Relative Risk of Pregnancy vs Risk of Contraception
Item
- Title
- Relative Risk of Pregnancy vs Risk of Contraception
- Date
- 1987
- extracted text
-
COMMUNITY HEALTH CELL
47/1,(First FloorlSt. Marks
BANGALOau - 560 001
Relative Risk of Pregnancy vs.
Risk of Contraception.
In the note I shall first discuss the possible adverse
effects of childrearing on maternal health (and on the
health of the child), and then exemine contraception
method-specific problems or risks. I draw on available
studies and research on these two themes. In the final
section, various issues which emerge are outlined for
discussion.
I. Effects of Child bearing on Maternal Health:
It has been a common wisdom that childbearing, the aspect
of human reproduction which is unique to female sex,
requires optimal age, say between the ages 20 and 30,
good health and good medical care to minimize maternal
risks. The factors which increase these risks are :
i) pregnancy at the two extremes of childbearing span,
i.e. before age 20 or teenage pregnancy and after age
30, but really speaking, after age 35; (ii) high parity 5
i.e. large number of children; and (iii) short inter
pregnancy inervals.
It has been shown that these pregnancies are more likely
to cause hemorrhage or high blood pressure, which lead to
maternal death. Also, closely spaced pregnancies may
lead to anemia and malnutrition among women.
Many surveys are replete with findings that support this
list of risk factors. "Risk" is measured in terms of
maternal mortality, and there are many studies both in
developed and less-developed countries which indicate
that maternal mortality or complications arising due to
pregnancy are higher among teenagers, among older women,
at the time of deliveries fourth and subsequent children
and when the birthinterval or inter-pregnancy interval
is very short. However, in developed countries, thanks
to good or excellent medical or obstetric care, maternal
mortality even in these "high risk" categories has been
brought down considerably, although compared to the risk
Background paper for XIII Annual Meet of the MFC at
undaipur 26 - 27 January., 1987 prepared by Leela Visaria
1
- 2 of maternal mortality in the ideal age group 20-30,
deaths in the presence of these factors are still several
times higher.
Maternal mortality rates for select countries or areas
shown in Table 1, suggest that the overall problem is
quite massive in Asia compared to any other region of
the world. However, one must concede that the estimates
based on vital statistics may underestimate the
levels of maternal mortality compared to the survey
results.
In developed countries, the low level of maternal morta
lity is believed to be achieved by reduction in the
number of high-risk pregnancies; i.e. only a small
fraction of births occur in the presence of the four
high risk factors. In the developed countries, mater
nal deaths account for less than 2 percent of all deaths
among women in the age group 15-W. In Mexico, this
proportion is 10 percent and according to Matlab data 9
maternal deaths accounted for 27 percent of deaths
among women in the reproductive ages.
Further, in addition to those who die, many women proba
bly suffer from serious illnesses related to pregnancy,
abortion or childbirth. A survey in Aiwa region in
Rajasthan state conducted between 197*+ and 1979 found
that, for each maternal death, there were 16.5 illnesses
related to pregnancy, childbirth and the puxp puerperium.
Wherever relatively good quality data are avilable,
maternal mortolity rates form a J-shape when plotted
against age and when plotted against parity. However,
the scales for developing countries are two to four times
higher than those for developed countries at every age,
although the shapes are similar.
3
- 3 Table - 1
Maternal Deaths per 100,000 Live Births,
Selected Areas, 1951 - 1982.
Country or Area
Year
Rate
1970
1979
I960
1976
1980
1977
1978
1978
1980
I960
1979
1978
20*+
99
Matlab, Thana, Bangladesh
132 villages.
Total Matlab
1967-68
1976-89
770
570
Villages of Bakripalnagar
Alwar, Rajasthan, -^ndia
Bali,5 Indonesia
197*+-79
1980-82
592
508
V ital Statistics
Kenya
Mauritius
Hong Kong
Philippines
Costa Rica
Ecudar
Mexico
Esypt
Australia
Japan
Sweden
U.S.
5
l*+2
2*+
199
103
83
10
21
1
10
Area Surveys
Note : Maternal death rate is the annual number of deaths
among women per 100,000 live births, caused by deli
veries and complications of pregnancy and childbirth
and the puerperium. Deaths resulting from complic
ations of induced abortion are also included in these
statistics.
Source: Rinehart, Ward arid Kols, Adrienne, "Healthier Mothers
and Children Through Family Planning " Population
Reports, Series J., Number 27, May - June 198*+.
P. J-661.
...*+....
- h- However, in recent years, there are certain studies,
which do question this model of "too many, too early or
too late,1 too quickly" leading to high maternal mortality,
Increasingly, it has been found that atleast. in developmed
world, teenage pregnancy per se is not risky or is m any
more or less risky than childbearing in the-early twen
ties. The factors causing higher mortality are not the
age but socio-economic and environmental factors. The
methodogical problems related to measuring effects of
childbearing on maternal health are discussed in the
last section.
The life-threatening complications affecting the mothers
are hemorrhage, pregnancy-induced hyper-tension and sep
sis. Hemorrhage is much more common among older women
with many children. Pregnancy-induced hypertension or
pre-eclampsia affects mainly women with no children and
older women with several children. xkk Sepsis or infection,
on the other hand, is not directly linked to maternal
age or parity and can accompany any delivery.
In developing countries, the major problem among mothers
is believed to be malnutrition and anemia, or often
referred to as maternal depletion syndrome, by Jellife.
Given the estimated extra untritional demands due to
pregnancy and breast -feeding, it is assumed that closely
spaced pregnancies, when work, are a cumulative drain on
nutritional status of women. If a woman cannot recover
fully from the effects of her last pregnancyand period
of breast-feeding before becoming pregnant again, her
nutritional status might be expected to deteriorate with
each successive pregnancy.
The evidence on this syndrome of maternal depletion is,
however, is inconsistent and weak. Studies conducted
in El Salvador,9 Bangladesh, Sudan, Thailand support this
hypothesis. On the other hand, the WHO studies on Family
Formation Patterns and Health (using a height for weight
as a measure of malnutrition, and hemoglobin level as a
measure of iron -deficiency anemia) found no link between
malnutrition or anemia and age ornumber of children.
5
- 5 Childbearing Patterns and Infant Mortality;
The patterns of childbearing which are statistically
found to be risky for mothers, are also found to be
risky for the infants. When pregnancies occur before
age 18, after age 35 or in women with four or more
children or within two years of another pregnancy, there
is a greater risk of stillbirth or death during infancy.
Most research that has examined the affects of the birth
interval has done so in the context of the interval
before the birth of the child under study. Such studies
undertaken in most developing countries (thanks to the
World Fertility Surveys) point to the conclusion that a
short preceding birth interval is dangerous to the infant
and that shorter the birth interval, the higher the
infant death rate.
When this is examined in the context of the mother's age
and birth order, it was shown that birth spacing had more
impact on infant mortality than either birth order or
mother's age.
However, it has been shown that early antenatal care,
a nutritious diet, safe delivery conditions, etc. do
compensate for some of the risk factors, Also, socio
economic status of the families is believed to be an
inportant confounding variable, and yet, due to pro
blems of small numbers, the socio-economic differences
are not taken into account in most studies.
II. Risk of contraception;
It has often been stated in literature that relative to
the risk of childbearing, the risk of contraception as
an alternative to maternity - is minimal. Not only that,
some methods are even considered to be prophlactic and
thus help in reducing the risk of mortality.
However, it has been recognized that the contraceptive
methods are equally safe; they very in their risks and
side effects. Before we examinemethod-specific risks
or dangers as well as advantages, tew two methodological
points should be made.
6
6 One, the relative safety of contraception compared to
pregnancy and childbearing has been established statis
tically so far for developed western countries. Further 9
it has been assumed that in the developing countries, the
safety of contraception is even greater because the dangers
associated with childbearing are high, This set of preraises are being increasingly questioned now as more and
more research is done on the effects of some of the
contraceptives on women's health.
Two, there are disparities in the safety of various contraceptives and therefore, the relative risks of each
method should be assessed in different ways. Often
people simply add up the relative risks of each method,
but this procedure is clearly faulty. Adding up deaths
directly causeu by each method is to an extent, warranted.
However, since the various methods do very in their relia
bility, a realistic assessment should take into account
deaths associated with pregnancy and childbirth when
contraceptives fail.
Table 2 presents the relative risk of each contraceptive
method. This exercise was undertaken in the early 70s
and since then medical research has brought to light
certain risks which were unknown then. The long term
effects of certain methods have become known only recen
tly. Also*? the data are for developed countries, where
the health status of women is relatively good. The same
method may, in the presence of certain physiological
conditions, increase the risk factor. For example, IUD
was considered a fairly safe method even through it is
associated with increased blood loss and infection. In
a developing country, where anemia or iron deficiency
among women is highly prevalent, excess blood loss can
be dangerous for the already anemic women.
A check-list kmki comparable to Table 2 for developing coun
tries is in order. However,good quality method-specific
large data set is needed to generate such probabilities
or simulation methods. Also recent evidence on the side
effects or complications which do not manifest themselves
7
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noniow 001
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- 7 o ai
ax di
jx bus
wit
in the short run, but which become evident
thd 1'dn'g'
run has to be built in such a model. This'‘Sb
not the place or time to undertake such an exercise
although its need is very great. I shall at this juncture
draw on redent evidence to examine contraceptive method
specific risks.
..j,3 n.j.
boaoso
Table 2
Safety of Family Planning Aleternati- es for Women Beginning
Birth Control at Age 30 (Developed Countries;
xjS.b yovifjS
Method, of Fertility
Control.
Cumulative Reproduction Related
Deaths from Age 30- tp' End of
Reproductive years .1/
(Deaths per 100,000 .women)
1. No. contraception
2. Legal abortion (first
trimester )£/
3. Oral contraception to
end. of reproductive years3_Z
*+. Oral Contraception to age 1+0,
followed by diaphram or
condom use.
J. Intrauterine devise (IUD)
6. Diaphram or condom
7. Diaphram or condom with
leval abortion as back up
8. Tubal sterilization.
9. Vasectomy (male risk)
2^5
92
? ri i>vawo rx
di nnc
.i
188
?• b
80
■
: -
■ )
• ■ dsntidaV. (■;
•
22
55
IM10 -20
0
-arro
2J Includes contraceptive-associated deaths , abortion-. .iUl
associated deaths and birth-associated deaths in case
of contraceptive failure or nonuse.
....
2/ Assumes abortion is the only fertility control’’used,
resulting in an average of 13 abortions per. women.
lo
3/ Oral contraceptives are not recommended for women over *+0 in
developed countries, where safer alternatives are available.
SOURCE; Based on'data from the''United States and Great Britain
and adapted from : Tietze, C., Bongaarts, J. and Scheater, B., "Mortality Associated with the Control of
Perspectives , Vol. 8 No.l
Fertility", Family Planning Perspectives
. 197^
. . >, pp. 6-1*+.
January - February
8.
8
Intra-Uterine Device or IUD;
Iji the mid-1970's after more than a decade of experience,
IUD, was considered to be the ideal contraceptive for
world wide use. It has not quite lived upto itg promise,
although a lot of research has focussed on improving its
performance. Three areas where research has been concerntrated are; (1) improvements in technique and training
fur insertion ( to reduce perforation and infection),
(2) optimal size and configuration of the device itself
and (3) addition of bioactive substances to reinforce the
contraceptive effect or reduce heeding and pain.
After a luU. period, IUD appears to be coming back again
world wide as sone of the safest, and effective forms of
birth control. The basic problems of IUD - increased
menstrual bleeding, expulsion soon after insertion,
pain and increased frequency of pelvic infection - remain
unresolved.
In addition, problems that are rarer but mora serious
than pain, bleeding and expulsion have emerged now when
long term and widaspread use has made it possible to
detect these events. The serious complications are a
higher risk of ectopic pregnancy, a septic second trimester
abortion (in cases where pregnancies occur with the device
in situ), and a higher risk of subsequent infertility
caused by pelvic infection than among women not using
IUDs.
Survey dq.ta on pregnancy and expulsion of various types
of IUDs world wide arie available and indicate that preg
nancy rate per 100 women is relatively low; it falls in
the range of OA to 3,0. Expulsion rate for certain types
of IUDs is relatively high. Lippes loop is the worst
among various IUDs on this score. The expulsion rate per
100 women has ranged from 2.2 to 19-3.
However, due to bleeding and pain, women opt for removal
and it is estimated that 8 to 18 percent of the women
have the device removed within one year. It has also been
estimated that these problems are more serious or that
9
- 9 both expulsion and removal rates are higher in developing
countries like India and Bangladesh than in European
countries or in the US.
As far as the newer problems which have come to light,
the available data base is scant and there is need to
closely monitor the performance of the device in a given
population. The need for better health service support
and follow-up is very very essential if the method has
to become acceptable as a safe reversible spacing method.
In the last three years, the number of yearly acceptors
of IUD - mainly Copper T - have Increased from 791,000
in 1981-82 to 2,962,000 in 1981+-89, indicating nearly
three and a half fold increase in just three years.
Continuation rates remain very low, but if the device
has to gain popularity, better follow-up and health
service support must receive priority.
Sterilization s
i) Vasectomy
As indicated in Table 2, the male risk in vasectomy a
surgical sterilization, is zero or nil. Vasectomy is
acclaimed as the safest, simplest and most effective
method of contraception. Yet, it is a neglected method
in much of the world, including India. After becoming
quite popular, through camps in India in the early 1970's,
the number of vasectomies has been declining, as the
emphasis has shifted to female sterilization.
The number of vasectomies performed per year in India
ranged between 879 thousand and 2613 thousand during 196773• Since then barring the emergency period of 1976-77
this number has steadily declined and in the 1980's
around 500 thousand vasectomies are performed every year.
There are several possible reasons for the recent declines
in the annual number of vasectomies. The increasing avai
lability of other methods, new procedures making female
sterilization sfifer and simpler than before (although still
more complex compared to vasectomy) are some of the possi
ble reasons for the popularity that vasectomy has lost.
....10....
- 10 Equally, if not more important are the male attitudes or
fear that vasectomy will adversly affect their sex lives
or virility. Even though such fears are totally unfounded, 5
nothing much has been done to counter these attitudes.
Quite the contrary. By officially promoting female
sterilization, on a mass scale, an indirect support is
being given to the prevailing attitude on vasectomy, even
when the procedure is extremely simple and the medical
problems are non-existent or minimal at best.
It is possible that vasectomy would become popular and
more acceptable if it were a reversible method. Theore tically, surgical rejoining of the vas is possible but as
of today, its reversibility cannot be guaranteed on a
large scale.
Female Sterilizations
In recent years, female sterilization - tubectomy, laparo
scopy or minilaparotmy - is the most widely used methou.
all over the world. In India, out of 32.3 percent of effe
ctively protected couples (in 198U—85), 25.0 percent (or
77 percent of all protected couples) were protected by
sterilization procedures. Of these 85 percent depended
upon female sterilizationto control their fertility.
This rapid spread of female sterilization in the last
decade or so has been made possible partly by improve
ments in the technique of sterilization. The new techniques
are believed to be highly effective and safe.
It is stated that female sterilization does not cause any
long-term complications. Some discomfort or pain is likely
after surgery. The risk of complications depends not only
on the type of procedure but also on the experience of the
doctor and the characteristics of the women. Female steri
lization should cause very few deaths, if performed by
trained, skilled doctors in acceptic situation and if the
clients are carefully screened before hand.'Large surveys
have reported 3 to 19 deaths per 100,000 procedures d in
developing countries. In India, an ICMR survey of 13
teaching hospitals, however, reported higher mortality
rates of ever 70 per 10Q,000 procedures. It is possible
....11...
-11 that many of these deaths could have been prevented by
following certain guidelines -effor proper selection and
insisting on asceptic conditions during surgery, since
infection and hemorrhage are the major causes of death.
Among the procedures of female sterilization, laparoscopy
is being promoted in the national family planning programme
because it can be performed very quickly and requires
a small indision and no hospitalization. However, it has
been increasingly brought to iihi light that the failure rate
of laparoscopy is quite high - may be as high as 20 percent.
It appears that some of the assential preconditions are
overlooked in a mass drive to promote family planning.
Laproscopy is suited to a specilized setting with the
x availability of certain back-up facilities. Doctors
performing it should have experience in abdominal surgery
or be specialists in obstetrics and gynacology. Some of
us, on the other hand, are aware of or have personal
experience of situations where laparoscopy has been condu
cted in camps with minimal facilities by doctors whose
skill is also less than optimal. While the sufferer is
the poor women who has opted for sterilization, the long
term effect of such instances ofi the programme would be very
adverse.
In sum, Table 3 attempts to present rather succinctly the
comparative advantages of vasectomy ahd female steriliz
ation. It is time, in my opinion, to propogate and popu
larize vasectomy as a permanent method of family plann
ing mainly because of its very low score ofassociated
risks,•> if for no other reason.
12.
12
Table - 3.
Comparison of Vasectomy and Female Sterilization.
Vasectomy.
Female Sterilization
Effectiveness.
Very effective, but slightly
higher rate of spontaneous
recanalization and pregnancy.
Very effective 5 slightly lower
failure rate
Effective 6 to 10 weeks after
surgery.
Effective immediately
Complications
Procedure involves almost no
Procedure involves slight risk
risk of internal injury or
of serious internal injuries
other life -threatening
and other life-threatening
complications.
complications
Very slight possibility of
serious infection
Slight possibility of serious
infection.
No anesthesia-related deaths
Few anesthesia-related deaths.
Minute scar.
Acceptability.
Scar can be small but still
visible.
Slightly more reversible
Less expensive
Slightly less reversible.
More acceptable in many cultures.
Personnel.
Can be performed by one
trained person with or without
an assistant
Team needed including one
doctor, one trained anesthetist,
and at least two assistants with
more training than needed for
vasectomy assistant.
Safely performed by
trained paramedics
More difficult for paramedics
to learn and to perform
Can usually be performed in
half the time of most female
sterilizations
Usually only physicians with
training in gynecology can per
form laparescopy and laparotomy.
Minilaparotomy is simpler.
Equipment
Laparoscopy requires expensive,
Requires no specialized
complex equipment, which needs
equipment. Equipment
to be carefully maintained.
readily available
Manilaparotomy requires only
simple standard surgical instru-
13-
Gan usually be performed
under local anesthesia
Systemic sedation necessary as
well as local anesthesia.
Back-Up Facilities.
No. back-up facilities needed
for immediate complications.
Back-up facilities needed in case
of damage to abdominal organs and
blood vessels or othercomplications that require laparotomy.
Possible Long-term Side Effects.
None demonstrated. Uncertainty Slight risk of ectopic pregnancy
about effect of increase in
sperm antibodies.
Source: Liskin, Laurie, "Vasectomy - Safe and Simple",
Population Reports, Series 3, Number h-, November December 1983, p. D-69.
Oral Contraceptives:
In India until recently, oral contraceptives or OCs were
essentially available frosl private sources only; they
were not part of the national programme until 1971+.Although
oral pills were included in the programme on a small pilot
project basis in 196r, the project was extended to urban
centres and to thoss PHCs which had "adequate monitoring
facilities" in 19rls- only. Since then, pills have been
promoted as a foom of birth control initially rather
cautionsly and jn the last two to three years quite
vigorously. Coapared to the distribution performance in
1982-83 of 2.L million cycles of oral pills, the number
increased tc 9.5 and 16.8 million during 1983-8>+ and
198>+-85, respectively. This several fold increase has
been possible because the pills are now distributed by
all the health personnel associated with the PHCs and
their svbcentres. The only condition is that the acceptor
of the oral pills must be examined by a doctor within
three months of acceptance.
1b-
- MKnowledge of the benefits and. risks of the pill has grown
considerably in recent years. Pills are acclaimed as the
most effective reversible means of preventing pregnancy
(effectiveness depends upon regular use). It has also
been noted that oral pills protect women against pelvic
inflammatory disease and also against ectopic pregnancy
(IUD fares badly on both these counts), against uterine
and ovarian cancer. In addition, pill provide relief
from a wide range of common menstrual disorders.
As far as risks are concerned, it has been found that .
among the women who smoke and who are over 35 years of
age, there is a siggifleant increased risk of problems
of circulatory system. More specifically, pill users
who smoke and are over 35 years of age, non-smokers who
are above Uo years of age reported significantly higher inci
dence of venous thrombo-embolism,' heait attack, stroke and
hypertension. A large study undertaken in Britain reported
that these high, risk women (i.e. older smokers)
were four times more likely to die of any of the circu
latory system cilment than nonusers of oral pills, Pills
are therefore not recommedned as a method of birth con
trol for older women.
However, most of the research on oral pills has been done
in the US and the UK and the large surveys have been con
ducted in these countries. It is difficult to know the
extent to which these findings hold true for women in
developing countries like India. It is often hypothe
sised that women in developing countries do not smoke as
much as they do in developed countries or that they do
not suffer from heart diseases to the same extent, and
therefore, they are likely to be less adversely affected
by the problems of oral pills. All the same, one ought
to be very coutious before prescribing pills to all and
sundry. A lot more medical research is still needed with
the specific health conditions of Indian women in mind
before promoting them for wider use.
•....
" 1<"
Injectables and Implantss
The place of injectables in family planning has remained
quite incertain. While the manufacturers consider them to be
quite effective and convenient, controversy surrounds
their safety. Depo Provers was until recently used as
the most popular injectable and was pushed in countries
like Thailand. However the controversy over the injeat
able s in the US, ranged for more than a decade, and
finally the Public Board of Inquiry on Depo Provara
recommended in its report to the Food and Drug Admini
stration that it not be approved for use as a contracep
tive in the US. However, this has international implica
tions and the injectable has come under attack in many
other areas.
The risks associated with the injectables are breast and
endormerial cancer, although most of th© studies are
animal studies. Studies on women suing Depo "rovera are
not of long duration or of adequate number to positively
assets that its use leads to malignancies. Other prob
lems associated with the use of injectable are excessive
bleeding, depression, headache, weightgain, etc. These
side effects, important in themselves, are not considered
to be ofserious medical consequences.
In India, another injectable known by the name of NETEN
is being tried out. Several phases of clinical trials
have been underway, and a decision to include NETEN
in the official family planning programme has been taken.
The results of the earlier trials are not in the public'
domain. What is known is that the ICMR conducted as a
part of the WHO project, a two year study (1981-83)This study pointed to a high pregnancy rate among the users &
a high dropout rate because of menstrual problesm.
In addition to these, of course, are the conventional
contraceptives such as condom, diaphragms, foam tablets
etc. which are, if used correctly, quite effective and
at the same time safe. They, however, require a fairly
high level of motivation and mutual understanding. Since
the risks associated with them are minimal, I have not
touched upon them in this rote.
16
- 16 -
Issues:
What the brief foregoing discussion points to is that the
risk of mortality due to different methods of fertility
control varies 9 that the risk varies also between various
age groups, i.e. a given method may be quite safe during
a certain phase of the reproductive span, but not towards
the beginning or the end of the period.
Further, any method which tampers with the normal hormo
nal balance carries greater risk than the mechnical
methods. This is quite evident in Table 4-.
What is noteworthy is also that the risk of childbearing
is higher at most ages than the risk of mortality due to
contraception use except for pills used by smokers. It
is tempting to conclude that the safest (in terms of risk
factor) approach is to use the condom and to back it up
Table 4
Cumulative Risk* of Mortality per 100,000 Nonsterile Women, by
Fertility Control Method, According to Age - Group.
Regimen
15-M+
15-3>+
15-19
20-24
25-29
30-3^
35.39 ‘+0-4-1
No control
Abortion
Pill/nonsmoker
Pill/smoker
462
li-l
251
977
192
26
21
132
35
3
3
12
37
6
3
18
14-6
74
10
10
129
9
70
14-1
6
160
’ 10
IUD
Condom
Diaphragm/
spermicide
Condom and
Abortion
Phythm
7
5
$5&34
^68
288
45
23
25
19
6
6
6
8
6
4
7
1
257
10
2
53
28
10
66
6
6
11
14
1
68
1
36
12
8
8
1U-
18
8
* Calculated by multiplying the age-specific annual death
rares by five.
@ Less than 1.0
Source: Howard W.Ory,"Mortality Associated with Fertility
and fertility Control s 1983", in Family Planning
perspectives, Vol. 15, No.2, March/April 1983,
P. 60.
....17....
2
r
22 -
with abortion in the event of method, failure. However,
women or individual couples do not make choices soley on
the basis of perceived risk of mortality. Similarly, the
decision to have children or to postpone childbearing is
generally make independently of the mortality risks asso
ciated with such choices.
What seems the most humane approach is to make available
various methods to the couples without zealously promot
ing one over the other in order to fulfill certain tergets,
along with knowledge about the associated risks,
failures etc. Equally important can be a sound education
on childbearing under certain risk conditions.
Methodologically, one must not add up the relative risks
of each method to arrive at a figures of contraceptive
risks because a given couple uses only one method at a
time. We must not sai cloud the issues unnecessarily.
/Ghayan/
Npn.
Position: 714 (8 views)