What percentage of women in the U.S. die from complications during birth?

Every year, an estimated 342,900 women die from complications of pregnancy and childbirth, 99% of these deaths occur in developing countries. Worldwide, for every 100,000 live births, about 251 women die. In some industrialized countries such as the U.S, this is 13 deaths for every 100,000 live babies born with American women having a lifetime risk of 1 in 2,100 of dying from childbirth related complications. However, in some countries, such as Afghanistan up to 1,600 women die for every 100,000 live births and women have a 1 in 11 lifetime risk of maternal death.

Non-pneumatic anti-shock garment

The non-pneumatic anti-shock garment (NASG) is a low-technology first-aid device used to treat hypovolemic shock. Its efficacy for reducing maternal deaths due to obstetrical hemorrhage is being researched. Obstetrical hemorrhage is heavy bleeding of a woman during or shortly after a pregnancy. Current estimates suggest over 300,000 women die every year, of which 99% occurs in developing countries, most of which are preventable. Many women in resource-poor settings deliver far from health-care facilities. Once hemorrhage has been identified, many women die before reaching or receiving adequate treatment. The NASG can be used to keep women alive until they can get the treatment they need.

For every woman who dies, there are 30 women who suffer a disability as a result of pregnancy or childbirth related complications (a maternal morbidity) and 10 who experience a 'near miss mortality' (a life-threatening obstetric complication). Morbidities can be serious, lifelong ailments which compromise a woman's health, productivity, quality of life, family health and ability to participate in community life. If a mother dies after childbirth, the newborn is ten times more likely to die before the age of two, other children are more likely to suffer from decreased nutrition and decreased schooling. Many motherless families find it difficult to survive, often with older children having to drop out of school in order to work to help support the family or being sent to live with a relatives intact family. In addition to this, maternal and newborn deaths are estimated to cost the world $15 billion in lost productivity annually, with maternal health proven to support a country's economic growth and cut poverty. Maternal death and disability is a human rights issue. It also means hardships and loss of productivity for families, communities and nations. This is of such great concern that in 2000, world leaders decided that improving maternal health should be one of the 8 Millennium Development Goals for the international community.

The leading cause of maternal mortality (deaths from pregnancy and childbirth related complications) is obstetric hemorrhage in which a woman bleeds heavily, most often immediately after giving birth. A woman dies every 4 minutes from this kind of complication. A woman can bleed to death in two hours or less, and in rural areas, where hospitals may be days away, this leaves little hope for women suffering from hemorrhage. Also, in areas that have limited resources, clinics and hospitals might not have the staff or supplies needed to save a woman's life. Women die waiting for treatment.

There are some emerging technologies which are currently being researched and implemented that seek to prevent these unnecessary deaths. One of these is the NASG which is a low-technology first-aid device that can be placed around the lower body of a woman who has gone into shock from obstetric bleeding. This garment decreases blood loss, recovers women from shock and keeps them alive while they are traveling to a hospital or awaiting treatment.

In the 1900s an inflatable pressure suit was developed by George Crile. It was used to maintain blood pressure during surgery. In the 1940s and after undergoing numerous modifications, the suit was refined for use as an anti-gravity suit (G-suit). Further modification led to its use in the Vietnam War for resuscitating and stabilizing soldiers with traumatic injuries before and during transportation. In the 1970s the G-suit was modified into a half-suit which became known as MAST (Military anti-shock trousers) or PASG (Pneumatic Anti-Shock Garment). During the 1980s the PASG garment became used more and more by emergency rescue services to stabilize patients with shock due to lower body hemorrhage. During the 1990s the PASG was added to the American College of Obstetrics and Gynecology, making it part of the recommended treatment for use by obstetricians and gynecologists in the USA. However, it was removed from the guidelines later and is no longer on the ACOG guidelines.

From the 1970s, NASA/Ames was involved in developing a non-pneumatic version of the anti-shock garment. This was originally used for hemophiliac children, but has since been developed into the garment known as the Non-pneumatic Anti-Shock Garment (NASG).

The non-pneumatic anti-shock garment is now off-patent and produced in several different locations.

The use of the garment for obstetrical hemorrhage in low-resource settings began in 2002 when Dr. Carol Brees and Dr. Paul Hensleigh introduced the garment into a hospital in Pakistan and reported on a case series of its use.

Suellen Miller and colleagues in Mexico, Egypt and Nigeria have completed studies of the NASG (also named the LifeWrap) for obstetric hemorrhage in hospitals in these countries with studies ongoing at primary health care centers in Zambia and Zimbabwe. An implementation program with the NASG as part of a Continuum of Care for Post-Partum Hemorrhage (CCPPH) has been underway since 2008 in India, Nigeria, Tanzania and Peru. The NGO Pathfinder International is the lead implementing organization on the CCPPH project. Dr. Suellen Miller has done extensive clinical trials with the device as an obstetric first aid. The U.S. based non-profit organization, Pathfinder International has worked on developing the Continuum of Care model.

The non-pneumatic anti-shock garment is a simple neoprene and Velcro device that looks like the bottom half of a wetsuit cut into segments. It can be used to treat shock, resuscitate, stabilize and prevent further bleeding in women with obstetric hemorrhage.

When in shock, the brain, heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs.
The NASG reverses shock by returning blood to the heart, lungs and brain. This restores the woman's consciousness, pulse and blood pressure. Additionally, the NASG decreases bleeding from the parts of the body compressed under it.

Mechanisms of action are based upon laws of physics. Recent research has identified that the pressure applied by the NASG serves to significantly increase the resistive index of the internal iliac artery (which is responsible for supplying the majority of blood ﬂow to the uterus via the uterine arteries). Another recent study has shown the NASG to decrease blood ﬂow in the distal aorta.

After a simple training session, anyone can put the garment on a bleeding woman. Once her bleeding is controlled, she can be safely transported to a referral hospital for emergency obstetrical care.

The non-pneumatic anti-shock garment is light, flexible and comfortable for the wearer. It has been designed to allow perineal access so that examinations and vaginal procedures can be performed without it being removed. Upon application a patient's vital signs are often quickly restored and consciousness regained. It is extremely important not to remove the NASG before a woman receives IV fluids, blood and before all vital signs are restored. Early removal can be dangerous and even fatal.

In Egypt and Nigeria, in separate and combined analyses, findings showed that women treated with the NASG fared much better than women who were not treated with the NASG. Results showed significant reductions in blood loss, rate of emergency hysterectomy and incidence of morbidity and mortality. Analyses examining the use of the NASG on cases of uterine atony, postpartum hemorrhage, and non-atonic etiologies (ante and postpartum) found similar results. Other analyses found that the NASG additionally resulted in a more rapid recovery from shock, helped women overcome treatment delays and had a similarly strong ameliorative effect on women in severe shock.

A combined analysis on 1442 women recently published, examined the effect of the NASG on women with obstetric hemorrhage. Despite being in a worse condition at study entry, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p<0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35–0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08–0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23–0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27–0.77). The number needed to treat (NNT) to prevent either mortality or severe morbidity was 18 (12–36).

Qualitative research in Mexico and Nigeria has examined acceptance of the NASG and found that overall, there were positive reactions to the garment as a relevant technology for saving women's lives.

Research is currently ongoing in Zambia and Zimbabwe to investigate whether the NASG is more successful if implemented at primary health care facilities where hemorrhage is first identified.

In 2012, the World Health Organization included the NASG in its recommendations for the treatment of postpartum hemorrhage.

In response to the high maternal mortality ratio, in 2013 the Department of State to created the Maternal Mortality and Morbidity Task Force. According to Amnesty International's 2010 report, five medical conditions collectively account for 74% of maternal deaths in the US.Postpartum depression is widely untreated and unrecognized, leading to suicide. Suicide is one of the most significant causes of maternal mortality, and reported to be the number one cause by many studies.

Maternal mortality in the United States

In 1986, the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) created the Pregnancy-Related Mortality Surveillance System to monitor maternal deaths during pregnancy and up to one year after giving birth. Prior to this, women were monitored up to 6 weeks postpartum.

In 2016 the CDC Foundation, the Centers for Disease Control and Prevention (CDC) and the Association of Maternal and Child Health Programs (AMCHP) undertook a collaborative initiative—"Building U.S. Capacity to Review and Prevent Maternal Deaths"— funded by Merck under the Merck for Mothers program. They are reviewing maternal mortality to enhance understanding of the increase in the maternal mortality ratio in the United States, and to identify preventative interventions. Through this initiative, they have created Review to Action website which hosts their reports and resources. In their 2017 report, four states, Colorado, Delaware, Georgia, and Ohio, supported the development of the Maternal Mortality Review Data System (MMRDS) which was intended as a precursor to the Maternal Mortality Review Information Application (MMRIA). The three agencies have partnered with Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina, and Utah to collect data for the Maternal Mortality Review Information Application (MMRIA); the nine states submitted their first reports in 2018.

After decades of inaction on the part of the U.S. Congress towards reducing the maternal mortality ratio, the United States Senate Committee on Appropriations voted on June 28, 2018 to request $50 million to prevent the pregnancy-related deaths of American women. The CDC would receive $12 million for research and data collection. They would also support individual states in counting and reviewing data on maternal deaths. The federal Maternal and Child Health Bureau would receive the remaining $38 million directed towards Healthy Start program and "life saving, evidence-based programs" at hospitals. MCHB's Healthy Start was mandated to reduce the infant mortality rate.

According to a 2016 article in "Obstetrics and Gynecology" by MacDorman et al, one factor affecting the US maternal death rate is the variability in calculation of maternal deaths. The WHO deems maternal deaths to be those occurring within 42 days of the end of pregnancy, whereas the United States Pregnancy Mortality Surveillance System measures maternal deaths as those occurring within a year of the end of pregnancy. Some states allow multiple responses, such as whether death occurred during pregnancy, within 42 days after pregnancy, or within a year of pregnancy, but some states, such as California, ask simply whether death occurred within a year postpartum.

In their article, the authors described how data collection on maternal mortality rates became an "international embarrassment". In 2003 the national U.S. standard death certificate added a "tick box" question regarding the pregnancy status of the deceased. Many states delayed adopting the new death certificate standards. This "muddied" data and obstructed analysis of trends in maternal mortality rates. It also meant that for many years, the United States could not report a national maternal mortality rate to the OECD or other repositories that collect data internationally.

In response to the MacDorman study, revealing the "inability, or unwillingness, of states and the federal government to track maternal deaths", ProPublica and NPR found that in 2016 alone, between 700 and 900 women died from pregnancy- and childbirth-related causes. In "Lost Mothers" they published stories of some of women who died. They ranged in age from 16 to 43.

Healthy People is a federal organization that is managed by the Office of Disease Prevention and Health Promotion (ODPHP) at the U.S. Department of Health and Human Services (HHS). In 2010, the US maternal mortality ratio was 12.7 (deaths per 100,000 live births). This was 3 times as high as the Healthy People 2010 goal, a national target set by the US government.

According to a 2009 article in "Anthropology News", studies conducted by but not limited to Amnesty International, the United Nations, and federal programs such as the CDC, maternal mortality has not decreased since 1999 and may have been rising.

By November 2017, Baltimore and Philadelphia, and New York City had established committees to "review deaths and severe complications related to pregnancy and childbirth" in their cities to prevent maternal mortality. New York's panel, the Maternal Mortality and Morbidity Review Committee (M3RC) doctors, nurses, "doulas, midwives and social workers". New York City will be collaborating with the State of New York, the first such collaboration in the US. In July 2018, New York City's de Blasio's administration announced that it would be allocating $12.8 million for the first three years of its five-year plan to "reduce maternal deaths and life-threatening complications of childbirth among women of color".

Maternal death can be traced to maternal health, which includes wellness throughout the entire pregnancy and access to basic care. More than half of maternal deaths occur within the first 42 days after birth. Race, location, and financial status all contribute to how maternal mortality affects women across the country.

Social determinants of health also contribute to the maternal mortality rate. Some of these factors include access to healthcare, education, race, and income.

Women in the US usually meet with their physicians just once after delivery, six weeks after giving birth. Due to this long gap during the postpartum period, many health problems remain unchecked, which can result in maternal death. Just as women, especially women of color, have difficulty with access to prenatal care, the same is true for accessibility to postpartum care. Also, postpartum depression can also lead to untimely deaths for both mother and child.

Insurance companies reserve the right to categorize pregnancy as a pre-existing condition, thereby making women ineligible for private health insurance. Even access to Medicaid is curtailed to some women, due to bureaucracy and delays in coverage (if approved). Many women are turned down due to Medicaid fees, as well. Women have also reported access and mobility as reasons why they are unable to seek prenatal care, such as lack of transportation and/or lack of health insurance. Women who do not have access to prenatal care are 3-4 times more likely to die during or after pregnancy than women who do.

It has been shown that mothers between ages 18 and 44 who did not complete high school had a 5% increase in maternal mortality versus women who completed high school.

African American women are four times as likely to suffer from maternal morbidity and mortality than Caucasian women, and there has been no large-scale improvement over the course of 20 years to rectify these conditions. Furthermore, women of color, especially "African-American, Indigenous, Latina and immigrant women and women who did not speak English", are deterred from seeking the care they need, due to discrimination.

Studies have shown that women are affected by the stress of being lower income, which then affects their pregnancies and unborn babies. In the US, women of color disproportionately experience stress related to financial burdens and racism when trying to gain access to healthcare. These women have a harder time maintaining or gaining access to healthy nutrition and even safe housing. These social factors are directly linked to the outcome of maternal care.

It is estimated that 99% of women give birth in hospitals with fees that average between $8,900-$11,400 for vaginal delivery, and between $14,900-$20,100 for a cesarean. Many women cannot afford these high costs, nor can they afford private health insurance, and even waiting on government-funded care can prove to be fatal, since delays to coverage usually result in women not getting the care they need from the start.

Some other risk factors include obesity, chronic high blood pressure, increased age, diabetes, cesarean delivery, and smoking. Attending less than 10 prenatal visits is also associated with a higher risk of maternal mortality.

The Healthy People 2010 goal was to reduce the c-section rate to 15% for low-risk first-time mothers, but that goal was not met and the rate of c-sections has been on the rise since 1996, and reached an all-time high in 2009 at 32.9%. Excessive and non-medically necessary cesareans can lead to complications that contribute to maternal mortality.

Inconsistent obstetric practice, increase in women with chronic conditions, and lack of maternal health data all contribute to maternal mortality in the United States. According to a 2015 WHO editorial, a nationally implemented guideline for pregnancy and childbirth, along with easy and equal access to prenatal services and care, and active participation from all 50 states to produce better maternal health data are all necessary components to reduce maternal mortality. The Hospital Corporation of America has also found that a uniform guideline for birth can improve maternal care overall. This would ultimately reduce the amount of maternal injury, c-sections, and mortality. The UK has had success drastically reducing preeclampsia deaths by implementing a nationwide standard protocol. However, no such mandated guideline currently exists in the United States.

To prevent maternal mortality moving forward, Amnesty International suggests these steps:According to the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, out-of-hospital births (such as home births and birthing centers with midwifery assistance) "generally provided a lower risk profile than hospital births."

Procedures such as Episiotomies and cesareans, while helpful in some cases, when administered unnecessarily increase the risk of maternal death. Midwifery and mainstream obstetric care can be complementary, which is commonly the case in Canada, where women have a wide arrange of pregnancy and birthing options, wherein informed choice and consent are fundamental tenants of their reformed maternity care. The maternal mortality rate is two times lower in Canada than the United States, according to a global survey conducted by the United Nations and the World Bank.

Gender bias and obstetric violence in the medical field are also important factors when discussing maternal wellness, care, and death in the United States.

In the U.S., hospital bills for maternal healthcare costs over $98 billion, and concerns about the degradation of the maternal resulted in a state-by-state breakdown.
No data on Alaska and Vermont.

*MMR: maternal mortality ratio- number of deaths per 100,000 births.

Comparison of the US maternal death rate to the death rate in that of other countries is complicated by the lack of standardization. Some countries do not have a standard method for reporting maternal deaths and some count in statistics death only as a direct result of pregnancy.

In the 1950s, the maternal mortality rate in the United Kingdom and the United States was the same—1 in 1000 pregnant and new mothers died. By 2018, the rate in the UK was three times lower than in the United States, due to implementing a standardized protocol. In 2010, Amnesty International published a 154-page report on maternal mortality in the United States. In 2011, the United Nations described maternal mortality as a human rights issue at the forefront of American healthcare, as the mortality rates worsened over the years. According to a 2015 WHO report, in the United States the MMR between 1990 and 2013 "more than doubled from an estimated 12 to 28 maternal deaths per 100,000 births." By 2015, the United States had a higher MMR than the "Islamic Republic of Iran, Libya and Turkey". In the 2017 NPR and ProPublica series "Lost Mothers: Maternal Mortality in the U.S." based on a six-month long collaborative investigation, they reported that the United States has the highest rate of maternal mortality than any other developed country, and it is the only country where mortality rate has been rising. The maternal mortality rate in the United States is three times higher than that in neighboring Canada and six times higher than in Scandinavia.


Where are septic tanks normally built?

A septic tank is an underground chamber made of concrete, fiberglass or plastic through which domestic wastewater (sewage) flows for basic treatment. Settling and anaerobic processes reduce solids and organics, but the treatment efficiency is only moderate (referred to as "primary treatment"). Septic tank systems are a type of simple onsite sewage facility (OSSF). They can be used in areas that are not connected to a sewerage system, such as rural areas. The treated liquid effluent is commonly disposed in a septic drain field which provides further treatment. However, groundwater pollution may occur and can be a problem.

Septic tank

The term "septic" refers to the anaerobic bacterial environment that develops in the tank which decomposes or mineralizes the waste discharged into the tank. Septic tanks can be coupled with other onsite wastewater treatment units such as biofilters or aerobic systems involving artificially forced aeration.

The rate of accumulation of sludge—also called septage or fecal sludge—is faster than the rate of decomposition. Therefore, the accumulated fecal sludge must be periodically removed which is commonly done with a vacuum truck.

A septic tank consists of one or more concrete or plastic tanks of between 4000 and 7500 liters (1,000 and 2,000 gallons); one end is connected to an inlet wastewater pipe and the other to a septic drain field. Generally these pipe connections are made with a T pipe, allowing liquid to enter and exit without disturbing any crust on the surface. Today, the design of the tank usually incorporates two chambers, each equipped with a manhole cover, and separated by a dividing wall with openings located about midway between the floor and roof of the tank.

Wastewater enters the first chamber of the tank, allowing solids to settle and scum to float. The settled solids are anaerobically digested, reducing the volume of solids. The liquid component flows through the dividing wall into the second chamber, where further settlement takes place. The excess liquid, now in a relatively clear condition, then drains from the outlet into the septic drain field, also referred to as a leach field, drain field or seepage field, depending upon locality. A percolation test is required prior to installation to ensure the porosity of the soil is adequate to serve as a drain field.

The remaining impurities are trapped and eliminated in the soil, with the excess water eliminated through percolation into the soil, through evaporation, and by uptake through the root system of plants and eventual transpiration or entering groundwater or surface water. A piping network, often laid in a stone-filled trench (see weeping tile), distributes the wastewater throughout the field with multiple drainage holes in the network. The size of the drain field is proportional to the volume of wastewater and inversely proportional to the porosity of the drainage field. The entire septic system can operate by gravity alone or, where topographic considerations require, with inclusion of a lift pump. Certain septic tank designs include siphons or other devices to increase the volume and velocity of outflow to the drainage field. These help to fill the drainage pipe more evenly and extend the drainage field life by preventing premature clogging or bioclogging.

An Imhoff tank is a two-stage septic system where the sludge is digested in a separate tank. This avoids mixing digested sludge with incoming sewage. Also, some septic tank designs have a second stage where the effluent from the anaerobic first stage is aerated before it drains into the seepage field.

A properly designed and normally operating septic system is odor-free and, besides periodic inspection and emptying of the septic tank, should last for decades with minimal maintenance.

A well designed and maintained concrete, fiberglass, or plastic tank should last about 50 years.

Waste that is not decomposed by the anaerobic digestion must eventually be removed from the septic tank. Otherwise the septic tank fills up and wastewater containing undecomposed material discharges directly to the drainage field. Not only is this detrimental for the environment but, if the sludge overflows the septic tank into the leach field, it may clog the leach field piping or decrease the soil porosity itself, requiring expensive repairs.

When a septic tank is emptied, the accumulated sludge (septage, also known as fecal sludge) is pumped out of the tank by a vacuum truck. How often the septic tank must be emptied depends on the volume of the tank relative to the input of solids, the amount of indigestible solids, and the ambient temperature (because anaerobic digestion occurs more efficiently at higher temperatures), as well as usage, system characteristics and the requirements of the relevant authority. Some health authorities require tanks to be emptied at prescribed intervals, while others leave it up to the decision of an inspector. Some systems require pumping every few years or sooner, while others may be able to go 10–20 years between pumpings. An older system with an undersize tank that is being used by a large family will require much more frequent pumping than a new system used by only a few people. Anaerobic decomposition is rapidly restarted when the tank is refilled.

Services for de-sludging tend to empty a septic tank completely, i.e. take out all septage, while the actual requirement is removal of settled solids, it's left purposefully incomplete so as to leave at least some of the microbial populations in place to continue the anaerobic degradation processes that take place in a septic tank. An empty tank may be damaged by hydrostatic pressure causing the tank to partially "float" out of the ground, especially in flood situations or very wet ground conditions.

Like any system, a septic system requires maintenance. The maintenance of a septic system is often the responsibility of the resident or property owner. Some forms of abuse or neglect include the following:
Septic tank additives have been promoted by some manufacturers with the aim to improve the effluent quality from septic tanks, reduce sludge build-up and to reduce odors. However, these additives—which are commonly based on "effective microorganisms"—are usually costly in the longer term and fail to live up to expectations. It has been estimated that in the U.S. more than 1,200 septic system additives were available on the market in 2011. However, very little peer-reviewed and replicated field research exists regarding the efficacy of these biological septic tank additives.

While a properly maintained and located septic tank does not pose any more environmental problems than centralized municipal sewage treatment, certain problems can arise with septic tanks in unsuitable locations. Since septic systems require large drainfields, they are not suitable for densely built areas.

Some constituents of wastewater, especially sulfates, under the anaerobic conditions of septic tanks, are reduced to hydrogen sulfide, a pungent and toxic gas. Methane may also be released. Nitrates and organic nitrogen compounds can be reduced to ammonia. Because of the anaerobic conditions, fermentation processes take place, which may generate carbon dioxide and/or methane.

Septic tanks by themselves are ineffective at removing nitrogen compounds that have potential to cause algal blooms in waterways into which affected water from a septic system finds its way. This can be remedied by using a nitrogen-reducing technology, or by simply ensuring that the leach field is properly sited to prevent direct entry of effluent into bodies of water.

The fermentation processes cause the contents of a septic tank to be anaerobic with a low redox potential, which keeps phosphates in a soluble and, thus, mobilized form. Phosphates discharged from a septic tank into the environment can trigger prolific plant growth including algal blooms, which can also include blooms of potentially toxic cyanobacteria.

The soil's capacity to retain phosphorus is usually large enough to handle the load through a normal residential septic tank. An exception occurs when septic drain fields are located in sandy or coarser soils on property adjoining a water body. Because of limited particle surface area, these soils can become saturated with phosphates. Phosphates will progress beyond the treatment area, posing a threat of eutrophication to surface waters.

In areas with high population density, groundwater pollution beyond acceptable limits may occur. Some small towns are experiencing the costs of building very expensive centralized wastewater treatment systems because of this problem, owing to the high cost of extended collection systems. To reduce residential development which might increase the demand to construct an expensive centralized sewerage system, building moratoriums and limits on the subdivision of property are often imposed. Ensuring existing septic tanks are functioning properly can also be helpful for a limited time, but becomes less effective as a primary remediation strategy as population density increases.

In areas adjacent to water bodies with fish or shellfish intended for human consumption, improperly maintained and failing septic systems contribute to pollution levels that can force harvest restrictions and/or commercial or recreational harvest closures.

In the United States, the 2007 American Housing Survey indicated that about 20 percent of all households rely on septic tanks, and that the overwhelming majority of systems are located in rural (50%) and suburban (47%) areas. Indianapolis is one example of a large city where many of the city's neighborhoods still rely on separate septic systems. In Europe, septic systems are generally limited to rural areas.

In the European Union the EN 12566 standard provides the general requirements for packaged and site assembled treatment plants used for domestic wastewater treatment.

Part 1 (EN 12566-1) is for septic tanks which are prefabricated or factory manufactured and made of polyethylene, glass reinforced polyester, polypropylene, PVC-U, steel or concrete. Part 4 (EN 12566-4) regulates septic tanks that are assembled in situ from prefabricated kits, generally of concrete construction. Certified septic tanks of both types must pass a standardized hydraulic test to assess their ability to retain suspended solids within the system. Additionally, their structural adequacy in relevant ground conditions is assessed in terms of water-tightness, treatment efficiency, and structural behaviour.

In France, about 4 million households (or 20% of the population) are using on-site wastewater disposal systems ("l’assainissement non collectif"), including septic tanks ("fosse septique"). The legal framework for regulating the construction and maintenance of septic systems was introduced in 1992 and updated in 2009 and 2012 with the intent to establish the technical requirements applicable to individual sewerage systems. Septic tanks in France are subject to inspection by SPANC ("Service Public d’Assainissement Non Collectif"), a professional body appointed by the respective local authorities to enforce wastewater collection laws, at least once in four years. Following the introduction of EN 12566, the discharge of effluent directly into ditches or watercourses is prohibited, unless the effluent meets prescribed standards.

According to the Census of Ireland 2011, 27.5% of Irish households (i.e. about 440,000 households), with the majority in rural areas, use an individual septic tank.

Following a European Court of Justice judgment made against Ireland in 2009 that deemed the country non-compliant with the Waste Framework Directive in relation to domestic wastewaters disposed of in the countryside, the Water Services (Amendment) Act 2012 was passed in order to regulate wastewater discharges from domestic sources that are not connected to the public sewer network and to provide arrangements for registration and inspection of existing individual domestic wastewater treatment systems.

Additionally, a code of practice has been developed by the Environmental Protection Agency to regulate the planning and construction of new septic tanks, secondary treatment systems, septic drain fields and filter systems. Direct discharge of septic tank effluent into groundwater is prohibited in Ireland, while the indirect discharge via unsaturated subsoil into groundwater, e.g. by means of a septic drain field, or the direct discharge into surface water is permissible in accordance with a Water Pollution Act license. Registered septic tanks must be desludged by an authorized contractor at least once a year; the removed fecal sludge is disposed of, either to a managed municipal wastewater treatment facility or to agriculture provided that nutrient management regulations are met.

Since 2015, only certain property owners in England and Wales with septic tanks or small packaged sewage treatment systems need to register their systems, and either apply for a permit or qualify for an exemption with the Environment Agency. Permits need to be granted to systems that discharge more than a certain volume of effluent in a given time or that discharge effluent directly into sensitive areas (e.g., some groundwater protection zones). In general, permits are not granted for new septic tanks that discharge directly into surface waters.

In Northern Ireland, the Department of the Environment must give permission for all wastewater discharges where it is proposed that the discharge will go to a waterway or soil infiltration system. The discharge consent will outline conditions relating to the quality and quantity of the discharge in order to ensure the receiving waterway or the underground aquifer can absorb the discharge.

The Water Environment Regulations 2011 regulate the registration of septic tank systems in Scotland. Proof of registration is required when new properties are being developed or existing properties change ownership.

In Australia, septic tank design and installation requirements are regulated by State Governments, through Departments of Health and Environmental Protection Agencies. Regulation may include Codes of Practice and Legislation. Regulatory requirements for the design and installation of septic tanks commonly references Australian Standards (1547 and 1546). Capacity requirements for septic tanks may be outlined within Codes of Practice, and can vary between states.

In many council districts (e.g. Sunshine Coast) septic systems have been banned and need to be replaced with much more expensive small scale sewage treatment systems that actively pump air into the tank producing an aerobic environment. Septic systems need to be replaced with any new building applications, regardless of how well the old system performed.

According to the US Environmental Protection Agency, in the United States it is the home owners' responsibility to maintain their septic systems. Anyone who disregards this requirement will eventually be faced with costly repairs when solids escape the tank and clog the clarified liquid effluent disposal system.

In Washington, for example, a "shellfish protection district" or "clean water district" is a geographic service area designated by a county to protect water quality and tideland resources. The district provides a mechanism to generate local funds for water quality services to control non-point sources of pollution, such as septic system maintenance. The district also serves as an educational resource, calling attention to the pollution sources that threaten shellfish growing waters.

While a properly maintained and located septic tank does not pose any more environmental problems than centralized municipal sewage treatment, certain problems can arise with septic tanks in unsuitable locations. Since septic systems require large drainfields, they are not suitable for densely built areas.

Septic tank

The term "septic" refers to the anaerobic bacterial environment that develops in the tank which decomposes or mineralizes the waste discharged into the tank. Septic tanks can be coupled with other onsite wastewater treatment units such as biofilters or aerobic systems involving artificially forced aeration.

The rate of accumulation of sludge—also called septage or fecal sludge—is faster than the rate of decomposition. Therefore, the accumulated fecal sludge must be periodically removed which is commonly done with a vacuum truck.

An Imhoff tank is a two-stage septic system where the sludge is digested in a separate tank. This avoids mixing digested sludge with incoming sewage. Also, some septic tank designs have a second stage where the effluent from the anaerobic first stage is aerated before it drains into the seepage field.

A properly designed and normally operating septic system is odor-free and, besides periodic inspection and emptying of the septic tank, should last for decades with minimal maintenance.

A well designed and maintained concrete, fiberglass, or plastic tank should last about 50 years.

Some constituents of wastewater, especially sulfates, under the anaerobic conditions of septic tanks, are reduced to hydrogen sulfide, a pungent and toxic gas. Methane may also be released. Nitrates and organic nitrogen compounds can be reduced to ammonia. Because of the anaerobic conditions, fermentation processes take place, which may generate carbon dioxide and/or methane.

Septic tanks by themselves are ineffective at removing nitrogen compounds that have potential to cause algal blooms in waterways into which affected water from a septic system finds its way. This can be remedied by using a nitrogen-reducing technology, or by simply ensuring that the leach field is properly sited to prevent direct entry of effluent into bodies of water.

The fermentation processes cause the contents of a septic tank to be anaerobic with a low redox potential, which keeps phosphates in a soluble and, thus, mobilized form. Phosphates discharged from a septic tank into the environment can trigger prolific plant growth including algal blooms, which can also include blooms of potentially toxic cyanobacteria.

In areas adjacent to water bodies with fish or shellfish intended for human consumption, improperly maintained and failing septic systems contribute to pollution levels that can force harvest restrictions and/or commercial or recreational harvest closures.

In the European Union the EN 12566 standard provides the general requirements for packaged and site assembled treatment plants used for domestic wastewater treatment.

According to the Census of Ireland 2011, 27.5% of Irish households (i.e. about 440,000 households), with the majority in rural areas, use an individual septic tank.

The Water Environment Regulations 2011 regulate the registration of septic tank systems in Scotland. Proof of registration is required when new properties are being developed or existing properties change ownership.

In many council districts (e.g. Sunshine Coast) septic systems have been banned and need to be replaced with much more expensive small scale sewage treatment systems that actively pump air into the tank producing an aerobic environment. Septic systems need to be replaced with any new building applications, regardless of how well the old system performed.

According to the US Environmental Protection Agency, in the United States it is the home owners' responsibility to maintain their septic systems. Anyone who disregards this requirement will eventually be faced with costly repairs when solids escape the tank and clog the clarified liquid effluent disposal system.

Septic tank

The term "septic" refers to the anaerobic bacterial environment that develops in the tank which decomposes or mineralizes the waste discharged into the tank. Septic tanks can be coupled with other onsite wastewater treatment units such as biofilters or aerobic systems involving artificially forced aeration.

The rate of accumulation of sludge—also called septage or fecal sludge—is faster than the rate of decomposition. Therefore, the accumulated fecal sludge must be periodically removed which is commonly done with a vacuum truck.

An Imhoff tank is a two-stage septic system where the sludge is digested in a separate tank. This avoids mixing digested sludge with incoming sewage. Also, some septic tank designs have a second stage where the effluent from the anaerobic first stage is aerated before it drains into the seepage field.

A properly designed and normally operating septic system is odor-free and, besides periodic inspection and emptying of the septic tank, should last for decades with minimal maintenance.

A well designed and maintained concrete, fiberglass, or plastic tank should last about 50 years.

While a properly maintained and located septic tank does not pose any more environmental problems than centralized municipal sewage treatment, certain problems can arise with septic tanks in unsuitable locations. Since septic systems require large drainfields, they are not suitable for densely built areas.

Some constituents of wastewater, especially sulfates, under the anaerobic conditions of septic tanks, are reduced to hydrogen sulfide, a pungent and toxic gas. Methane may also be released. Nitrates and organic nitrogen compounds can be reduced to ammonia. Because of the anaerobic conditions, fermentation processes take place, which may generate carbon dioxide and/or methane.

Septic tanks by themselves are ineffective at removing nitrogen compounds that have potential to cause algal blooms in waterways into which affected water from a septic system finds its way. This can be remedied by using a nitrogen-reducing technology, or by simply ensuring that the leach field is properly sited to prevent direct entry of effluent into bodies of water.

The fermentation processes cause the contents of a septic tank to be anaerobic with a low redox potential, which keeps phosphates in a soluble and, thus, mobilized form. Phosphates discharged from a septic tank into the environment can trigger prolific plant growth including algal blooms, which can also include blooms of potentially toxic cyanobacteria.

In areas adjacent to water bodies with fish or shellfish intended for human consumption, improperly maintained and failing septic systems contribute to pollution levels that can force harvest restrictions and/or commercial or recreational harvest closures.

In the European Union the EN 12566 standard provides the general requirements for packaged and site assembled treatment plants used for domestic wastewater treatment.

According to the Census of Ireland 2011, 27.5% of Irish households (i.e. about 440,000 households), with the majority in rural areas, use an individual septic tank.

The Water Environment Regulations 2011 regulate the registration of septic tank systems in Scotland. Proof of registration is required when new properties are being developed or existing properties change ownership.

In many council districts (e.g. Sunshine Coast) septic systems have been banned and need to be replaced with much more expensive small scale sewage treatment systems that actively pump air into the tank producing an aerobic environment. Septic systems need to be replaced with any new building applications, regardless of how well the old system performed.

According to the US Environmental Protection Agency, in the United States it is the home owners' responsibility to maintain their septic systems. Anyone who disregards this requirement will eventually be faced with costly repairs when solids escape the tank and clog the clarified liquid effluent disposal system.

Effluent sewers also currently serve fewer people than septic systems, which also use septic tanks, but simply dispose of the effluent by draining it into a leach field. About one quarter of United States homes dispose of their wastewater with septic tanks. However, effluent sewers are being looked at as a sewage treatment solution in areas where gravity sewer systems are not well-suited or when the high capital cost to build a gravity system is prohibitive. Areas that are less than ideal for gravity systems include areas that are large, but extremely flat and areas that require long-distance pumping, such as where homes are widely spread out or when several small villages or towns connect their sewage systems so that a centralized plant can be built.

Effluent sewer

Effluent sewer systems, also called septic tank effluent drainage (STED) or solids-free sewer (SFS) systems, have septic tanks that collect sewage from residences and businesses, and the effluent that comes out of the tank is sent to either a centralized sewage treatment plant or a distributed treatment system for further treatment. Most of the solids are removed by the septic tanks, so the treatment plant can be much smaller than a typical plant. In addition, because of the vast reduction in solid waste, a pumping system can be used to move the wastewater rather than a gravity system.

Effluent pumping sewers have small diameter pipes that follow the contour of the land and are only buried a metre or two underground. While an effluent sewer can use gravity to move waste, the ability to move waste with a pressure system can be a big advantage in places where a gravity system is impractical. Compared to conventional sewer systems, effluent sewer systems can be installed at a shallow depth and do not require a minimum wastewater flow or slope to function.

Effluent sewer systems, as well as all sewer systems, can use two methods to transport wastewater to a treatment facility. These methods are gravity and pumping, also called pressure systems. Gravity systems use pipes that are laid on a slight downhill slope to transport wastewater. Effluent pumping systems have pipes that are buried at a constant depth, such as a metre and a half, and rely on pumping stations that create pressure to move the waste to a treatment facility. An effluent sewer that uses gravity may be called a septic tank effluent gravity (STEG) system, while a pumping system may be called a septic tank effluent pumping (STEP) system. It is also possible to have a hybrid system that uses gravity and pumping. Gravity and pumping effluent sewer systems both have advantages and disadvantages. The best type of system to use depends on the area it will be serving. Factors such as population size, topography, groundwater level, as well as locations for pumping stations and the treatment plant, must be taken into account. STEG systems should not be confused with traditional sewer systems that use gravity to transport untreated sewage to a wastewater treatment plant, which are typically referred to as gravity sewer systems.

Effluent sewer systems are a much less common sewage disposal method than gravity sewer systems that use gravity, as well as pumping where needed, to send raw sewage and other wastewater straight from consumers to a sewage treatment plant. There are two main types of gravity sewers, sanitary and combined. Sanitary sewers only treat the wastewater from homes and business. Combined sewers have storm drains that are connected to the sewerage. In areas with high rainfall, this results in an enormous additional amount of wastewater that has to be treated. Combined sewers have higher operating costs due to the larger volume of wastewater that has to be treated, and they may require larger treatment plants, as well. In addition, when it rains very hard, the treatment plant will not be able to keep up, which can result in untreated wastewater being dumped into the plant's outfall, which may be a river, lake or ocean. When this occurs, the operator of the sewer is usually fined by one or more of the government bodies that oversee the body of water that the wastewater was dumped into. To prevent this, some cities have tanks, pits or ponds to store the excess wastewater until it can be properly treated. To prevent groundwater contamination, the pits and ponds should have liners if sewage has already been combined with the storm runoff.

Another problem area is a place where there are many homes or businesses at or near the lowest elevation in the area, such as sea level for a coastal city. Typically, waste is pumped uphill under low pressure to the main sewer line in such situations, either after it has been through a septic tank or after it has been ground up into a slurry by a grinder. Grinding can be done when the waste of many homes or businesses is combined or smaller grinders can be installed at each home or business. A disadvantage of using grinders is that they require electricity, and a disadvantage of using septic tanks is that they require solid waste buildup to be removed every one to three years, depending on the size of the tank and the number of people using the system.

Septic tanks also have a higher capital cost if they are being installed for new homes or if the existing septic tanks must be replaced. If there is a suitable septic tank in place, pumping the effluent from the tank is the lowest cost option for initial costs. Whether the septic tank is the lowest cost option over time depends on the cost of electricity in the area, how often the tank must be emptied and how much it costs to have the solids pumped out of the tank.


When was the Follow Through educational program introduced?

In President Lyndon B. Johnson's 1967 state of the union address, he proposed $120 million for the program, to serve approximately 200,000 children from disadvantaged backgrounds. However, when funding for the project was approved by the United States Congress, a fraction of that amount—merely $15 million—was authorized. This necessitated a change in strategy by the Office of Economic Opportunity (OEO), the government agency charged with oversight of the program Instead, program administrators made the "brilliant decision... (to) convert "Follow Through" from a service program to a research and development program".

Follow Through (project)

Follow Through was the largest and most expensive experimental project in education funded by the U.S. federal government that has ever been conducted. The most extensive evaluation of "Follow Through" data covers the years 1968–1977; however, the program continued to receive funding from the government until 1995. "Follow Through" was originally intended to be an extension of the federal "Head Start" program, which delivered educational, health, and social services to typically disadvantaged preschool children and their families. The function of "Follow Through", therefore, was to provide a continuation of these services to students in their early elementary years.

"Follow Through" planners felt that they were responding to an important challenge in the education of disadvantaged students. It was generally hypothesized that the mere provision of specific supports in the form of federal compensatory programs—such as "Head Start" and Title I of the Elementary and Secondary Education Act—would result in increased academic achievement for disadvantaged children, if implemented faithfully by committed teachers. However, studies had shown that despite its successes, in general any gains that children made from "Head Start" (in measures of academic achievement) "faded out" during the first few years of elementary school. It was unclear to policy makers and others if the elementary school experience itself caused this phenomenon, or if specific approaches to instruction within schools were the problem. "Follow Through" intended to solve the problem by identifying what whole-school approaches to curriculum and instruction worked, and what did not. Subsequently, effective models were to be promulgated by the government as exemplars of innovative and proven methods of raising the academic achievement of historically disadvantaged students.

Conceived and implemented in the midst of President Johnson's War on Poverty campaign of the 1960s, "Follow Through" "came out of larger plan which attempted to lay out the causes and cures of poverty in American society on a systemic basis". In addition to the landmark Elementary and Secondary Education Act of 1965, other initiatives included economic policies designed to maintain levels of high employment and federally subsidized job training specifically targeted at people from disadvantaged backgrounds. These programs were implemented amidst the turbulent era of the 1960s and 1970s; marked by the struggles and eventual enfranchisement of a number of formerly excluded constituencies "including African Americans, feminists, Hispanics, Native Americans, and parents of handicapped children".

In typical scientific experiments, treatment and control groups are selected through random assignment. Because "Follow Through" was an experiment designed to evaluate the efficacy of a number of interventions in local districts, districts chose the interventions they wanted implemented in their schools. This method of selecting a desired intervention among several candidates is called planned variation. One publication refers to it as "random innovation". Actually, there is nothing random about it. Planned variation was thought to be advantageous over random assignment because it gave local communities (e.g. community members, parents, administrators, and teachers) an element of local control over the implementation of their program. In fact, Hill believed that programs like "Follow Through" "can be... permanent sources of advocacy pressure on behalf of the goals and beneficiaries of federal programs".

"Follow Through", like "Head Start", was enormous in scope, and designed to remedy the fact that "poor children tend to do poorly in school". Despite the cut in funding, it nevertheless served a substantial number of students. At its height, the program would grow to encompass 20 different sponsored interventions and approximately 352,000 "Follow Through" and comparison children in 178 projects nationwide.

In addition to identifying the most effective instructional practices and disseminating them to schools and districts, it was also hoped that "Follow Through" would help reduce the number of potentially conflicting federal intervention programs in schools, which was thought by some to be counterproductive and expensive. Moreover, if models could be identified that were effective with needy children, these interventions could be staged in regular education classrooms as well.

Because "Follow Through" came into existence because of executive and not legislative action, overall control for the program rested in Johnson's Office of Economic Opportunity (OEO), which spearheaded Johnson's War on Poverty policy. A major component of the policy was community involvement. The Community Action Program (CAP) was charged with fulfilling this function through the establishment of local agencies and programs that carried out various federally sponsored initiatives for disadvantaged populations. However, CAP (and, to some extent, OEO) fell into disrepute among legislators and others, because "it resulted in the political mobilization of the poor and the undermining of local government agencies". "Follow Through" was intended to be an extension of the "Head Start" community action program. Since "Head Start" was politically popular, a program associated with "Head Start" would put the OEO "back in the good graces of Congress". Although "Follow Through", like "Head Start", was initially intended as a social action program, the decision to transform "Follow Through" from a social action program to a social experiment was not correspondingly changed in the congressional legislation.

"Head Start" personnel remained involved in the design and implementation of "Follow Through", although it appeared they were working at separate ends from the planning group of the OEO, who viewed "Follow Through" as an empirical investigation. Much of what occurred during the planning stage—which Egbert describes "as a time of haste and confusion"—was an attempt to satisfy constituencies of both perspectives.

Due largely to the sociocultural context in which "Follow Through" was born, planners deliberately structured the program to minimize the involvement of federal officials in the implementation effort. The more "Follow Through" could be perceived as a locally controlled effort, the better. OEO hoped "idealistically" that "Follow Through" could satisfy both empirical and social action purposes.

It seems doubtful that any form of experiment could realistically and faithfully serve both aims. According to Hill, true program evaluators should be "technical rather than political or programmatic, and their attitudes skeptical and dispassionate". The planning group of OEO wanted a true empirical investigation that would determine the most effective models. Conversely, CAP and "Head Start" personnel advising the "Follow Through" planners viewed it as a social program. Thus, "neither set of constituent groups was fully satisfied with this solution".

In addition to the planners of "Follow Through" having conflicting views on the real purpose of the program, the selection of sponsors was equally imprecise. "Follow Through" sponsors were an eclectic mix of individuals or groups conducting research on instructional methods. Some came from universities, including schools of education. Others were involved in private or grant-based research efforts. The selection method was unclear. According to Watkins, "invitations were apparently extended to any group conducting research on instructional methods".

Some of the sponsors had fairly well developed interventions based on theories of instruction. Others merely had ideas for what might constitute effective interventions. The sponsors also differed widely on the outcomes they expected as a result of their programs. Some sponsors had very specific goals which they believed would lead to very specific outcomes, such as improved literacy skills on measures of reading achievement. Others had more general goals, such as increased self-esteem, or heightened parental involvement in schooling. Most of the programs were in a very early stage of development and had not been extensively (or even moderately) field-tested or piloted. Some programs were so ambiguous that Elmore wrote that "most program developers were simply not clear what their programs would actually look like in a fully operational form". Many sponsors could not explain precisely which aspects of their models would lead to the stated outcome goals of the model.

Despite ambiguities among many of the models (and the minute shades of distinction between some models) the "Follow Through" literature classified models according to the degree of structure they offered, and where they place emphasis on learning.

The "degree of structure" (e.g. "low", "medium", or "high") offered by a particular model is evidenced by how closely teachers were instructed to adhere to specific procedures, including: ways of arranging the classroom and delivering instruction, the degree of interaction between adults and children, the level of parental involvement, and so forth. Below are brief examples of two models that represent extremes of the spectrum.

Direct Instruction model. Developed by Siegfried Engelmann and Wesley Becker of the University of Oregon, direct instruction is scripted and specifies precisely what the teacher says and what the students' responses should be. Moreover, the program designers carefully sequenced the instruction so that students do not progress to higher-order skills unless they have mastered prerequisite basic skills. There is a high degree of interaction between teachers and students so the teacher may receive continuous feedback about how well the students are doing, and adjusts instruction accordingly. The program makes a specific distinction between on-task and off-task behavior: instruction is arranged so that students are fully engaged in learning (via frequent checking for understanding and praises by the teacher) the majority of the time. According to the program sponsors, anything presumed to be learned by students must first be taught by the teacher.

Bank Street model. The Bank Street model was developed by Elizabeth Gilkerson and Herbert Zimiles of the Bank Street College of Education in New York. In this model, the students themselves direct learning: they select what tasks they wish to engage in, alone or with peers. The teacher arranges the classroom in ways that the sponsors believe will create the conditions for successful learning: various objects and media are available for children to interact with, and the teacher acts as a facilitator, guiding students through activities. According to the program sponsors, students use previously learned knowledge to construct new knowledge. According to the sponsors, given a safe and stable environment, learning is a process that occurs naturally.

In his evaluation of the operational facets of "Follow Through", Elmore expressed concern that the shades of distinction among models in terms of structure made comparisons and final analysis among models problematic. Descriptions of the interventions derived from the sponsors themselves. There was no other reliable source from which the program administrators could obtain information about them. Had they been able to see examples of the different models being implemented, they might have been able to ask clarifying questions in order to better distinguish between them—which might have been important for purposes of assessment.

Program models were also classified by where they place emphasis on learning, according to three educational orientations: basic skills, cognitive conceptual skills, and affective/cognitive behavior (also see Appendix A).Despite the differences, there were points of agreement among all sponsors. Sponsors agreed that their interventions should be developmentally appropriate—that is, models take account of where students are in their development as learners. Second, everyone agreed that teaching and learning should be responsive to the needs of individual learners. Third, they agreed that all students—even those from the most disadvantaged backgrounds—could learn to the level of their more fortunate peers. Fourth, classroom management procedures that create an appropriate learning environment should be emphasized. Fifth, school should be a place where students experience both high self-esteem and academic success. Ironically, the last point of agreement—as far as Maccoby and Zellner were concerned—was that all interventions should have very clear objectives about the content and skills that students should know and be able to do. This last detail is worth noting for two reasons. First, the program outcome goals that were provided by sponsors appeared relatively broad. For example, the sponsors of the Tucson Early Education Model explain that "there is relatively less emphasis on which items are taught and on the transmission of specific content, and more emphasis on 'learning to learn'". Likewise, teachers of the Cognitive Curriculum design their own approaches to instruction (including the specification of learning goals), with assistance from sponsors and fellow staff members. While the outcome goals might commonly be described as high levels of academic achievement or mastery of basic and higher-order thinking skills, exactly how students demonstrate these skills is missing in the "Follow Through" literature. During sponsor meetings, there were several heated arguments between some sponsors about the degree of specificity to which they should link facets of their models to student outcomes or behaviors. "Follow Through" administrators could not investigate models more thoroughly because of limited time; indeed, only eight months separated the selection of the sponsored model approach and the start of the experiment. Because Congress had already reduced the program budget, there was legitimate concern among planners that a delay in implementation could be disastrous to the program. Another reality was simply the lack of alternate interventions. Because such a large-scale experiment in education had never been done before, the Office of Education had no arsenal of interventions to try out.

Selection of "Follow Through" implementation sites proceeded in concert with the selection of models. With the assistance of various state and federal education agencies, 100 communities were invited to apply to the program, based on criteria established by the OEO. According to Egbert, 90 districts applied, of which 30 were chosen for participation in "Follow Through". However, due to pressure from influential politicians, additional sites were later added. Not coincidentally, the inclusion of several additional districts appears to have been an attempt to satisfy a number of local political figures by including their communities in the program.

While Elmore laments that sites could have been chosen with a greater degree of scientific rigor (e.g. stratified random sampling), this was impossible, for at least two reasons. First, "Follow Through" administrators had the obligation to select a minimum number of sites with "Head Start" programs, because the ostensible purpose of "Follow Through" was to complement "Head Start". Second—aside from political pressures—communities had to be willing participants in the process (ostensibly) to preserving the fidelity of the implementations. On this point, Elmore tends to agree.

Because of the range of models, a broad range of instruments and analytical methods was selected in order to measure the targeted outcomes of basic skills, affective behavior, and cognitive behavior. Adams and Engelmann wrote, "while critics have complained about test selection and have usually suggested more testing, the assessment effort in this study went well beyond any other educational study conducted before, or since". In all, 14 instruments were selected and administered at various times throughout a student's participation in "Follow Through". Three groups of students, known as Cohorts (i.e., Cohorts I, II, and III) were followed longitudinally from the time they entered "Follow Through" (e.g., Kindergarten or Grade 1) until they exited the program (Grade 3). While the authors of the "Follow Through" report rated the instruments as having high reliability, some sponsors questioned the validity of the instruments in measuring the varied orientations of the models. Other critics, such as House "et al." in a Ford Foundation-funded and widely disseminated analysis, also criticized the instruments. However, the evaluators believed that the instrument battery represented the "best compromise" given the range of models. Despite the relatively large number of students who participated in "Follow Through", the evaluators imposed rigorous restrictions on the sample that was actually in the statistical analysis. The comparison group—students from the community identified as not participating in "Follow Through"—was not subject to precisely the same restrictions as the control group, as long as they entered and exited school in the same districts and at the same time as "Follow Through" students.

Due to the number of intervention sites and range of instruments the analysis was complex and extensive. According to Watkins, there were over 2,000 comparisons between "Follow Through" and non-"Follow Through" groups alone. In 1968, Stanford Research Institute (SRI) was awarded the contract for the "Follow Through" evaluation. However, due to a variety of factors—including, perhaps, SRIs underestimation of the complexity involved in such a comprehensive analysis—Abt Associates, Inc. later inherited the evaluative duties in the summer of 1972. The summary of results, entitled "Education as Experimentation: A Planned Variation Model" was published in 1977.

The empirical goal of the "Follow Through" evaluation was to determine which models were effective in raising student achievement in the three domains as evidenced by positive effects using the selected instruments. Within models, the evaluators compared performance on the various instruments between "Follow Through" (FT) and non-"Follow Through" (NFT) comparison groups at each site. Within groups, the evaluators averaged students' scores on each measure (or outcome variable) in order to yield a "group" score. Thus, the group scores of FT students were compared to the group scores of NFT students. An important—and later controversial—statistical adjustment technique was employed by the evaluators in order to "improve the integrity of the results". Because there were differences between treatment and comparison groups (e.g. the average score on an outcome measure for a NFT group might have been higher than the corresponding average score for a FT group), the evaluators employed a statistical method known as analysis of covariance (ANCOVA) in order to adjust for these and other differences. The difference between the FT and NFT students was then used to measure the effects of a given model. Sites where models met the criterion for "educational effectiveness" were assigned a value of 1; negative effects were assigned -1; and null effects—"insignificant educationally, statistically, or both"—were assigned a zero. According to Elmore, adjusted results using the ANCOVA technique should be interpreted cautiously for two reasons. First, ANCOVA "is not a substitute for random assignment, but it has become a conventionally accepted technique for handling initial group differences in quasi-experimental data". Second, the larger the initial differences between treatment and control groups, the weaker the strength of the results.

The results of "Follow Through" did not show how models that showed little or no effects could be improved. But they did show which models—as suggested by the less than ideal conditions of the experiment—had some indications of success. Of these models, Siegfried Engelmann's Direct Instruction method demonstrated the highest gains in the comparative study. The most notable critique of "Follow Through" (described in detail below) takes issue with the fact that the models which showed positive effects were largely basic skills models. Abt Associates identified five major findings related to the question of differential model effectiveness; the principal empirical findings of the experiment were reported as follows:

A separate analysis examined the impact of Siegfried Engelmann's Direct Instruction method on students over several decades. This analysis suggested a long term benefit.

Wisler "et al", in their review of the "Follow Through" experience, wrote that it was likely that no other educational data has been examined more extensively, excepting the Equality of Educational Opportunity Survey. At least three major reevaluations of the "Follow Through" data exist in the literature: House, "et al." (1978); Bereiter and Kurland (1981); and Kennedy (1981). All largely confirm the original statistical analysis conducted by Abt Associates. Generally, the consensus among most researchers is that structured models tended to perform better than unstructured ones, and that the Direct Instruction and Behavior Analysis models performed better on the instruments employed than did the other models.) Most critiques of the "Follow Through" experiment have tended to focus on the operational and design problems that plagued the experiment. In particular, these critiques note that there was more variation within a particular model than there was from model to model. This problem has largely been attributed to the problem of how to measure the effectiveness of a particular implementation; the measures used were largely qualitative and anecdotal. In some instances, sites were included in the analysis that had ceased to implement specific models, or the model sponsors had serious reservations about the way particular models were implemented.

The most vocal critique was the House, "et al." (1978) reanalysis. The article—along with several rebuttals from the original evaluation team and other researchers—was published by the Harvard Educational Review in 1978. The authors were extremely dissatisfied with the pronouncement of the evaluators that the basic skills models outperformed the other models. The authors approach the critique on the assumption that basic skills are decidedly just that—basic. The authors imply that basic skills are only taught through "rote methods"—a decidedly negative connotation (p. 137).
Regarding the finding that "models that emphasize basic skills produced better results on tests of self-concept than did other models", the authors question the efficacy of the self-esteem measures; implying, among other things, that young students cannot possibly have a concrete understanding of self-concept (pp. 138–139). While the article intended to review the operational design of the "Follow Through" evaluation, instead it appears to (1) refute the finding that cognitive-conceptual and affective-cognitive models were largely failures, and (2) unilaterally condemn the models that emphasize basic skills. The implication is that the goal of education should not be increased student achievement in solely basic skills, and that "Follow Through" would have been better employed to discover how measures of all three orientations could be made successful. Absent from the critique is the finding that, for third graders, only the Direct Instruction model demonstrated positive effects in all three domains, and that one of the remaining two models (Behavior Analysis; the other was the Parent Education model) that had positive effects in at least two domains was also a self-described "basic skills model".

In 1972, the OE created the Joint Dissemination Review Panel (JDRP) and the National Diffusion Network (NDN) to disseminate information about effective models to schools and districts nationwide. JDRP reviewed programs for effectiveness according to a mixture of empirical and holistic criteria. NDN was responsible for disseminating the results based on the recommendations of JDRP. Watkins (1997) criticizes the dissemination criteria for two reasons. First, the organizations identified programs for dissemination that had not been part of the "Follow Through" experiment and for which there was no empirical validation. Second, JDRP and NDN endorsed programs that showed improvement in areas "such as self-concept, attitude, and mental or physical health (of students)... (or) if it has a positive impact on individuals other than students, for example if it results in improved instructional behavior of teachers" (p. 47), but did not raise students' academic achievement. Thus, programs "that had been incapable of demonstrating improved academic performance in the "Follow Through" evaluation" were recommended for adoption by schools and districts. Watkins cites the former Commissioner of Education, Ernest Boyer, who wrote with dismay that "Since only one of the sponsors (Direct Instruction) was found to produce positive results more consistently than any of the others, it would be inappropriate and irresponsible to disseminate information on all of the models".

Of course, it would have been ideal to have the kind of conclusiveness associated with laboratory experiments when we conduct social experiments in communities and schools. Andy B. Anderson (1975) wrote that "the idea of a controlled experiment has long been recognized as a goal worth pursuing in the social and behavioral sciences for the same obvious reason that made this mode of inquiry the predominant research strategy of the natural and physical sciences: the controlled experiment permits the most unequivocal assessment of a variable's influence on another variable". Particularly when experimentation is used as a tool for informing policy decisions (e.g., in recommending the efficacy of some instructional approaches with disadvantaged students over other, less effective interventions), the design should be of the highest degree of rigor possible. For a variety of reasons, "Follow Through" did not have the classic characteristics of a true experiment.

Lack of systematic selection of interventions and lack of specificity of treatment effects. Due to a variety of circumstances detailed earlier, the "Follow Through" programs were not systematically developed or selected according to any type of uniform criteria. Given more time, sponsors may have been able to better identify the types of treatment effects that an observer might expect to occur under controlled conditions. More importantly, program sponsors might also have been required to show those specific facets of their interventions (e.g., particular pedagogical techniques) which would produce the intended effects. Despite these flaws, the sponsors agreed on being subject to the same evaluation instruments. Unfortunately, the instruments shed little light on what about the ineffective programs made them so unsuccessful. The converse is also true. Since structured programs tended to show better effects than the unstructured ones, it would appear logical that efforts might have been made to identify commonalities among the effective structured programs. These shared characteristics might have informed the development of additional effective programs or made the ineffective approaches better. Starting in 1982, funding was in fact reduced for those programs that were identified as successful in "Follow Through", perhaps on the presumption that funding would be better diverted to assisting failed programs. Ultimately, programs that had lesser empirical validation were nonetheless recommended for dissemination along with the successful models.

Lack of random assignment. Random assignment of subjects into treatment and control groups is the ideal method of attributing change in a sample to an intervention and not to some other effect (including the pre-existing capabilities of students, teachers, or school systems). However, for a variety of practical reasons, this procedure was not done in "Follow Through". Instead, sites were selected "opportunistically", based on their readiness to participate in the evaluation, and on their unique circumstances of need. As Stebbins "et al." point out, the treatment groups were often the neediest children. To randomly select some of the most disadvantaged children (many of whom participated in Head Start prior to "Follow Through") out of the evaluation would certainly have been negatively perceived by community members. Stebbins "et al." point out that there were "considerable variations in the range of children served"; yet despite the presence of "many of the problems inherent in field social research...evaluations of these planned variations provides us with an opportunity to examine the educational strategies under real life conditions as opposed to contrived and tightly controlled laboratory conditions".

Narrowness of instruments. Adams and Engelmann note that many critics have suggested that more instruments should have been used in the "Follow Through" evaluation. Egbert agrees with Adams and Engelmann that the data collection efforts were extensive. Despite the agreement among model sponsors on a uniform set of instruments to evaluate the effectiveness of their models—that model sponsors believed their programs achieved gains on more intrinsic, less measurable indicators of performance, such as increased self-worth or greater parental involvement. To the extent that these desired outcomes occurred, and benefited the lives of students in ways that might never be measurably through quantitative means, those aspects of many models were successful. Both the House "et al." critique and others (cited in Wisler) express concerns about the inadequacy of the instruments used to measure self-esteem the "Follow Through" evaluation (i.e., the Intellectual Achievement Responsibility Scale (IARS) and the Coopersmith Self-Esteem Inventory). But it was better, according to many researchers, to measure outcomes imperfectly rather than not to measure them at all. Thus, while "perfect" measures of desired outcomes might never exist, one should not let the perfect be the enemy of the good—in other words, one could call into question the efficacy of conducting any experiment at all on the basis that some bias or imperfection exists.

Was "Follow Through" a social or scientific program? After an initial period, new regulations mandated that 80 percent of "Follow Through" funding was to be allocated to the provision of service while 20 percent was to be used for knowledge production. The regulations themselves suggest that "Follow Through" was principally "a federally funded education program which contained a built-in research component". An inevitable conflict exists when one attempts to operationalize a federal program in education that possesses both service delivery and research and development objectives. Rivlin "et al." point out that "the byzantine complexity of the public policymaking process makes the conduct of social experiments extremely difficult". Given the reduction in funding, the decision to engage in an effort to evaluate the effectiveness of various interventions in an empirical experiment appears appropriate and straightforward. However, if the change is not reflected in Congressional legislation or communicated clearly at the local level, issues of implementation and conflict with deeply held values inevitably result. There is much evidence that indicates confusion about the intent of the "Follow Through" evaluation at the administrative level.

Issues of local control. The planned variation aspect of "Follow Through" was thought to be beneficial—perhaps superior—to other forms of experimentation (e.g., selection of sites based on randomized assignment) because it would give local communities and schools an element of ownership integral to the successful implementation of the models. Despite the planned variation design, local communities in many sites were nevertheless deeply critical of the program. In some ways, criticism of "Follow Through" had preceded directly from Head Start. Ostensibly, the social service purpose and goals of the Head Start program were clearer than those of the "Follow Through" evaluation. Nevertheless, community leaders had felt that Head Start did not give enough decision-making responsibility to parents and community members. Local interests wanted to make curricular decisions, including the changing of facets of some program models Evans cautioned that "educational communities and contexts vary", which can have a direct effect on the implementation of a model. More problematic, however, is Elmore's and Hill's assertions that the "Follow Through" models interfered with local teaching methods and practices. As Elmore writes, "for "Follow Through", the problem was how to implement program variations in a system where most day-to-day decisions about program content are made at the school or classroom level". Rhine "et al." suggest that it is difficult to get teachers to modify their behavior. And if the objective of changing behavior is achieved, teachers feel little ownership on the model—a decidedly dubious investment. What inevitably seems to happen is that teachers reject programs outright, while others "surrender to the program".

The "fact-value dichotomy". Ernest R. House, co-author of the 1978 critique of the "Follow Through" evaluation, penned an article about what he calls the "fact-value dichotomy" in social experimentation and educational research: "the belief that facts refer to one thing and values refer to something totally different". House elucidates the writings of Donald Campbell, a researcher in the field of evaluation. House noted that, according to Campbell, facts cannot exist outside the framework of one's values because inevitably, an investigation that uncovers a certain fact is either consistent with the researcher's internal values or against them. What results is a difficult choice: the researcher must either reject the fact, or modify his or her value to accommodate the fact. Campbell also believed, according to House, that values—as opposed to facts—could be chosen rationally. House agrees with Campbell's assertion in part, but departs from Campbell in that he believes that facts and values cannot exist in isolation; rather, they "blend together in the conclusions of evaluation studies, and, indeed, blend together throughout evaluation studies". House suggests that the reader envision facts and values as existing on a continuum from "bute facts to bare values". Accordingly, rarely do "fact claims" or "value claims" fall entirely at one end of the spectrum or the other. House provides examples: "Diamonds are harder than steel" might fall at the left of the spectrum, while "Cabernet is better than Chardonnay" falls to the right. In conclusion, House proposes an entirely a new method of empirical investigation called "deliberative democratic evaluation". In it, evaluators arrive at "unbiased claims" through "inclusion of all relevant stakeholder perspectives, values, and interests in the study; extensive dialogue between the evaluator and stakeholders...and extensive deliberation to reach valid conclusions in the study". House decries the use of entirely rational methods when applied to evaluations; indeed, he recommends a degree of subjectiveness, because evaluations like "Follow Through" cannot exist outside deeply held values.

Hill writes: "There is seldom anyone at the local level whose commitment to an externally-imposed curricular innovation, planning process, or financial management scheme springs spontaneously from deeply held personal values." House argues that all decision-making that stems from evaluations in education is the result of a compromise. Watkins argues that "Follow Through" resulted in a clash over values based on different beliefs about how children learn, which can be boiled down to "natural growth" or "unfolding" theories versus. theories of "changing behavior". Watkins asserts that most education experts today do not judge programs by their relative effectiveness with different student populations, but rather by their "congruence with prevailing philosophies of education".