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POPULATION DYNAMICS OF SUB-SAHARAN AFRICA DEMOGRAPHIC CHANGE IN SUB-SAHARAN AFRICA DEMOGRAPHIC EFFECTS OF ECONOMIC REVERSALS IN SUB-SAHARAN AFRICA EFFECTS OF HEALTH PROGRAMS ON CHILD MORTALITY IN SUB-SAHARAN AFRICA FACTORS EFFECTING CONTRACEPTIVE USE IN SUB-SAHARAN AFRICA POPULATION DYNAMICS OF KENYA POPULATION DYNAMICS OF SENEGAL SOCIAL DYNAMICS OF ADOLESCENT FERTILITY IN SUB-SAHARAN AFRICA
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NOTE: This map which has been prepared solely for the convenience of the readers, does not purport to express political boundaries or relationships. The scale is a composite of several forms of projection.
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POPULATION DYNAMICS OF SUB-SAHARAN AFRICA Effects Of Health Programs on Child Mortality in Sub-Saharan Africa Douglas C. Ewbank and James N. Gribble, Editors Working Group on the Effects of Child Survival and General Health Programs on Mortality Panel on the Population Dynamics of Sub-Saharan Africa Committee on Population Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1993
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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Robert M. White is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Robert M. White are chairman and vice chairman, respectively, of the National Research Council. Library of Congress Catalog Card No. 93-84761 International Standard Book Number 0-309-04941-5 Additional copies of this report are available from: National Academy Press, 2101 Constitution Avenue, N. W., Box 285, Washington, D.C. 20418. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). B165 Copyright 1993 by the National Academy of Sciences. All rights reserved. Printed in the United States of America
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WORKING GROUP ON EFFECTS OF CHILD SURVIVAL AND GENERAL HEALTH PROGRAMS ON MORTALITY DOUGLAS C. EWBANK (Chair), Population Studies Center, University of Pennsylvania ROBERT E. BLACK, Department of International Health, Johns Hopkins University MICHEL GARENNE, Center for Population and Development Studies, Harvard University ALLAN G. HILL, Center for Population and Development Studies, Harvard University PATRICK O. OHADIKE, Regional Institute for Population Studies, Accra, Ghana JAMES N. GRIBBLE, Staff Officer JOAN MONTGOMERY HALFORD, Senior Project Assistant* PAULA J. MELVILLE, Senior Project Assistant * through July 1992
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PANEL ON THE POPULATION DYNAMICS OF SUB-SAHARAN AFRICA KENNETH H. HILL (Chair), Department of Population Dynamics, Johns Hopkins University ADERANTI ADEPOJU, Institut de Dévelopment Economique et de la Planification (IDEP), Dakar, Senegal JANE T. BERTRAND, School of Public Health and Tropical Medicine, Tulane University CAROLINE H. BLEDSOE, Department of Anthropology, Northwestern University WILLIAM BRASS, Centre for Population Studies, London School of Hygiene and Tropical Medicine, England DOUGLAS C. EWBANK, Population Studies Center, University of Pennsylvania PHILIPPE FARGUES, Centre d'Etudes et de Documentation Economique, Sociale et Juridique (CEDEJ), Cairo, Egypt RON J. LESTHAEGHE, Faculteit van de Economische, Sociale en Politieke Wetenschappen, Vrije Universiteit, Brussels, Belgium PATRICK O. OHADIKE, Regional Institute for Population Studies (RIPS), Accra, Ghana ANNE R. PEBLEY, The RAND Corporation, Santa Monica, California DANIEL M. SALA-DIAKANDA, Institut de Formation et de Recherche Démographiques (IFORD), Yaoundé, Cameroon
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COMMITTEE ON POPULATION SAMUEL H. PRESTON (Chair), Population Studies Center, University of Pennsylvania JOSE-LUIS BOBADILLA, World Bank, Washington, D.C. JOHN B. CASTERLINE, Department of Sociology, Brown University KENNETH H. HILL, Department of Population Dynamics, Johns Hopkins University DEAN T. JAMISON, School of Public Health, University of California, Los Angeles ANNE R. PEBLEY, The RAND Corporation, Santa Monica, California RONALD R. RINDFUSS, Department of Sociology, University of North Carolina, Chapel Hill T. PAUL SCHULTZ, Department of Economics, Yale University SUSAN C.M. SCRIMSHAW, School of Public Health, University of California, Los Angeles BETH J. SOLDO, Department of Demography, Georgetown University MARTA TIENDA, Population Research Center, University of Chicago BARBARA BOYLE TORREY, Population Reference Bureau, Washington, D.C. JAMES TRUSSELL, Office of Population Research, Princeton University AMY O. TSUI, Carolina Population Center, University of North Carolina, Chapel Hill LINDA G. MARTIN, Director BARNEY COHEN, Research Associate SUSAN M. COKE, Senior Project Assistant KAREN A. FOOTE, Research Associate DIANE L. GOLDMAN, Administrative Assistant* JAMES N. GRIBBLE, Program Officer JOAN MONTGOMERY HALFORD, Senior Project Assistant** CAROLE L. JOLLY, Program Officer DOMINIQUE MEEKERS, Research Associate* PAULA J. MELVILLE, Senior Project Assistant * through December 1991 ** through July 1992
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Preface This report is one in a series of studies that have been carried out under the auspices of the Panel on the Population Dynamics of Sub-Saharan Africa of the National Research Council (NRC) Committee on Population. The Research Council has a long history of examining population issues in developing countries. In 1971 it issued the report Rapid Population Growth: Consequences and Policy Implications . In 1977, the predecessor Committee on Population and Demography began a major study of levels and trends of fertility and mortality in the developing world that resulted in 13 country reports and 6 reports on demographic methods. Then, in the early 1980s, it undertook a study of the determinants of fertility in the developing world, which resulted in 10 reports. In the mid- and late-1980s, the Committee on Population assessed the economic consequences of population growth and the health consequences of contraceptive use and controlled fertility, among many other activities. No publication on the demography of sub-Saharan Africa emerged from the early work of the committee, largely because of the paucity of data and the poor quality of what was available. However, censuses, ethnographic studies, and surveys of recent years, such as those under the auspices of the World Fertility Survey and the Demographic and Health Survey programs, have made available data on the demography of sub-Saharan Africa. The data collection has no doubt been stimulated by the increasing interest of both scholars and policymakers in the demographic development of Africa and the relations between demographic change and socioeconomic developments.
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In response to this interest, the Committee on Population held a meeting in 1989 to ascertain the feasibility and desirability of a major study of the demography of Africa, and decided to set up a Panel on the Population Dynamics of Sub-Saharan Africa. The panel, which is chaired by Kenneth Hill and includes members from Africa, Europe, and the United States, met for the first time in February 1990 in Washington, D.C. At that meeting the panel decided to set up six working groups, composed of its own members and other experts on the demography of Africa, to carry out specific studies. Four working groups focused on cross-national studies of substantive issues: the social dynamics of adolescent fertility, factors affecting contraceptive use, the effects on mortality of child survival and general health programs, and the demographic effects of economic reversals. The two other working groups were charged with in-depth studies of Kenya and Senegal, with the objective of studying linkages between demographic variables and between those variables and socioeconomic changes. The panel also decided to publish a volume of papers reviewing levels and trends of fertility, nuptiality, the proximate determinants of fertility, child mortality, adult mortality, internal migration, and international migration, as well as the demographic consequences of the AIDS epidemic. This volume, one of the four cross-national studies, attempts to document the effects of general health and child survival programs on mortality. Although progress has been made, infant and child mortality levels in parts of sub-Saharan Africa remain among the highest in the world. The disease-specific orientation of this report draws attention to a variety of strategies and interventions that have been developed in an effort to reduce the mortality effects of many of the most important diseases. It also examines the effects of general health programs that have been implemented in various settings of sub-Saharan Africa. As is the case for all of the panel's work, this report would not have been possible without the cooperation and assistance of the Demographic and Health Survey (DHS) Program of the Institute for Resource Development/Macro Systems. We are grateful to the DHS staff for responding to our inquiries and facilitating our early access to the survey data. We are also grateful to the organizations that provided financial support for the work of the panel: the Office of Health, the Office of Population, and the Africa Bureau of the U.S. Agency for International Development; the Andrew W. Mellon Foundation; the William and Flora Hewlett Foundation; and the Rockefeller Foundation. Besides providing funding, the representatives of these organizations were a source of information and advice in the development of the panel's overall work plan. This report results from the joint efforts of the working group members and staff and represents a consensus of the members' views on the issues
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addressed. The Committee on Population and the Panel on the Population Dynamics of Sub-Saharan Africa appreciate the time and energy that all the working group members devoted to the study. The working group was assisted in its efforts by several commissioned background papers. Charles Katende authored a paper on infant and child mortality and the proximity of health facilities in Liberia and Zimbabwe. Margaret Luck wrote a paper on mortality trends in Senegal. Special thanks are also due Joan Montgomery Halford and Paula Melville for providing superb administrative and logistical support to the working group and to Florence Poillon for her skillful editing of the report. Eugenia Grohman and Elaine McGarraugh were instrumental in guiding the report through the report review and production processes. SAMUEL H. PRESTON, Chair Committee on Population
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Contents EXECUTIVE SUMMARY 1 1 INTRODUCTION 5 2 TRENDS IN MORTALITY AND CAUSES OF DEATH IN AFRICA 11 Trends in Child Mortality 11 Causes of Death Among African Children 17 Summary 25 3 IMMUNIZATION PROGRAMS 26 MEASLES 29 Epidemiology 29 Vaccine Efficacy 30 Why Africa Might Be Different 32 Evidence of Mortality and Morbidity Effects from Africa 33 Nonlinearities in Relationship Between Coverage and Effect 39 Program History, Coverage, and Quality 44 Treatment of Measles (Including Vitamin A) 47 Summary 48
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PERTUSSIS (WHOOPING COUGH) 49 Pertussis in Developed Countries 50 Pertussis in Africa 52 Program Effort 53 Summary 56 TUBERCULOSIS AND LEPROSY 56 Epidemiology of Tuberculosis 56 Prevention and Treatment of Tuberculosis 57 Efficacy of Bacille Calmette-Guérin (BCG) Vaccination 59 Epidemiology of Leprosy 60 Program Coverage 62 Summary 64 TETANUS 64 Epidemiology 64 Programs to Reduce the Incidence of Neonatal Tetanus 65 Program Coverage 69 Programs to Reduce Nonneonatal Tetanus Mortality 70 Summary 70 CONCLUSION 72 4 OTHER INTERVENTIONS TARGETED AT SINGLE DISEASES 74 DIARRHEAL DISEASE CONTROL PROGRAMS 75 Epidemiology 75 Treatment 77 Summary 81 MALARIA CONTROL PROGRAMS 82 Epidemiology 82 Malaria Mortality in Sub-Saharan Africa 84 Program Options 85 Studies of the Effects of Malaria Eradication on Mortality 86 Presumptive Treatment of Fevers with Antimalarial Drugs 89 Programs Based on Chemoprophylaxis Among Pregnant Women 96 Programs Based on Vector Control 100 Summary 101
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ACUTE RESPIRATORY INFECTIONS 104 Epidemiology 104 Interventions 105 Summary 107 5 NUTRITION AND NUTRITION PROGRAMS 108 Introduction 108 Protein-Energy Malnutrition (PEM) 109 Low Birthweight 123 Vitamin A Deficiency 128 Summary 131 6 INTEGRATED AND GENERAL HEALTH PROGRAMS 132 Introduction 132 Case Studies of Long-Term Mortality Trends 134 Hospitals and Health Centers 137 Primary Health Care Programs 138 Child Survival and Expanded Programs on Immunization 141 Summary 144 7 CONCLUSIONS AND RECOMMENDATIONS 146 Disease- and Intervention-Specific Conclusions 147 General Observations about the Evaluation of Health Programs in Africa 149 APPENDIX A CASE STUDIES OF CHILD MORTALITY: 155 APPENDIX B DEMOGRAPHIC AND HEALTH SURVEY (DHS) REPORTS: 164 REFERENCES 166
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