 5.0 5.2 4 8.6 2 8.7 4.8 4 20.0 1.9 2 11.8 5 or more 13.0 6 26.0 4.9 7 35.0 1.5 17 Total 23 20
203 TABLE IV AGE DISTRIBUTION AND INCIDENCE ACCORDING TO PARITY IN CHORIOCARCINOMA
1lG1- 190 1961 - 1970 1971 - 1978
Per cent of No. of Per cent of No. of Per cent of No. of Age deivedee cae % deltvedes c" % delivedee co" %
Under 19 6.4 1.7 1 2.8 0.8 20-29 61.8 10 38.5 61.6 14 40.0 66.6 13 46.4 30-39 29.3 12 46.1 34.3 10 28.6 31.3 5 17.9 Over 40 2.5 4 15.4 2.4 10 28.6 1.4 10 35.7
Psilty
0 27.2 2 7.7 33.2 5 14.3 44.5 4 14.3 1 21.8 4 15.4 28.1 5 14.3 32.4 8 28.6 2 17.1 5 19.2 19.4 7 20.0 14.5 1 3.6 3 12.3 6 23.1 9.6 5 14.3 5.2 4 14.2 4 8.6 3 11.5 4.8 3 8.5 1.9 3 10.7 5 or more 13.0 6 23.1 4.9 10 28.6 1.5 8 28.6
Total 26 35 28
Table V shows the relative incidence of getational tro- In the series of 1957-1966 it was 0.48%(7), and in recent phoblastic diseases in the surgical specimens excrmined at the 10 years 0.40% (8). These figures represent closely the whole Department of Pathology of National Taiwan Un;!versity and area of Taiwan. It seems to be quite high in this area compared the Taipei Medical College in the 10-year period of 1957 with that of other pathological institutes. 1966 and 1967 - 1976.
TABLE V
RELATIVE INCIDENCE OF TROPHOBLASTIC DISEASE IN SURGICAL SPECIMENS' (1957 - 1956) (1957 - 1976)
Years and source Hydatldlform Destructive Chodocerclnoma Unclassified Total No. of % mole mole Surg. specimen
1957-1966 Taiwan Unlv. Hospital 228 70 57 355 73,413 0.48
1967 - 1976 Taiwan Unlv. Hospital 191 24 30 28 273 121,735 0.22
1967 - 1976 Taipei Med. College 290 34 50 23 397 97,731 0.40
Total 709 128 137 51 1,025 292,879 0.35
* Dr. T.Y. Chen, Department of Pathology, TUH & TMC.
In both destructive mole and choriocarcinoma the dia- hydatidiform mole. Of 301 patients, 110 were followed over 5 gnosis of the patients with or without tissue is shown in Table years and 97 were 1 to 4 years. There were 8 deaths in 1950's VI. group but none in both 1960's and 1970's. Of these 8 fatal cases, 3 died during or immediately after evacuation and 5 died In this study one fifth of destructive mole and one third of during follow-up, among which 3 were possibly due to chorio choriocarcinoma could not obtain positive tissue proof. The carcinoma. The follow-up rata was 71.4%. proportion of the patients with choriocarcinoma in which the tissue proof available remained unchanged throughout the three periods. However, the acquisition of tissue proof in the With transition of periods more uteri were conserved. The patients with destructive mole has greatly decreased in the subsequent pregnancy rate was very high as seen from Table 1970's because of the early chemotherapeutic intervention. VII, but it does show a decreasing tendency. More than half of the first subsequent pregnancies occurred within one year T. ')le VII shows the results of follow-up in patients with after evacuation of molar pregnancy.
204 TABLE VI
CLASSIFICATION OF GESTATIONAL TROPHOPLASTC DISEASES
1961 - 1960 1961 - 1970 1971 - 1978 No. of came Total Condition No. of cases No. of cam 17 60 Destructive mole 23 20 7 48 With tissue proof 22 19 1 10 12 Without tissue proof 1 28 89 Chorlocarcinoma 26 35 23 20 60 With tissue proof 17 8 29 Without tissue proof 9 12 45 149 Totsl 49 55
TABLE VII FOLLOW-UP STUDY OF HYDATIDIFCoRM MOLE Total 1951 - 1960 1961 - 1970 1971 - 1978
61 66 207 Living and well 80 20 Over5 years 64 26 7 9 4 to 5 years 3 6 3 to 4 years 4 9 6 12 2 to 3 years 4 13 19 1 tu 2 years 5 23 48 No follow-up available 15 0 0 Died 8. 84 114 Total 103 2 4 9(4.3%) Malignant sequelae 3 62 105 Uterus conserved 72 34(54.8%) 49(48.7%) Subsequent pregnancy 58(80.6%) 1IS(30.6 %) Within 6 months 34(58.6%) 13(38.2%) 23(67.6%) 27(55.1%) Within 1year 45(77.6%)
among Three died immediately after evacuation, 5 died during follow-up, which 3 were possibly due to chorloca,,cinoma.
not show any significant difference in this study. distribution of cases by use or ncn-use of metho- trexate did The groups had a high survival rate well over 80%. trexate and the survival is shown in Table ViII. Of 60 patients Both destructive mole, 42 were followed more than one year, with by use or in which 32.were followed more than 5 yesrs. Seven deaths The distribution of cases with choriocarcinoma ot'which 2 occurred after 2 years anda solitarythe remaining tissue non-use of methotrexate and survival is shown inTabie X. occurred, Th6 2 late deaths had 5 died within 2 years. of destructive moie. evidence Of 89 patients, 80 were followed over one year, of which living and well over 50 years. There were 48 deaths, Comparison of the outcome in the pitients with destruc- 18 were all within 2 years, in which 37 died within 6 months, 8 between tive mole, with and without tissue proof, is shown in Table IX. 7-12 months, 2 in 1-1 1h years and 1 in 11h -2 years. The survival rate in groups betwc.en use and non-use of metho-
205 TABLE VIII FOLLOW-UP STUDY OF DESTRUCTHE MOLE (1951 - 1976)
Non-uso of MTX Use of MIX Total With Without W.th Withotd t:ue proof tlsue proof tisse proof Ueaue proof
Living and well 29 2 8 3 42 Over5 years 26 1 5 4 to 5 yara 0 0 0 0 3 to 4 yeaa 1 0 3 0 2 to 3 years 2 0 0 1 1 to 2 years 0 I 0 2 Died 4 1 1 1 7 Within I ye 2 0 0 1 1 to 2 yeara 1 1 0 0 2 io 3 years 1 0 0 0 3 to 4 yera 0 0 1 0 No follow-up available 4 1 2 4 11
Total 37 4 11 8 60
TABLE IX COMPARISON OF THE RESULTS IN OVER-ALL DESTRUCTIVE MOLE AND SUSPECTED PATIENTS (1961 - 1976)
Total No. No. of l~ing A Survivl Groups "f ase well over I year Death rate
Non-use of MTX 36 31 5 86.1% Use of MTA 13 11 2 84.6%
Total 49 42 7
TABLE X FOLLOW-UP STUDY OF CHORIOCARCINOMA (1961 - 1978) No-use of MTX Use of MTX
With Without With Without tiseue proof tissue proof tlasue proof tlssue proof Total
Died 21 15 9 3 48 Within 6 months 15 13 7 2 37 7 to 12 months 3 2 2 1 8 13 to 18 months 2 0 0 0 2 l9to 24 months 1 0 0 0 1 Living and well 5 0 18 9 32 Over 5 yera 5 0 9 4 18 1 to 4 years 0 0 9 5 14 No follow-up available 1 2 6 0 9
Total 27 17 33 12 89
206 Comparison of the survival rate in the patients with choria- different between the use or non-use of methotrexate, 69.2% value carcinoma is shown in Table XI. versus 12.2%. Inthis respect methotrexate has definitive on the cure of choriocarcinoma. As seen from the Table, the survival rate was clearly
TABLE XI 1978) COMPARISON OF THE RESULTS IN OVER-ALL CHORIOCARCINOMAS AND SUSPECTED PATIENTS (1951 - Total No. No. of living & No. of dead Survival Groups of cases well over Iyear within 2 years rate Non-use of MTX 41 5 33 12.2% Use of MTX 39 27 12 69.2% Total 80 32 48
DISCUSSION diseases. Of course th'e true incidence is e.."remely difficult to determine from this hcspital basad statistics. However, the 2 hospital per year is un In our previous (eports( , 9) the extraordinarily high in- actual number of patient- seen in our in Western countrics except cidence of gestational trophoblastic disease in Taiwan had doubtedly larger than an',' clinic disease centers. been explai; ad by the following three facts. Fitst, cut hospital some well-organized trop ioblastic be caller tewastebasket of pathologic cases; was what may trophoblastic the hospital detivery rate was low, and tnird, Chinese The age distribution of the gestational second, series was dispropor were very prolific, the birth rate being over 40, thus the diseases relative to deliveries in this women all categories. A of the individual to pregnancies favors the tionately high in women over 40 years old of frequent subjection group in hydatidiform of trophoblastic diseases. similar high incidence in the older age development mole was reported by others(15, 17). of hospital deliveries in From that time on the number 18 19 in year due to the growth of population Edmonds( ) and Bagshawe( ) found an increased creased rapidly year by The relative planning has been practiced on a large cidence in women under 20 and over 40 years rld. in Taipei area. Family is varied. Our Consequently the birth rate dropped consider- frequency of hydatidiform mole in their teens scale recently. incidence among the very ably in 150's. It is around 20 in the 1970's. On the one hand data did not show an elevated high standard hospitals have increased in num- young. However, Marquez-Monter ot al.(12) reported nosigni well-equipped, of moles in their ber with the expansion of Taipei area, rapid growth of popula- ficant correlation between age and incidence tior and impiovtement of the level of living. 0,:.cordingly, the series. ;y to concentrate in our hospital does not tendi.-n for patients destructive mole In a word our hospital is no longer the waste- Incidence in the older age group with exist ,icently. shows much higher than for pathologic cases. The im-provement of nutritional and choriocarcinoma in this series basket 3 19). In this respect :he advancing age status dKo became remarkbble with the economic growth. that of others( , 10, 20, appears to nave clearly been establibied as u predisposing diseases 111,21, 22). In this study the incidence relative to deliveries was much factor to the gestational trophoblastic later somewhat decreased with the in higher in the 1950's, in this series was number of the hospital deliveries, but yet the inci- The relative incidence of each categories creased 5 or more, grand multiparas. remained 1:136 in 1970's, obviously much higher than disproportionately high in parity dence 10 1 3 the relative incidence of from Western sources( , 11). However, the Chun et a1.( ) found in Hong Kong that reported low with first and number of the patients increased in 1970's in spite of the hydatidiform mole was disproportionately actual high ;n sub3equent pregnancies. In great improvement of socio-economic status in Tai,:'n. second pregnancies and relation to parity it might be considered that there is either no that the association is complicated by geogra A number of attempt-, have been made to relate low socio- association or3 phical factor( , 12, 19). economic status to a relatively hi h frequency of gestational 2 , 13, 14). However, Douglas was trophoblastic diseases(1 of deliveries of teens and over to find an association between the frequency of mole Inour hospital the number unable decreased in 1970's, so does that of and socio-economic status in data for New York, and also 40 years old has markedly evidence of high incidence of mole amongst the parity of 3or more. unable to find ( 5 ) Oriental women living in Western countries 1 . The relative incidence of trophoblastic diseases among the Department of Pathology, Na On i -,,.her hand Ishizuka (16) has reported a relatively the surgical specimens in experienced substantial tional Taiwan University Hospital and Taipei Medical College high incidnce in Japan, which has of 1957 Thn t. .mber of hydatidiform mole was 0.48% and 0.40% respectively in a 10-year period economic (A9velopment. might be regarded 522 registered pregnancies or 1 per 348 live -1966 and 1967-1976(7, 8). These figures occurred 1 per in whole Taiwan. It is quite 10-year period from 1962 through 1971 based on ioughly as the relative incidence births for with the advancement of period census figures in Aichi Prefecture of mid-Japan. the same in relative incidence and seems to have a high incidence in this locality from an Fronr our data it is unable to find that the tremendous im- other angle. in the socio-economic status in Taiwan has any provement of the patients in our series the diagnosis effect upon the occurrence of the gestational trophoblastic In the majority
207 was based upon Novak's histologic criteria(3) by our patholo- tiva to total deliveries is substantially higher in the age gists(4). But some patients in whom the histologic evidence group of over-40 and in grand multiparas. did not permit positive proof were categorized by undquivocal clinical, hormonal and radiologi~al evidence. 4. A high incidence is also shown in this locality from astand point of surgical specimens submitted to pathological The morphological classification system is becoming little examination. use since the precise histologic diagnosis is frequently unavail able and the early detection of malignant transformation has 5. The survival rate in hydatidiform mole and destructive been possible by the sonsitive tests for human chorionic gona- mole, either with or without chemotherapy, is equally dotropin(23, 24, 25), and thus chemothe.-ipy is instituted in good. In contrast, choriocercinoma is quite mqlignant. the majority of patients regardless of the histologic type. To The survival rate prior to chemotherapy was only 12.2%, overcome the short-comings of morphologic classification, clearly aifferent with destructive mole. several clinically oriented classification systems have been suggested(27, 28, 29, 30, 31). To find an ideal and suitable 6. The histological diagnosis is completely acceptable, how clinical classification system of trophoblastic diseases for use ever, its availability is limited because of the improvement in our locality is now under way. in early detection and in early institution of chemotherapy in the occasion of malignant transformation. Accordingly, The subsequent postmolar pregnancies occurred in a practical and ideal clinically oriented classification 80.6%, 54.8% and 46.7% respectively in each period in whom system should be adopted in this locality. the uterus was conserved. More than half of these subjects became pregnant within one year. Although the patients were 7. After chemotherapeutic intervention, the survival rate of instructed to avoid further pregnancy for at least one year after choriocarcinoma has been improved very much. Metho evacuation, the incidence revealed considerably higher. How- trexate has adefinitive value on cure of choriocarcinoma. ever, the declining tendency can be seen with the advance ment of the period. In the ocassion of distinguishing between REFERENCES normal and postmolar sequelae, ultrasonic scanning has been shown to be a safe and practical method (32). 1. Joint Project for Study of Choriocarcinoma and Hydatidi form Mole in Asia (1959). Geographic variation in ihe The survival rate in hydatidiform mole was 96.3%, and in occurrence of Hydatidiform mole and choriocarcinoma. destructive mole before the introduction of chemotnerapy was Ann. N.Y. Acad. Sci., 80, 178-196. 86.1 %, whereas in destructive mo!e with use uf methotrexate was84.6%. There are no significant differences between these 2. Wei, P.Y. and Ouyang, P.C. (1963). Amer. J. Obstet. two groups. Gynec., 85, 844-849.
A review of the 1960 USA and UK literature by Ober et al. 3. Novak, E., and Seah, C.S. (1954). Amer. J. Obstet. revealed 94% of the survival rate with destructive mole(33). Gynec., 67, 933-961. Generally speaking, hydatidiform mole and destructive mole are rather benign conditions, thus rarely fatal. It could be cured 4. Chen. T.Y., Peng, T.L. and Yeh, S. (1957). Reports, by hysterectomy even with metastases. Institute of Pathology, National Taiwan University. 8, 57-83. In contrast, the survival rate in choriocarcinoma before introduction of methotrexate was only 12.2%, whereas with 5. Li, M.C., Hertz, R.and Spencer, D.B. (1956). Pror. Soc. use of chemotherapy it was improved to 69.2%. It is generally Fxp. Biol. (N.Y.), 93,361-366. agreed that the survival rate of choriocarcinoma prior to che motherapy is somewhere between 10 and 20% in the litera- 6. Wei, P.Y. and Ouyang, P.C. (1967). Amer. J. Obstet. ture(14, 34). Gynec., 98,79-84.
In this study a great majority of the patients with chorio- 7. Chen, T.Y. (1967). Acta Path. Jap. 17,417-437. carcinoma before the introduction of chemotherapy ter minated fatally, usually within one year. In comparison of the 8. Chen, T.Y. (1978). Personal communication. results it c)3n be definitely concLided that methotrexate therapy 9. Wei, P.Y., Ouyang, P.C. and Peng, T.L. (1957). reports, has asubstantial value on cure of clioriocarcinoma. Institute of Pathology, National Taiwan University. 8, 27-56. SUMMARY 10. Brewer, J.1. and Gerbie, A.B. (1967). Choriocarcinoma: transactions of a conference of the International Union Hreshchy 1. Four hundred and fifty-seven patients with gestational against Cancer ed. by J.F. Holland and M.M. trophoblastic diseases were treated and investigated be- shyn. pa. 45-53. Springer-Verlag, Berlin. tween 1951 and 1978. 11. Yen, S. and MacMahon, B. (1968). Amer. J. Obstet. 2. The over-all incidence relative to deliveries was 1:124. Gynec. 101, 126-132. This figure is considerably higher than that of Western Robles, M. countries. However, the actual number of the patients is 12. Marquez-Monter, H., Alfara dela Vegga, G., Gynec., 85, not decreased, though, a remarkable improvement in and Bolio-Cicero, A. (1963). Amer. J. Obstet. socio-economic status has been achieved in Taiwan in 856-864. recent years. 13. Chun, D., Braga, C., Chow, C. and Lok, L. (1964). J. 3. The frequency of gestational trophoblastic diseases rela- Obstet. Gynec. Brit. Cwlth., 71, 180-184.
208 14. Manahan, C.P., Manuel-Umson, G. and Abad, R. J. Obstet. Gynec., 113, 751-758. (1964). Ann. N.Y. Acad. Sci., 114, 875-880. 25. Kardana, A. and K.D. Bagshawe. (1976) J. of Immunol. 15. Douglas, G.W. (1959). Ann. N.Y. Acad. Sci., 80, 195- Methods. 9, 297-305. 196. 26. Bagshawe, K.D. (1976). Cancer. 38, 1373-1385. 16. Ishizuka, N. (1976). Gann. 18, 203 27. Holland, J.F. and Hreshchyshyn, M.M. (eds), Springer- 17. Chun, D., Braga, C., Chow, C. and Lok, L. (1934). J. Verlag, Berlin. Obstet. Gynec. Brit. Cwtth, 71,185-191. 28. Hertz, R., Lewis, J. Jr. and Upsett, M.B. (1961). Amer. 18. Edmonds. H.W. (1959). Ann. N.Y. acad. Sci., 80, 86- J. Obstet. Gynec., 82, 631-640. 104. 29. Hammond, C.B., Borchert, L.G., Tyrey, L., Creasman, 19. Bagshawe, K.D. (1969). Choriocarcinoma, The Clinical W.T. and Parker, R.T. (1973) Amer. J. Obetet. Gynec., Biology of the Trophoblast and its Tumors p. 4 Blatimore, 115,451-457. The Williams and Wilkins Company. 30. Hammond, C.B., and Parker, R.T. (1970). Obstet. Gynec., 20. Scott, J.S. (1962). Amer. J. Obstet. Gynec., 83, 185- 35, 132-143. 193. 31. Goldstein, D.P. (1977). Intemational J. Gynec. Obstet., 21. Curry, S.L., Hammond, C.B., Tyrey, L., Creasman, W., 15, 207-215. and Parker, R.T. (1975). Obste. Gynec. 45, 1-8. 32. Hassani, S.N. (1978). Ultrasound in Gynaecology and 22. Divack, D.M. and Janowski, N.A. (1962). Obstet. Gynec., Obstetrics. pp. 83-84. 19, 76-80. 33. Ober, W.B., Edgcomb, J.H. and Price, E.B. (1971). Ann. 23. Vaitukatis, J., J.B. Robbins, E.Nieschlag and G.T. Ross. N.Y. Acad. Sci., 172, 299-326. (1971). J. Clin. Endocrinol. 33,988-991. 34. Brewer, J.l., Smith, R.T. and Pratt, G.B. (1963). Amer. J. 24. Vaitukatis, J., G. Braunstein and G. Ross. (1972) Amer. Obstet. Gynec., 85, 841-843.
209 ROSTER OF THE SEMINAR
LIST OF PARTICIPANTS Denpasar Bali, Indonesia INDONESIA 6. Dr. Abdul Rachman Soerono 1. Dr. R.Henry Pardoko Director Deputy for Population Programme Family Planning Medical Services National Family Planning Coordinating Board Directorate for Family Planning Medical Services Jalan Let. Jen. M.T. Haryono Ministry of Health P.O. Box 186 Jalan Kwini No. 7 Jakarta Jakarta Pusat Indonesia 2. Dr. Sudraji Sumapraja Head 7. Mr. Multazam Sumarno Sub-Division of Human Reproduction Head Family Planning of the Armed Forces School of Medicine Republic of Indonesia University of Indonesia J. Merdeka Barat 2 Jakarta Mailing Address: Indonesia Klinik Raden Saleh Jalan Raden Saleh 49 8. Dr Haryono Suyono Jakarta Deputy for Family Planning National Family Planning Coordinating Board 3. Professor M.J. Hanafiah Jalan Let. Jen. M.T. Haryono Head P.O. Box 186 Department of Obstetrics & Gynaecology Jakarta University of North Sumatra Indonesia Medical School Medan MALAYSIA
9. Datin (Dr.) Nor Laily Aziz, JSM Mailing Address: Director General 47, Jalan Prof. H.M. Yamin National Family Planning Board Medan P.O. Box 416 Indonesia Kuala Lumpur Malaysia 4. Dr Tina Agoestina Director of Post-Partum Family Planning 10. Dr. Azizan bt. Aiyub Ghazali Hasan Sadikin Hospital Assistant Director of Health (Family Planning) Department of Obstetrics & Gynaecology Ministry of Health Padjadjaran University ,Jalan Young Jalan Pasteur No. 38 Kuala Lumpur Bandung Malaysia
5. Dr. Ida Bagus Astawa 11. Dr. Johan A.M. Thambu Chairman of the BKKBN of Bali Senior Consultant and Head BKKBN Bali Department of Obstetrics and Gynaecology Box 266 General Hospital
210 Johor Bahru Mailing Address: Malaysia College of Medicine University of the Philippines 12. Professor Chong Chun Hian P. Gil Street Professor of Obstetrics and Gynaecology Manila Department of Obstetrics and Gynaecology Philippines Faculty of Medicine University Kebangsaan Malaysia 20. Dr. Flora B. Bayan P.O. Box 2418 Director 124 Jalan Pahang National Family Planning Officer Kuala Lumpur 02-14 26, Kanlaon Street DTA. Mesa Heights Mailing Address: Quezon City 6 Jalan Beka Philippines Damansara Heights Kuala Lumpur 23-08 21. Professor Ruben Apelo Malaysia Professor of Obstetrics and Gynaecology College of Medicine 13. Mrs. Rita Raj Hashim University of the Philippines Planning/Research Officer National Family Planning Board Mailing Address! P.O. Box 416 Dr. Jose Fabella Memorial Hospital Kuala Lumpur Comprehensive Family Planning Center Malaysia Lope De Vega St. Sta. Cruz 14. Dr. Raj Karim Manila Ministry of Health Philippines Jalan Young Kuala Lumpur 22. Dr. Lydia Aznar Alfonso Chairman 15. Dr. Hamid Arshat Depaitment of Family Planning Director of Medical Research Southwestern University National Family Planning Board College of Medicine P.O. Box 416 Cebu City Kuala Lumpur Philippines Malaysia 23. Dr. Melanio P. Gabriel, Jr. Administrator NEPAL INC Mobile Family Planning Program 20 M.H. Del Pilar 16. Dr. (Mrs) Vaidya Kokila Tugatog Malabon Deputy Chief Metro Manila Family Planning and MCH Project Philippines P.O. Box 820 Kathmandu SINGAPORE Nepal 24. Professor Mark Cheng Chi Eng 17. Dr. (Mrs) Malla Dibya Shree Associate Professor Medical Superintendant Department of OBGYN Maternity Hospital University of Singapore Thapathali Kathmandu Mailing Address: Nepal University Department of OBGYN Kandang Kerbau Hospital PHILIPPINES Singapore
18. Mr. Benjamin de Leon THAILAND Acting Executive Director Commission on Population 25. Dr Somboon Vachrotai Population Center Building Director General South Super Highway Department of Health Makati Ministry of Public Health Metro Manit i Devaves Palace Philippines Bangkok 2 Thailand 19. Porfessor Gloria T. Aragon Board Member 26 Or Suporn Koetsawang Commission on Population Director Philippines Siriraj Family Planning Research Unit
211 Department of Obstetrics & Gynecology Mahidol University Faculty of Medicine 420/1 Rajvithi Road Siriraj Hospital Bangkok Mahidol Universit, Thailand Bangkok 7 Thailand 35. Miss Tongplaew Narkavonakit Chief 27. Dr. Suvanee Satayapan Research and Evaluation Section Senior Medical Officer Family Health Division Family Health Division Department of Health Department of Health Ministr/of Public Health Ministry of Public Health Devaves Palace Devaves Palace Bangkok 2 Bangkok 2 Thailand Thailand 36 Dr. Laddawan 28. Mrs. Chusie Sujpluem Department of OBGYN Chief Woman's Hospital Training, Supervision and Education Section Bangkok Family Health Division Thailand Department of Health Ministry of Public Health HONG KONG Devaves Palace Bangkok 2 37. Professor Ho-Kei Ma Thailand Department of Obstetrics and Gynaecology Queen Mary Hospital 29. Dr. Nikorn Dusitsin Hong Kong Deputy Director Institute of Health Research JAPAN Chulalongkom University P.O. Box 1311 38. Dr. Takashi Wagsts.ma Gyneecology Bangkok Director of Dept of Obstetrics & Thailand National Medical Center Hospital No. 1Toyama-Cho 30. Mrs. Anuri Wanglee Shinjuku-Ku Population Survey Division Tokyo National Statistical Office Japan Larn Luang Road BangPok 1 KOREA Thailand 39. Dr. Taek.l Kim
Professor Kamheang Chaturachinda, Director 31. for Family Planning Associate Professor Korean Institute Department of Obstetrics & Gynaecology 115 Nokbun-Dong Mahidol University at Seodsemoon-Ku Ramathibodi Hospital Seoul Korea Bangkok 4 Thailand TAIWAN
32. Dr. Edwin B. McDaniel 40. Dr. Fu-Min Chen Head Tri-Service General Hospital Department of Obstetrics and Gynaecology Tin-Chow St. Family Planning Taipei McCormick Hospital Tqiwan (107) P.O. Box 56 Chiang Mai 41. Professor Pei.Chuan Ouyang Thailand Department of Obstetrics and Gynaecology 33. Dr. Sutham Hiranniramol Taipi National Taiwan University Hospital Taiwan c/o Dr. Somboon Vachrotai Director General Department of Health IFRP Ministry of Public Health Devave Palace 42. Mr. Thomas W. Hardy Bangkok 2 Regional Coordinator Thailand International Fertility Research Program 34. Dr. Debhanom Muangman Research Triangle Park, Dean North Carolina 27709 Faculty of Public Health U.S.A.
212 43. Dr. Malcolm Potts Regional Office for Asia Executive Director Tanglin International Fertility Research Program P.O. Box 101 Research Triangle Park Singapore 10 North Carolina 27709 U.S.A. 6 Mr. B.J. Kukielka Ag. WHO Programme Coordinator 44. Dr. J.Y. Peng WHO Associate Director for Internaticnal Activities Devavesm Palace International Fertility Research Program Bangkok North Carolina 27709 Thailand U.S.A. 7. Dr. Vitura Sangsingkeo 45. Dr. David Edelman Executive Secretary Research in International Fertility Research Program International Committee on Applied Research Triangle Park Population of Asia (ICARP ASIA) North Carolina 27709 Rm625, R.S. Hotel U.S.A. Larn Luang Road Bangkok 46. Dr. Roger Bernard Thailand International Fertility Research Program Triangle Park 8. Dr. K.Panikkar Research Kedah FPA North Carolina 27709 Chairman Training FFPAM/Chairman U.S.A. c/o Kedah Klinik Alor Star IPPF Kedah Malaysia 47. Dr. Jose B. Catindig Deputy Director 9. Dr. Ching-Kun Yeh Clinic International Planned Parenthood Federation Chung-Hwa OB-GYN East and South East Asia and Oceania Region 162-4, Chin Hwa St. P.O. Box 2534 Taipei Kuala Lumpur 16-03 Taiwan Malaysia 10. Dr. Jan-Yang Lee OBSERVERS F/2 No. 157 Nan-Chong Road 1. Dr. J. Jarrett Clinton Section One Senior Representative for South & East Asia Taipei Population Council Taiwan P.O. Box 11-1213 Bangkok 11. Mrs. Charunee Hiranniramol Thailand Department of Health Ministry of Public Health 2. Dr. Richard T. Mahoney Devaves Palace Programme Officer/Asia Bangkok 2 PIACT Asia Thailand MCC P.O. Box 189 Makati IGCC Secretariat Manila Philippines 1. Dr. L.S. Sodhy Secretary General 3. Mr. Lloyd D. Emerson IGCC Secretariat Liaison for Regional Programmes P.O. Box 550 UNFPA Kuala Lumpur 01-02 G.P.O. Box 618 Malaysia Bangkok 2 2. Dr. Soebagjo P. Thailand Programme Officer 4. Ms. Laura Olson IGCC Secretariat Chief P.O. Box 550 Clearing House and Information Section Kuala Lumpur 01-02 Division of Population and Social Affairs Malaysia UN-ESCAP United Nations Building 3. Mr. Yap Tat Leong Bangkok Assistant Secretary Thailand IGCC Secretariat P.O. Box 550 0l-02 5. Dr. Marjorie A. Koblinsky Kuala Lumpur International Development Research Centre Malaysia
213 4. Ms. Mahani Yusoff 9. Mr. Benjamin de Leon Personal Ass;stant Commission on Population IGCC Secretariat Philippines P.O. Box 550 Kuala Lumpur01-02 10. Dr. (Mrs) Malla Dibya Shree Malaysia Maternity Hospital Nepal SUPPORTING STAFF FROM THE MINISTRY OF PUBLIC HEALTH THAILAND 11. Dr. Somboon Vachrotai Ministry of Health 1. Mrs. Amara Sriboonlue Thailand
2. Mrs. Srisavangvong 12. Dr. Hamid Arshat National Family Planning Board 3. Mrs. Swangpan Saubhayana Malaysia
4. Mrs. Daranee Kwangyauh 13. Dr. Sutham Hiranniramol Ministry of Health 5. Miss Somnuk Pukhav Thailand RESOURCE PERSONS Sukomol 6. Mr. Santi 1. Dr. Somboon Vachrotai 7. Mrs. Chanpen Baosri Ministry of Health Thailand Chaisari 8. Mrs. Anusorn 2. Dr.VI Kim/Jae Mo Yang (Yonsei University) 9. Mr. Mathee Thusranonth Korean Institute for Family Planning Korea Onchang 10. Mr. Preecha 3. Dr. David Edelman 11. Mr. Chumsok Pojamanpimon IFRP U.S.A. Sudchai 12. Mr. Sommai 4. Dr. Malcolm Potts IFRP C-TEERING COMMITTEE U.S.A.
1. Dr. J.Y. Peng 5. Dr. Edwin B. Mcrltqniel IFRP McCormick Hospital U.S.A. Thailand
2. Dr. Malcolm Potts 6. Dr. (Mrs) Malla Dibya Shree IFRP Maternity Hospital U.S.A. Nepal
3. Dr. Roger Bernard 7. Dr. Gloria Aragon IFRP University of the Philippines U.S.A. Philippines
4. Dr. David Edelman 8. Mr. Benjamin de Leon IFRP Commission on Population U.S.A. Philippines
5. Datin (Dr) Nor Laily Aziz, JSM 9. Dr. Johan A.M. Thambu National Family Planning Board General Hospital Johore Bahru Malaysia Malaysia
6 Dr. L.S. Sodhy 10. Dr. J.Y. Peng IGCC IFRP Malaysia U.S.A.
7. Dr. Jose B. Catindig 11. Dr. Jose B. Catindig IPPF IPPF, ESEAOR Malaysia Malaysia
8. Dr. Haryono Suyono 12. Dr. Ho-Kei Ma National Family Planning Coordinating Board Queen Mary Hospital Indonesia Hong Kong
214 13. Dr. Tina Agoestina 17. Dr. Mark Cheng Chi Eng Padjadjaran University, Bandung University of Singapore Indonesia Singapore
14. Dr. Roger Bernard 18. Dr. Takashi Wagatsuma IFRP National Medical Center Hospital U.S.A. Japan
15. Dr. Haryono Suyono 19. Professor Pei-Chuan Ouyang National Family Planning Coordinating Board National Taiwan University Hospital Indonesia Taiwan
16. Dr. Azizan bt. Aiyub Ghazali 20. Dr. Hamid Arshat Ministry of Health National Family Planning Board Malaysia Malaysia
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