MCHS: an application software for family welfare programmes.

Medical Informatics

ISSN: 0307-7640 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/imif18

MCHS: An Application Software for Family Welfare Programmes K. Moidu, A. K. Singh, K. Boström, O. Wigertz, E. Trell & B. Kjessler To cite this article: K. Moidu, A. K. Singh, K. Boström, O. Wigertz, E. Trell & B. Kjessler (1992) MCHS: An Application Software for Family Welfare Programmes, Medical Informatics, 17:4, 279-291, DOI: 10.3109/14639239209079810 To link to this article: http://dx.doi.org/10.3109/14639239209079810

Published online: 12 Jul 2009.

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Date: 22 May 2016, At: 02:34

MED. INFORM.

(1992), VOL. 17, NO. 4,279-291

MCHS: an application software for family welfare programmes K. MOIDU*?f., A. K. S I N G H t f . , K. BOSTROMtg, 0. WIGERTZ?, E. TRELLS and B. KJESSLERg

Downloaded by [RMIT University Library] at 02:34 22 May 2016

? Department of

Medical Informatics; f. Department of General Practice; 4 Department of Obstetrics, Faculty of Health Sciences, University of Linkoping, S 581 83 Linkoping, Sweden (Received March 1992)

Abstract.

At the level of first contact, a primary health care centre, information management is an unwieldy task, therefore health information systems are reported to be inadequate and weak. Microcomputers could improve information management at this level, but there is little success due to a lack of specialized application software. In this paper we describe software developed after a multi-centre systems analysis study, on an essential data set, to support the delivery of the public health programmes for family welfare, i.e. maternal health care, family planning and immunization programmes. T h e modular approach was taken to develop a common application software for information management use at multiple sites. T h e software is tested in a laboratory mode by retrospective data entry from sites in Sweden and in India. All the information could be entered and site-specific reports that were generated are compared. T h e software provided a common data collection format, an essential platform for outcomes research.

Keywords: Essential data sets; Heald. information systems; Microcomputers; Primary health care; Family welfare programmes; Outcomes research.

1. Introduction A World Health Organization (WHO) report reviewing the world health situation, identified that the health information systems of the member nations were unable to support programme delivery [l]. T h e manual process of data management at the level of first contact takes the care providers away from their primary activity of care delivery into doing the mundane tasks of collation and reporting, and this makes the foundation of the information system weak. That implementation of computers could strengthen the information infrastructure has been demonstrated in a WHOsponsored project [2]. Advances in hardware development have been spectacular and a large number of powerful yet inexpensive microcomputers are now available. However, the specialized application software to support health care providers and derive the expected benefits is not available [3]; this despite the fact that some notable technical breakthroughs in computer application have been in the areas of medicine, such as the expert system MYCIN [4]. T h e diffusion of computers in clinical use, specifically at the point of first contact, i.e. the primary health care (PHC) centre, has not met with the expected upsurge, even in the developed countries. A Swedish study of technology dispersion in primary health care reports that only 5% of P H C centres had computers to support *To whom correspondence should be addressed. 0307-7640/92 $3.00

0 1993 Taylor

& Francis Ltd.

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their clinical activities [S]. T h e slow state of progress is due to failure in bringing a critical mass of functionality to desktop computers with specialized application software to support health care professionals. Attaining quality performance in a narrow task will not be enough to attract the majority of physicians to computational tools for clinical practice [6]. I n a report from a workshop of health and computing professionals, where the audience was mainly representative of the developed countries, to the question ‘what are the problems limiting doctor use of primary care systems’ the responses listed were:


(1) lack of a standard ‘adequate minimum data set’; (2) variance in user preferences, acceptance and attitudes; (3) the economic issue of the high costs involved; (4) the lack of any demonstrable clinical benefit [7]. On the basis of the field experiences with microcomputers in Egypt, it was recommended that international cooperative research programmes be initiated to develop flexible and versatile package software, for implementation of health activities relating to primary health care to be undertaken [2]. Taking cue from the earlier recommendations, an international research project was initiated to conduct a multi-centre systems analysis study at PHC centre level to identify the shared characteristics and provide a basis for a common application software design. Diversity is seen in the socio-organizational factors, but the infrastructure to support computers at a PHC centre exists, and it is recommended that the human factor (end-users) be considered foremost in any implementation [8]. Given the dataintensive nature of health care delivery, information management related to record keeping will be a primary function of many clinical systems to support. In information analysis it was identified that the entire vertical hierarchy of a programme is linked through data. At different hierarchic levels of a health care organization there is variance in the degree of detail required, but a core data set is shared and data collection is similar even between sites [9]. This core data set for the delivery of a maternal health services programme was identified by infological modelling as an essential data set (EDS) [lo] and on it the maternal and child health system (MCHS) was developed. A tool developed to collect data in a common format, preferably prospective, is a condition much desired for conducting outcomes research and to identify effective and appropriate medical protocols [ll]. T h e software was developed to demonstrate the feasibility of the E D S representation in a real-world testing framework [lo]. It was also developed to test the potential as regards common application software for information management by a modular approach. T h e MCHS was tested in a laboratory mode by retrospective data entry from a site in Sweden and India by the domain experts. This was accomplished with no loss of information, and the data entered provided a basis for reports that are compared, since it was collected by a common tool.

2. Family welfare programme objectives Among the many vertical health programmes that are delivered at the PHC centre level the family welfare programmes are given importance world-wide. The implementation and approach of the maternal health service programme may vary between countries, but the essential component remains provision of care during pregnancy and childbirth. T h e family planning programme promotes the aim of


MCHS : application software for family welfare programmes

28 1

planned parenthood and reduction of net reproduction rates. T h e immunization programme aims at combating preventable communicable diseases through prophylaxis, and the strategy is to ensure immunization of all those susceptible with the right dose, at the correct interval. T h e target group for the programmes is common or related, and this group constitutes a major segment of the population. T h e care providers maintain records manually to track the target population, to monitor and follow up those identified in need of care, and from the records they generate reports for the administration of their activities and resources utilized. As a result the data management activities take a large part of the care provider’s time, and the health information system emerges as a separate entity from the delivery of care [8]. However, administrators at all levels need these reports to follow the process of care, monitor resource utilization and define a policy based on the health status of the community [9]; it is therefore essential to strengthen the information infrastructure and integrate the information system within the delivery of care process. T h e technology as hardware is available, it is the software that is needed and as a possible solution MCHS was developed.

3. MCHS software A description of some M C H S features is preceded by the objectives and guidelines adopted for directions in the design and development.

3 . 1 . Objectives T h e M C H S was designed with an objective of supporting health care providers in information management with respect to the delivery of family welfare programmes: collect data at encounters, process the data and generate reports to support the care providers and administrators; hold data for researchers and provide an information base for integration of the delivery of care. T o ensure quality in care for the community was the first objective of the MCHS software design, and for this it must have an information base that is the foundation for continuity in care of the target population. T h e second objective is to assist the P H C care providers in information management with a tool to systematically collect data, to manage it efficiently and receive feedbacks on their activities, specifically on the impact of the care provided b y them. T h e third objective is to generate reports that give feedback to the care providers, that assist the administrators to monitor and evaluate the outcome of M C H / F P programme implementation. T h e last objective is to collect data avaiable in a common format from multiple participating sites using the same software and build an MCH registry (without person-specific data). This database could be available for outcomes research studies, and identify the most effective protocols applied in delivery of care. The MCHS software is designed as a module of a primary health care information system to support information management related to public health programmes of MCH, FP and immunization. A set of guidelines was adopted on the basis of the user characteristics derived from the multi-centre study [8], in order to build a simple functional application package that would work in the real world at multiple sites; something that could be described as right tech. Much in line with

K . Moidu et al. what Schumacher described, in an economic and developmental perspective, as appropriate intermediate technology that is functional [121. T h e guidelines adopted were:


(1) that it must support essential information management functions in the family welfare programme delivery at a PHC centre; (2) the development approach must be by rapid prototyping; (3) the design must be modular; (4) run on a commonly available configuration of hardware; (5) distribute on a common format single diskette (360 K limit); (6) use menu-based human-computer interface with form-filling for data entry screens; (7) validate data on entry and make provisions for handling missing data; (8) be user-friendly and provide feedback to care providers; (9) with minimum (NO?) errors. T h e software was designed in modules and then developed by prototyping, an approach that is well recognized [13]. T h e prototype was programmed over the application development software dBase I11 t taking the defined E D S as required for a function and presenting the screens to the MCH project group. Then the modules were integrated and the output modules were tested with data from field tests of the data collection interface. T h e program file with a code length of 6500 lines was compiled in Clipper (Summer 87 version) to produce MCHS.EXE an executable file, that only requires the operating system software PC/MSDOSf version 2.0 or greater to run. T h e other files such as the database files (*.dbf), the index files (*.ndx), and the report or output forms (+.frm) are required. All were copied to a single disk with the specialized application software as an executable file and with the database files empty took nearly 340 Kbytes. It will run on a computer that is an IBMS PC compatible with a CPU that is an I N T E L 7 8088 or a higher processor (such as 80286 or 80386), internal memory of 512K RAM at least and a hard disk with 5 Mbytes available to cover a community with a target population of 2000-1000, over a few years, and depending on the number of encounters.

+

3.2. MCHS-some features T h e M C H S program is designed to collect data during encounters and manage it. T h e software is delivered on a single diskette with a manual to describe the functions to users. Also included in the pack are forms that are also designed with the same data set for manual data collection if required. T h e human (user)-computer interaction for data retrieval and management is through a menu interface and this is organized in a hierarchy. T h e level 1 menu is the main menu which acts as the gateway to data entry, retrieval and management. T h e level 2 menus permit either entry or retrieval, the level 3 menus to functions or functional subgroups with functions at level 4 to handle specific functions (figure 1).

f dBase 3

+ is registered by Ashton Tate.

$ MSDOS is the registered trademark of the Microsoft Corporation. SIBM, PCDOS are registered trademarks of the IBM Corporation. 1INTEL is the registered trademark of the Intel Corporation.


M C H S : application software for family welfare programmes

Figure 1.

283

T h e hierarchical arrangement of the menus according to functions (not all menu functions at level 4 are shown here).

T h e software must assist in follow-up and tracking of the cohort group; hence it must have the feature to generate a unique personal identification code (ID code), as many countries do not have a social security or a personal number. This feature has been inbuilt and on registration will give each individual a unique I D code, which is generated by the computer and is essential for retrieval and management of data during encounter updates. By using the I D code the record link in the M C H S databases is maintained. An example is used to show how it is generated for the dummy registration in figure 2, and for this the I D code KGJD12501 is generated (see in figure 3), where: K is the code for the PHC site, i.e. given prior to compilation; G is derived from the first letter of the village/town-Gotham City; J comes from first letter of the first name Jane; D is the first letter of name of the lady’s father-Doe (in case of an infant from the name of the infant’s mother) 12 the month of birth; 50 the year of birth; 1 unique control number that is automatically generated; could go up to 99 at present and this could be set to 999 also. If a similar entry that could generate the same ID code is entered later, then before allotting the ID code a prompt will appear: ‘similar registration exists! view’, and it then shows the user a list of all with similar sets as in figure 3. T h e MCHS program

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I

~~~

* * * M A T E R N A L & C H I L D H E A L T H S Y S T E M * * ’ * * * Reqistration Female Population ( 13 to 45 y r s ) * * *

I

Information Required from t h e Lady

First Name

Jane

Father‘s Name


II

I

Doe John

Villaqe/Town/City

1

GOTHAM CITY

Date of Birth iDD/MM/YYl

1-1

TO STOP DATA ENTRY

Figure 2.

-

PRESS ESC / RETURN

Data entry screen for registration.

Page No 1 15/05/90 List of Female Target Population Registered

__________________________________

Individual’s CODE

First Name

+ * Village GOTHAM CITY KGJD12501 JANE

Address Home

Street

villaqe

123 House

Haunted Street

GOTHAM CITY

456 House

Ghost Avenue

GRAND LAND

* * Village GRANDLAND KGJD12502

Figure 3.

JUDY

An MCHS output of entries that generated a similar code.

user can confirm after reading whether the entry is new and must be made; if the new entry is to be accepted then it is allotted the next unique number in the same serial as, in figure 3, we see KGJD12502. T h e possibility of duplicate registration exists only if the user is not attentive to the screen prompt in the last line and permits it. How can one find the ID code at a later encounter? This is possible from a function under the menu for encounters. T h e search stategy is by pattern matching based on the first name and the village name provided by the user. It is important that the names must be spelt in the same form as when reigstered earlier; a list of all those registered could also be printed, and kept to help out on such occasions. For data collection the design takes the assumption that if a condition exists, then a description would be entered. There are defined fields such as logical or numerical elements, and descriptive fields. T h e other issue tackled was the validation of date entered in the defined fields by checks set up with prompts to the user. To ensure semantic clarity in the potentially large database that could evolve, in the defined fields we have used trivalent logic of ‘Y’ when yes, ‘N’ for no and when not collected or not known; similarly for numeric fields we have recommended the use of 1 when not collected or not known. For each module the help messages have been I-’

M C H S : application software f o r family welfare programmes

285

programmed to respond to the ‘ F l ’ function key. T h e M C H S outputs are designed to support care providers to act upon, such as lists and statistical profiles, as shown in tables 2 and 3; also reports of activity and utilization of resources that are required by the administration.


4.

Method

Before release of the M C H S fl version it was tested in a laboratory perspective by retrospective data entry from records of a maternal health care centre in Sweden. I t was a random sample and the sample size (of 101) constituted a third of the total number registered at the centre in the year 1989. T h e records had been first analysed for the actual data content recorded, i.e. the quantity recorded in a real-world setting [14]. Data from these records were entered after exclusion of personal identification particulars and addresses, to test the acceptability of the EDS and the applicability of the software. This was folllowed by the entry of a similar sample size from an urban hospital in India. T h e data were entered by members of the project team (A.K. and K.B.) associated with the sites providing the records. T h e software modules that support the maternal health services programme were tested.

5.

Test results T h e data entry was done by physicians associated with the source of the records, since there were no summary sheets, and it was necessary for them to be familiar with the original record layouts and the local practices in recording, especially abbreviations. T h e process was time-consuming at the start, and it took 15 min to enter a record from Sweden and about 10min for a record from India. T h e process was speeded u p as the flow of data required for entry became familiar. All the information in the records was successfully sentered into the computer-based system. I n the Swedish sample seven records, and in the Indian sample two, were rejected as the data were incomplete (table 1). T h e time taken to enter Swedish records may have been longer due to the much larger number of prenatal visits. T h e average number of visits in the Indian sample was seven, which is less than the minimum number of prenatal visits by the Swedish sample, i.e. eight. T h e acceptance or awareness of maternal health services is higher in Sweden, reflected in the early registration by the beneficiaries of the service with the centres. Most visits and deliveries in Sweden are conducted by midwives. Table 2 is an epidemiological profile output produced by MCHS from the Swedish data, and is compared with the output from the Indian data. T h e mean age of the Swedish sample is 31, and for the Indian sample it is 27; the mean number of children for the Swedish sample is 0.72 and for the Indian sample it is 0.93. T h e mean weight of a baby at birth in the Swedish sample is 3483 g and in the Indian sample it is 2873 g; there are no births below 2200 g in the Swedish sample but 4.76% of the Indian sample have babies with a lower birth weight, and there is also a relatively higher percentage of pre-term deliveries. Table 3 is yet another output from MCHS which a care provider could use to identify the types of high-risk cases present in the current active register of women under cover for perinatal care. Perinatal care in terms of M C H S extends from the first registration of pregnant state to the second postnatal visit; thereafter the records are held in an archived file and can be reviewed as files related to earlier pregnancy. These reports were generated before the second postnatal visit was recorded, and as such also take the data from the record of the last prenatal visit encounter and the

1318 699

94 105

7t 2t

101 107

Sample from

Sweden India

14$ 7§

Mean no. of visits

5 In

India, number of visits ranged from one to 14.

$ In Sweden, number of visits ranged from eight to 23.

t Records were discarded by the data entrants as they were incomplete.

Total prenatal visits entered

No. of records data entered from

NO. discarded as found incomplete

71 15

One

24 48

Two

Midwives

80 47

0 42

14 58

Physicians

Delivery conducted by

Three

At her first visit was in (trimester)

During pregnancy each woman

A summary of the data entered and some findings in data reports from Sweden and India.

Total no. of records in the sample

Table 1 .


m

ca

N

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i d F Y I Fl ' " M A T i R N A L b C H I L 3 H E A L T H S Y S T E M " ' + * * E n c o u n t e r Update - Females 1 P r e n a t a i Care) * * *

Date of V i s i t :

)12/11/89]

VISIT NO 8

Prenatal V i s i t

I d Code KGJD12501 N a m e J a n e

DOB 1 2 / 1 2 / 5 0

C l i n i c a l ExamiD

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Weiqht i n Kq : 69.? BP D i a s t o l i c : 90 P e d a l Oedema L O - 3 1

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Seen by:=

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Next v i s i t on:122/11/89

~

~

Figure 4. Data entry screen for a prenatal care encounter.

Table 2.

Comparison of epidemiological profiles of the Indian and Swedish data by an MCHS output. ~~

Epidemiological profile

Swedish site

Indian site

Mean age (years)

30.80

26.56

Normal delivery (%) Caesarean section (%)

84.2 7.4

92.4 7.6

Term births ( 3 7 4 1 weeks) (%) Preterm ( < 37 weeks) (%)

9 45 2.1

90.5 7.6

0-72 3483-3 0

0.93 2873-3 470

No. of children/women (mean) Mean birth weight (9) Low birth weight (< 2200 g) (%)

Table 3.

T h e high-risk profiles generated by MCHS from the Swedish and Indian data Swedish site

Indian site

0 10 16 0 5 0 1

0 0 1 0

-

1.

2. 3. 4. 5. 6. 7.

Age < 18 years Age >35 years Elderly primigravida Haemoglobin < 8 g% Gravida > 4 Multiple pregnancies High blood pressure

8 0

5

history of current pregnancy. T h e major difference is in the larger number of women > 35 years and elderly primigravida in the Swedish sample. While the incidence of multigravida, i.e. more than four gravida, and persons with a systolic blood pressure > 140 mmHg, is higher in the Indian sample.

6. Discussion Most health information systems (today) are designed to collect administrative data, often as simple 'headcounts' [15]. T o fully utilize the computer power it is vital that the design of health information systems is revised [9]. The design of information systems must be with a 'bottom-up' approach [16], and if the benefit of


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introducing microcomputers is to be realized then, as recommended, it must be introduced as close as possible to the point of data production [2]. It is well recognized that to make an information system more meaningful the data must be collected in more detail, or by adding modifiers to derive secondary data, and the use of a common data collection tool is much desired [15]. T h e data collected for outcomes research should be individual-level data with as much detail as possible, and be linkable longitudinally to increase the amount of information on an individual over time [l 11. T h e foundation of a health system is the P H C centre, and it is the point of routine data for the health information system [S]. A P H C centre currently is the feasible limit to consider [9]. T h e only shared characteristic between the sites was the data collection, and from the systems analysis it was evident that in a core data set lay the potential foundation for an application software. T h e approach in defining an EDS was to take the middle path and avoid an overkill of data or a lack of data. The definition of the EDS was largely with the soft problem setting perspective, then the functional and finally the traditional one of problem solving [lo]. T h e multi-centre systems analysis approach permitted us to see beyond a single organization, and thus avoid incorporating features in the resulting design that does not fit the needs of others. T h e focus in design was based on the common bond identified by the systems analysis study, i.e. the EDS [lo], and an understanding of the potential user’s expectations and apprehensions [8]. T h e recommendations with reference to ideal health information system properties [2,15,16] were considered. T h e domain experience of the designers (K.M. and A.K.), as they were physicians and familiar with the domain, had an impact on the design, and this possibility has been discussed by Adelson and Soloway [17]. I n the delivery of maternal health services the need to act upon information is immense, since the risk approach is well established as the aim is to do somethong for all, but more for those in need. There is, however, a lack of consensus in the riskscoring methods, and their efficacy is questioned [la]. However, a computer-based system designed as a sentinel system can track and follow the target population. There has been interest in computer systems to support the area of perinatal care and obstetrics for some time, and dedicated professional group meetings have been held [19]. In order to cover the interest needs of computing in obstetrics and gynaecology a recent publication covered many aspects from a technical background, computer technology in perinatal monitoring, expert systems and including data collection systems [20]. Many systems have been developed to build perinatal registries with data entered from the summary of the events, either as a minimal set [21] or in detail [22]. On microcomputers a minimal database package has been described that also generates the birth certificate [23]. There has been a more elaborate system with an extensive local area network communication developed to link the key stations of a maternity hospital in Japan which is large-scale information storage which is easily retrieved at the touch of a key [24]. MCHS is designed to generate reports in two modes: one mode is data-driven as for the administrative reports; the other is on request. The reports are designed to support the care providers in the follow-up of high risk, to make M C H S a sentinel system. T h e modular approach permits data to be held in some modules and be absent in others, some modules being active in some versions and not active in others. In the



289

Indian release version the data item to record tetanus toxoid vaccination is included, and is excluded in the Swedish version. This was to ensure that there is no loss in recording information that the data set for Swedish release has some specific data elements added, such as to record results from laboratory investigations [lo]. Data collected with the same data set format, even with the same validation checks, would still have the inherent problems of inter-observer variation. T h e absence of coded entries permits less errors by users in entry. Sweden has a lower maternal mortality rate than most other countries [ 2 5 ] , and comparing the data with that from India presents some points of contrast. However, it must be noted that the Indian sample is from an urban metropolis and socioeconomically a more privileged group. T h e Swedish sample appears to have a higher acceptance and utilization of prenatal health care services; they were all registered before the end of the second trimester and they attend prenatal clinics more frequently, even the minimum encounters in the Swedish sample of eight visits was more than the Indian average of seven visits. However, most of the visits and deliveries are handled by midwives in Sweden, whereas in India they are mostly handled by physicians. There were differences observed with respect to age and weight of the infant at birth. In comparing the maternal health services the number of Caesarean sections is often taken as an indicator; it is observed here that the figures at the two sites are nearly the same, even with the average baby weight being lower in India. This could be a point for further investigation, as Lindmark and Cnattingus, in their report on the search for a scientific basis of antenatal care, have suggested. T h e availability of a common data collection tool as MCHS, if linked with an agreement on protocols of care, could provide a framework for large-scale research efforts [26]. M C H S was developed on a standard ‘adequate minimum data set’, the EDS, and with a sensitivity to variance in user preferences, acceptance and attitudes. T h e economic issue of the high costs involved was tackled by using Clipper to develop the run-time packages to avoid costs for any other software in the delivered package, and the very concept of an application package for multiple sites is with an aim to reduce costs by ‘economies of scale’. As for meeting the demand to demonstrate clinical benefits for larger acceptance of computers [7], that is only possible after review of implementations over a long period; based on the early reports on experiences by users this appears promising [27]. T h e approach to develop software independent of organizational behaviour provided us with a package that could be used by different health organizations. Experiences from sites in India confirm this, as it was implemented differently by different organizations [28]. T h e package has its limitations, and is not yet the total information management system. It may be compared to an early word processor and needs to be enhanced over time. A module has recently been implemented in the laboratory version of MCHS software to retrieve data elements from the database files that are required to study the predictive value of the EDS variables, and this effort could be extended to build a query feature along with many other features that are desired, as for example knowledge-based decision support and graphic outputs. T h e addition of features, though entirely possible, will make the single-floppy-based deliverable into a manyfloppy-based deliverable, and also make demands for more features in the hardware before it can be operated. Sooner or later this will lead to the development of more complex application packages, a trend much like the development seen in word processors. T o support a larger number of care providers there must be some simple

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and effective software, the basic package could be extended to more complex systems that could suit any budget. T h e issues of error-free software and data security will have to be sorted, and only then will a larger critical mass of care providers use computers to support their clinical activities.


7. Conclusions With microcomputers the possibility for users to interact directly has increased, as also has the number of potential users. T h e development of common application software packages should by economies of scale reduce the costs in implementation of computer systems in health organizations. The MCHS approach to design systems and develop software independent of organizational behaviour influences provided us with a package that could be used by different health organizations. Experiences from implementation at sites in India show the diverse modes with which the implementation has been made [28]. T h e use of the MCHS and introduction of information culture has brought an essence of quality in care with economic savings demonstrated at a site. T h e effort must continue to consolidate on early gains in experiences, especially if the weakness of the current health information systems [13 are to be strengthened by appropriate use of available technology. T h e issues of error-free software and data security will have to be seriously addressed, and a futher dramatic fall in prices of hardware to offset the rise in prices of software is needed. Only then will a larger critical mass of care providers use computers to support their clinical activities, leading to a better information base at the foundation of the health information system.

Acknowledgements Thanks are due to the programme for Quality in Care and Technology, WHO EURO at Copenhagen, for support in development of MCHS software, by their contractual service agreement No. ICP/CLR 525 5966N. We thank Hans Gill for his help in fine tuning the software, Dr S. Sundararajan of Ealing Health Authority for his critical comments on the earlier versions of the software that were pertinent (and we did try and respond to all of them). Thanks are due to Ms R. Sadana, Dr A.-M. Worning and D r K. S. Johansen for their suggestions, and to colleagues in the field who are collaborating with us in the MCH project, especially Professor E. Hamrin, Marianne Lindahl, D r Rathi, D r P. Arora and Dr Aruna Moidu for their useroriented viewpoints. We thank Ms J. Wigertz for tidying the linguistic faults in this paper.

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