|Year : 2013 | Volume
| Issue : 1 | Page : 16-23
Current knowledge and pattern of use of family planning methods among a severely ill female Nigerian psychiatric outpatients: Implication for existing service
Mosunmola F Tunde-Ayinmode
Department of Behavioral Sciences, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
|Date of Web Publication||7-Mar-2013|
Mosunmola F Tunde-Ayinmode
Department of Behavioral Sciences, University of Ilorin Teaching Hospital, Ilorin, Kwara State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Despite the acknowledged benefits accruable to the mentally ill from the use of contraceptives, research and dedicated reproductive health services for this group of people in Nigeria are still underdeveloped or non-existent in many cases. This study aims at identifying the current status of knowledge and pattern of use of modern contraceptives in a clinic population.
Materials and Methods: A cross-sectional descriptive study of 100 women with severe mental illness attending psychiatric outpatient clinic in Ilorin, Nigeria, using a semi-structured questionnaire.
Results: A majority (88%) of the women had good knowledge of family planning, many (61%) were interested in its use but at least half of them had not used any method and current use was just 27%. Attitude to family planning was generally positive as indicated by desired family size (71%) of less than 4 children with 6 out of 10 desiring future intention to use. The male condom was the most known and ever used method (68%, 37%), respectively. Most (81%) of these women desired that family planning information be provided at the psychiatric clinic but fewer of them discussed this with their partners.
Conclusion: Considering discrepancies between knowledge, interest and use, the potential health benefits of fertility regulation, and the adverse effects of unregulated family, and contraceptive use is still relatively low. There is need for improvement which might only be possible if psychiatric focused programs are initiated. The large number of women who desired clinic-based family planning education suggests that the introduction of such program is feasible.
| Abstract in French|| |
Contexte: Malgré le reconnu prestations rapprocherait les malades mentaux de l'utilisation des contraceptifs, recherche et dédié à des services de santé génésique pour ce groupe de personnes au Nigéria sont encore peu développé ou inexistant dans de nombreux cas. Cette étude vise à identifier l'état actuel des connaissances et le mode d'emploi des contraceptifs modernes dans une population clinique.
Méthodes et matériaux: Une étude descriptive transversale de 100 femmes avec des troubles mentaux sévères traitant clinique psychiatrique à Ilorin, Nigeria, à l'aide d'un questionnaire semi-structuré.
Résultats: Une majorité (88%) des femmes avait bonne connaissance de la planification familiale, nombreux (61%) se sont intéressés à son utilisation, mais au moins la moitié d'entre eux n'avait pas utilisé une méthode et utilisation actuelle n'était que de 27%. Attitude à la planification familiale a été généralement positive, comme indiqué par taille désirée de la famille (71%) des enfants de moins de 4 à 6 sur 10 désirant venir intention d'utiliser. Le préservatif masculin est la méthode la plus connue et jamais utilisée (68%, 37%), respectivement. La plupart de ces femmes (81%) souhaite que fournir des renseignements de planification familiale à la clinique psychiatrique, mais peu d'entre elles a discuté cette question avec leurs partenaires.
Conclusion: Compte tenu de différences entre connaissances, intérêt et utilisation les bienfaits potentiels de la régulation de la fécondité et les effets néfastes des non réglementée, familles et contraception utilisent est encore relativement faible. Il y a nécessité d'une amélioration qui seulement serait possible si des programmes ciblés psychiatriques sont lancés. Le grand nombre de femmes qui ont désiré l'éducation axée sur la clinique de planification familiale donne à penser que l'introduction d'un tel programme est réalisable.
Mots clés: Connaissances actuelles, l'utilisation de la planification familiale, patients psychiatriques femmes gravement malades
Keywords: Current knowledge, family planning use, severely ill female psychiatric outpatients
|How to cite this article:|
Tunde-Ayinmode MF. Current knowledge and pattern of use of family planning methods among a severely ill female Nigerian psychiatric outpatients: Implication for existing service. Ann Afr Med 2013;12:16-23
|How to cite this URL:|
Tunde-Ayinmode MF. Current knowledge and pattern of use of family planning methods among a severely ill female Nigerian psychiatric outpatients: Implication for existing service. Ann Afr Med [serial online] 2013 [cited 2019 Dec 6];12:16-23. Available from: http://www.annalsafrmed.org/text.asp?2013/12/1/16/108245
| Introduction|| |
The reproductive health of patients with severe mental illness is an important part of their care that is often neglected. Globally, there has been a transformation of the care of the mentally ill from institutionalized care to community, day or outpatient management with limited hospital admission. ,, This trend has affected the sexuality and fertility behavior of these patients and has increased their risk of reproductive hazards related to unintended pregnancies, abortions, and sexually transmitted diseases. ,,
Pregnancy in patients with severe mental illness should be properly planned to avoid adverse consequences for the patient, the child, and the family. , Large family result from unregulated fertility which has adverse consequences for the mother, her children, and the family too. , Family members could become overburdened because of care for the patient and her children particularly during periods of exacerbation, relapse, or hospital admission and if the children are many such families could become dysfunctional if the stress is not mitigated. , Pregnancy and childbirth can exacerbate pre-existing mental illness and children born to these patients particularly those with schizophrenia are at higher risk of future social and psychological problems.  Regulating family size in heritable conditions like schizophrenia could serve preventive purposes by limiting potentially the number of children exposed to the risk of the disorder. 
Modern contraceptives are the best methods of family planning (FP) because of their effectiveness in regulating fertility and family size and as tools in preventive reproductive health. This probably is the reason why the two terms are used, many times, almost interchangeably. Generally, reproductive health programs are also concerned about infertility too, a condition in which patients with mental illness have elevated risk due to their medications. ,
Unlike in developed countries, there is little or no evidence in literature from developing countries like Nigeria that mental health workers have adapted to the trends in sexuality, fertility, and marriage counseling of patients with severe mental illness. There are reports of discharged and continuing care patients being counseled on these issues and of successful separate family planning services for institutionalized psychiatric patients from more developed countries. ,,, Even at that, inadequacies exist in knowledge of mental health workers about how to provide family planning, manage fertility issues, handle ethical issues, how to obtain informed consent, and role of reproductive decision on family life and on the management of the patient. ,,,
In Nigeria, while the importance of family planning in the mental health has for long been recognized, , we still do not have any organized fertility regulation program. The presence of homeless mentally ill patients or psychotic vagrants on the streets of many of the cities in Nigeria with some who may be pregnant or nursing or rearing children presents an unfortunate scene. Anecdotal evidence points to the need for fertility regulation program for such patients. , However, the role of the family in the occurrence of mental health needs to be further researched, it is also important to study the reproductive decision making in these patients.
Mentally ill patients in Nigeria are managed in the community often as day care. The severely ill may be admitted in the hospital with a revolving door policy since they are discharged back into the community. Research on marriage, fertility and sexuality pattern, or trends of these patients is important to maximize the opportunity for preventive mental and reproductive health care.
Nigeria is still a high fertility country with a total fertility rate of 5.7%,  like the rest of sub-Saharan Africa it has a relatively low contraceptive use prevalence, which is put at 9.6%;  family planning is part of primary care but special services for the mentally ill is nonexistent.
Factors that may restrict the mentally ill patients from being able to use the regular family planning program for the general population include stigma, socio-economic and educational disadvantages, illness-related and decision-impairing factors (e.g., mental instability, disorganized thought process, difficulty with social communication, social isolation, delusional disorders, and hallucinations that may occur in schizophrenia), ,, prevailing preference for traditional methods and high default rate by users of orthodox care. 
Based on differences in level of social and economic development, the reasons why this group of women may not be using any method are likely to vary according to local or geographical settings. Illness-related factors are more likely to be fairly homogeneous in occurrence; and may include: Impairment of responsible decision; ignorance of methods; potential for dependence on others; possibility of forgetting to take the pills; higher risk of infection with IUD because of the ever present risk of multiple sexual partners. ,,
Scientific literature search for evidence of sexuality pattern, fertility behavior, and special family planning programs, pattern of knowledge, and use of family planning among women with severe mental illness in Nigeria has not been too rewarding. In fact, a literature search did not yield any study from the North central zone of the country which was the setting of this investigation. This study is an attempt to characterize knowledge and use of family planning among these patients attending our clinic and thus provide some insight into their fertility behavior.
| Materials and Methods|| |
Study design and population
This paper is reporting a segment of data from a larger descriptive cross-sectional analytic study on marital, parenthood, parenting, family profiles, and reproductive behavior of women with severe mental illness. The study population consisted of 100 women with severe mental illness in their reproductive age groups (18-52 years) who have been in remission (mentally stable) in the preceding 2 months and attending the psychiatric outpatient facility. Women considered to have severe illness included those with schizophrenia, bipolar disorders, major depression and other psychotic disorders. Those who had impaired ability to adequately respond to questions were excluded, e.g., those with impaired cognition from whatever cause or unresolved psychotic episodes.
Location and background of study
The study was carried out at the outpatient clinics of the department of Behavioral Sciences, University of Ilorin Teaching Hospital, Ilorin, North-central Nigeria. The department runs outpatient clinics three times a week. Usually health education talks are given by nurses to patients at the start of the clinics.
All consecutive patients approached, who met the inclusion criteria and gave consent to participate during the period of the study were recruited into the study.
The study was carried out using a semi-structured questionnaire with four sections respectively on socio-demographic characteristics, family characteristics, illness-related characteristics, and family planning characteristics of the subjects.
Data collection and analysis
Three research assistants and the investigator collected the data. Although the questionnaire was supposed to be self-administered, they were read to the patients as pilot study showed some discrepancy between reported literacy levels and competence in correctly filling the questionnaire. The participants were interviewed in either English or Yoruba language the locally spoken language.
EPI info 6.02 was used for the analysis of data. Simple frequencies were generated, Chi-Square test and Fishers exact test were used to test for significant differences. A P value less than 0.05 was regarded as a statistically significant difference.
| Results|| |
A total of 100 women were recruited, 74% had ICD 10 diagnosis of schizophrenia, 9% severe depression, 6% bipolar affective disorder, 9% other psychotic disorders, 2% severe obsessive-compulsive disorder. The mean duration of illness was 8.0 years (SD = 6.7). The range of duration of illness was 1-29 years. A majority of women were older than 20 years, age range was 19-52. The average age was 35.4 (SD = 8.2). A majority of the subjects had some formal education and were gainfully employed. Two-thirds were currently in a marriage with monogamous relationship predominating [Table 1].
|Table 1: Some clinical and socio-demographic characteristics of the women|
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Family planning characteristics
Knowledge and use
The level of knowledge of any family planning method was 88% and that of interest in using was 61% but only 27% were currently using a method and 51% had never used a method before. The gap in family planning need is 61% (i.e., 88-27%). The method of family planning known in decreasing order was: Male condom (68%); injectables (64%); the pills (56%); IUD (37%); and sterilization (16%). The methods currently being used in decreasing order were: Condom (10%); injectables (6%); IUD (6%); and the pills (2%) [Table 2].
Less than half (48%) discussed family planning issues with their spouses, only 5% had ever received family planning information from our clinic or hospital even though 81% desired to have such information provided by the clinics.
Reasons for non-use
The most common reason for not using family planning despite knowledge and interest was categorized as follows in order of frequency: Fear of side effects of the methods (25/63); desire for more children or for as many children as possible (21/63); dislike of methods because of cultural and religious inhibitions (9/63); indecision (2/63); and spousal opposition (1/63).
Reasons for use
The most common reasons for using family planning can be categorized in order of frequency as follows: Termination of child bearing (15/27); increasing inter-birth intervals, i.e. birth spacing (8/27) and limiting the number of children likely to have.
The reasons for not having interest at all in any family planning method in order of frequency include: Want unlimited number of children (16/39); dislike of methods because of cultural and religious inhibitions (6/39); fear of side effects of the methods (5/39); "I don't just like it" (12/39) [Table 3].
Reasons for discontinuations
The reasons for family planning discontinuation following previous use were: Fear of methods (16/22); pregnancy (3/22), and termination of sexual relationships (2/22). Methods used previously and stopped include: Pills (8/27); injectables (7/27); male condoms (4/27); and IUD (3/27) [Table 3].
| Discussion|| |
This is a study of knowledge and use of family planning among an outpatient population of women with severe mental illness, a majority of whom had schizophrenia, were educated, and gainfully employed. These women were relatively knowledgeable about modern methods of family planning but had low level of interest and much lower level of use. The study also suggests that many of the women are still at risk of large family size and unintended pregnancies. Many of them may have been unreached as far as the hospitals preventive reproductive health is concerned; the pattern of interest and use may have been consequential to this fact. Desire for family planning education program was high, creating opportunity of modifying reproductive behavior at the individual level in the clinic.
Several studies in Nigeria suggest that the knowledge of family planning in the general population may have increased substantially despite the low prevalence of use. ,,, This may explain the high knowledge prevalence rate got in this study. In the case of our women with severe mental illness, discrepancies between knowledge, interest, and use may have resulted from the potential obstacles that make the regular family planning outlets unattractive or inaccessible to these patients. Some of obstacles relate to stigma, education, poverty, communication, supervision, contact tracing, and other illness-related issues. , To expatiate, these factors affect their ability to take responsible decisions on correct choice and use of methods and on effective use of community resources. These points have been used to support psychiatric clinic-based family planning initiatives, more so that many of these patients have frequent contact with mental health workers and hardly the general health service.
A number of patients among those using contraception (56%) in this study wanted to stop child bearing and needed long term or terminal methods of contraception but reported that their spouses were using the condoms regarded as inappropriate or suboptimal in the circumstance. Ignorance of appropriate methods is highly probable, for example, terminal contraceptives like sterilization and implant were not known or used at all. Inaccessibility or acceptability of the regular sources of family planning may be another explanation. This reason is not without example, there are reports from more developed countries about women who have completed their families and requiring long term or even terminal contraceptive not able to assess it from community services; specialized services will help these group of people. ,,
Several suggestions have been made as to the most appropriate method for evaluating these patients for family planning. There is consensus on individualized approach since inappropriateness may be personalized on the basis of certain problems. For example, the probability of inconsistency of use, deficient cooperation, or poor hygiene may negate use of IUD so will the risk or the presence of depression contraindicate use of the hormonal contraceptives.  On the other hand, when compliance cannot be guaranteed and no contraindications then injectables can be used. It has been suggested that all patients should be give equal opportunity to use at least a method based on merits.  When patient is indecisive on all methods, the condom is suggested; in fact some experts have suggested that it should be used irrespective of any method used because of the protection of the patient from STDs. 
Just as the gap between knowledge and use is remarkable and is a measure of unmet need so is the similarities between method known and method used; it indicates efforts at improving knowledge will eventually improve level of use. Both facts suggest that much more efforts will have to be made to get this group of women to further use family planning. Most common factors that are known to be responsible for non-use of family planning in Nigeria include: Fear of side effects of methods, myths about family planning, cultural and religious oppositions, and opposition by spouses. , The findings of this study are similar except that spousal opposition was not prominent.
In the general population in Nigeria, the order of frequency of methods known and used is the pills, condom, the injectables, and IUD; ,, this is slightly different from this study in which the condom was the most frequently used method. Although relatively not as effective, it offers the benefit of lowering the risk of STDs in high risk patients like those with severe mental illness. , Female condom is still very rarely used in Nigeria.  The male condom will require the motivation of sexual partner to use. The condom transfers the burden of instruction and consistency of use and by extension responsibility of fertility regulation from the ill decisionally incompetent female partner to the male partner who is assumed to be psychiatrically normal. Since most of the women were married, some degree of consistency of sexual partner can be assumed which again supports the propriety of the condom in the circumstance. The need to educate the male partner on the appropriate use and limitations of condoms should be emphasized, particularly what to do in cases of inappropriate use to avoid unintended pregnancies.
Although it can be sometimes difficult to get the male partner to accept family planning and even more difficult to come to the clinic in our setting being often occupationally engaged. Encouragingly the male factor as the reason for not using family planning was not a major factor in this study contrary to its generally recognized impact in many studies. , Men continue to determine the level of fertility of their families and contraceptive decisions; their rate of acceptance and willingness to adopt family planning has a great impact on prevalence and family size.  The fact that the male condom was the most known and used method suggests the significant role male spouses play in the reproductive health of the affected women and not surprising only very few of them gave their spouses opposition as a reason for not having interest or using family planning.
Similar to the general population, the use of hormonal contraceptive injectable and the pills in this study was frequent occupying the second and fourth position, respectively; ,,, Traditional methods (deliberate postpartum sexual abstinence) although on the decline are still important methods particularly in developing countries like Nigeria. , Abortion as a method of family planning is illegal in Nigeria but there are reports that its rate may be quite high.  It has been reported that female patients with severe mental illness are at increased risk of having abortions. ,,
The most common reason for using family planning in Nigeria is for birth spacing. ,, In this study, a majority of the women desired less than 4 children and majority had less than 4 children alive. A majority of those who were using family planning used it because they had completed their families and wanted to terminate child bearing, this positive trend of more terminal contraceptors than birth spacing contraceptors and the remarkable desire for smaller family is not compatible with the condom being the most frequently used method. It is suboptimal for terminal contraceptors, IUD, hormonal implants or sterilization that would be more effective and efficacious.  Although some of the women knew sterilization, none used it conforming to the national trend; sterilization is a poorly accepted or used method in Nigeria because of cultural and religious opposition; , there is a lot of work that need to be done to redirect the interest of women to the more effective means of contraception. Women who are well motivated to use family planning should be encouraged to use effective methods.
Fear of side effects was the main reason for discontinuation of contraceptive use. A majority of those who had never used any family planning method gave cultural and religious reason for this resistance which poses serious challenge for public enlightenment and family planning education at the clinic level.
| Conclusion|| |
The study has provided some evidence that many of our women with severe mental illness are knowledgeable and interested in family planning but are not using any modern methods; this gap suggest that a lot still need to be done to meet their family planning needs. In addition, many current users were using methods incongruent with family size or reproductive aspirations; therefore, intervention at psychiatric outpatient clinics is necessary to change reproductive behavior of these women and improve their reproductive health. This may include clinic-based psychiatric-focused patient education and referral service to be delivered by specially trained mental health workers or family planning providers.
One limitation of this study is that it is hospital based thus limiting the ability to generalize it to the wider population but the sample is representative of the target population of women with severe mental illness. This is a preliminary descriptive study intentioned to determine existence of problems it could serve as basis for a larger study with more robust instrument and methods; however, this can be considered a valuable investigation.
| References|| |
|1.||Nicholson J, Biebel K, Hinden B, Henry A, Stier L. Critical issues for parents with mental illness and their families. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. 2001. |
|2.||Miller LJ. Sexuality, reproduction, and family planning in women with schizophrenia. Schizophr Bull 1997;23:623-35. |
|3.||David HP, Lindner MA. Family planning for the mentally handicapped. Bull World Health Organ 1975;52:155-61. |
|4.||Pehlivanoglu K, Tanriover O, Tomruk N, Karamustafalioglu N, Oztekin E, Alpay N. Family planning needs and contraceptive use in female psychiatric outpatients. Turkish J Fam Med Primary Care 2007;3:32-5. |
|5.||Coverdale JH, Turbott SH, Roberts H. Family planning needs and STD risk behaviors of female psychiatric out-patients. Br J Psychiatry 1997;171:69-72. |
|6.||Miller LJ, Finnerty M. Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders. Psychiatr Serv 1996;47:502-6. |
|7.||WHO. Child mental health and psychosocial development. Report of WHO Expert Committee. Technical Report Series 613. Geneva: WHO; 1977. |
|8.||Barker P, editor. Basic child psychiatry. 6 th Edition, Blackwell Science LTD. Oxford UK. 2000. |
|9.||Hosseini SH, Sheykhmounesi F, Shahmohammadi S. Evaluation of mental health status in caregivers of patients with chronic psychiatric disorders. Pak J Biol Sci 2010;13:325-9. |
|10.||Giron M, Gómez-Beneyto M. Relationship between family attitude and social functioning in schizophrenia: A nine-month follow-up prospective study in Spain. J Nerv Ment Dis 2004;192:414-20. |
|11.||Mowbray CT, Oyserman D, Zemencuk JK, Ross SR. Motherhood for women with serious mental illness: Pregnancy, childbirth, and the postpartum period. Am J Orthopsychiatry 1995;65:21-38. |
|12.||Aboud FE. Health psychology in global perspective. In: Mental health and illness. USA: SAGE Publications; 1998. p. 244-64. |
|13.||Ladipo OA. Reproductive health and health benefits of family planning. Forum Magazine (pathfinder project) 1983;2:14-6. |
|14.||Howard LM, Kumar C, Leese M, Thornicroft G. The general fertility rate in women with psychotic disorders. Am J Psychiatry 2002;159:991-7. |
|15.||Miller LJ, Finnerty M. Family planning knowledge, attitudes and practices in women with schizophrenic spectrum disorders. J Psychosom Obstet Gynaecol 1998;19:210-7. |
|16.||Jegede RO, editors. Psychiatry for the Health Professions Macmillan tropical nursing and health science series. London: Macmillan Publishers Limited; 1985. |
|17.||Jegede RO. Preventive child psychiatry in Africa: Prospects and limitations. Am J Psychiatry 1981;7:1-10. |
|18.||Taiwo H, Ladapo O, Aina OF, Lawal RA, Adebiyi OP, Olomu SO, et al. Long stay patients in a psychiatric hospital in Lagos, Nigeria. Afr J Psychiatry (Johannesbg) 2008;11:128-32. |
|19.||Gureje O, Alem A. Mental health policy development in Africa. Bull World Health Organ 2000;78:475-82. |
|20.||National Population Commission [Nigeria] and ICF Macro. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro; 2009. |
|21.||Tom G, Sanders R, Ross J. Analyzing Family Planning Needs in Nigeria: Lessons for Repositioning Family Planning in Sub-Saharan Africa. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1; 2009. |
|22.||Odejide AO, Oyewumi LK, Ohaeri JU. Psychiatry in Africa: An overview. Am J Psychiatry 1989;146:708-16. |
|23.||Hankoff LD, Darney PD. Contraceptive choices for behaviorally disordered women. Am J Obstet Gynecol 1993;168:1986-9. |
|24.||Odimegwu CO. Family planning attitudes and use in Nigeria: A Factor analysis. Int Fam Plan Perspect 1999;25:86-90. |
|25.||Oye-Adeniran BA, Adewole IF, Umoh AV, Oladokun A, Gbadegesin A, Ekanem EE, et al. Community based study of contraceptive behavior in Nigeria. Afr J Reprod Health 2006;10:90-104. |
|26.||Ankomah A, Anyanti J, Oladosu M. Myths, misinformation, and communication about family planning and contraceptive use in Nigeria. Open Access Journal of Contraception 2011;2:95-105. doi.org/10.2147/OAJC.S20921. |
|27.||Neinstein LS, Katz B. Psychiatrically impaired patients often exposed to pregnancy risk. Contracept Technol Update 1985;6:88-90. |
|28.||Monjok E, Smesny A, Ekabua JE, Essien EJ. Contraceptive practices in Nigeria: Literature review and recommendation for future policy decisions. Open Access Journal of Contraception 2010:19-22. |
|29.||Odimegwu O, Ojo M, Siyagande A. Regional correlates of Choice of contraceptive methods in Nigeria. Korea J Popul Dev 1997;26:131-45. |
|30.||Anate M. Factors influencing family planning use in Ilorin, Nigeria. East Afr Med J 1995;72:418-20. |
|31.||Jagha TO, Mantell JE, Adedimeji AA. Female condom acceptability and continuation in Ibadan/Nigeria: Estimates from a cohort survey. Poster Exhibition: The XIV International AIDS Conference: Abstract no. MoPeD3582". International AIDS Society, 2012. |
|32.||Duze MC, Mohammed IZ. Male knowledge, attitude and family practice in northern Nigeria. Afr J Reprod Health 2006;10:53-65. |
|33.||Izugbara CO, Ezeh AC. Women and high fertility in Islamic northern Nigeria. Stud Fam Plann 2010;41:193-204. |
|34.||Feyisetan BJ. Postpartum sexual abstinence, breastfeeding, and child spacing, among Yorubawomen in urban Nigeria. Soc Biol 1990;37:110-27. |
|35.||Oni GA. Breastfeeding: Its relationship with postpartum amenorrhea and postpartum sexual abstinence in a Nigerian community. Soc Sci Med 1987;24:255-62. |
[Table 1], [Table 2], [Table 3]