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This is a general overview of family planning programs in developing countries, with a focus on east and southeast Asia and Sub-Saharan Africa. The author concludes that "by the year 2000, the number of contraceptive users in developing countries will have to be 40 percent higher if fertility declines are to match projections." Suggestions for program improvement are included.
CONTEXT: Family planning programs and policies increasingly focus on the male partner's roles and responsibilities in contraceptive decision-making and use. To effectively tailor services for males, policymakers and providers must refine their understanding of men's psychosocial and reproductive health needs. METHODS: Using self-administered questionnaires, 1,540 sexually active males aged 19 and younger who attended family planning clinics in California provided information about their sexual behavior, contraceptive use, pregnancy and parenting history, and psychosocial characteristics. Logistic regression was used to examine factors that contributed to effective contraceptive use. RESULTS: Although 73% of participants reported having used a birth control method at first intercourse, only 59% said that they or their partner had used an effective method at last intercourse, and 35% had used no method. If the client was uncomfortable with his method, the odds that he had used an effective method at last intercourse were reduced (odds ratio, 0.4). The likelihood of use at last intercourse was increased among males who agreed with their partner about their method and those who had never impregnated a partner (1.4 and 1.9, respectively). CONCLUSIONS: To adequately serve young males, clinics must take into account their sexual and contraceptive histories. But screening should go beyond traditional family planning techniques to discuss how to improve communication with partners and other lifestyle issues that may interfere with consistent use.
This is a report on a theoretical model called PROJUSE, which was designed "to determine whether the proposed reduction in the growth rate of the South African population is a viable proposition." The model calculates the number of users of a family planning program needed to achieve certain population targets. An example is demonstrated using the black population in South Africa.
There is good evidence that lactational amenorrhea (LAM) is an effective method of fertility regulation during the first 6 months postpartum, provided no other food is given to the baby and the mother remains amenorrheic. However, although breast-feeding is strongly promoted in many maternity hospitals that also run postpartum family planning programs, LAM is rarely included among the contraceptive options being offered. This paper presents the results of an operational study which compared the prevalence of contraceptive use and the cumulative pregnancy rate at 12-months postpartum among 350 women observed before and 348 women studied after introducing LAM as an alternative contraceptive option offered to women following delivery at the Instituto Materno Infantil de Pernambuco (IMIP), in Recife, Brazil. The percentage of women not using any contraceptive method was significantly lower (p<0.0001) after the intervention (7.4%) than before (17.7%). This difference remained statistically significant after controlling for age, number of living children, marital status and years of schooling. The proportion pregnant one year postpartum was also significantly lower (p<0.0001) after the introduction of LAM (7.4%) than before (14.3%), but the difference was no longer significant after controlling for the same variables. It is concluded that LAM is a useful addition to family planning postpartum programs.
This paper examines the effects of public health, family planning, education, electrification, and water supply programs on fertility, child mortality, and school enrollment decisions of rural households in East Java, Indonesia. The theoretical model assumes that parents maximize a utility function, subject to 1) a budget constraint that equates income with expenditures on children (including schooling and health inputs), and 2) a production function that relates health inputs to child survival possibilities. Public programs affect prices of contraceptives, schooling and health inputs, and environmental conditions that in turn affect child survival. Data are taken from the 1980 East Java Population Survey, the Socio-economic Survey, and the Detailed Village Census. The final sample consists of 3170 rural households with married women of childbearing age. Ordinary least squares and logit regressions of recent fertility, child mortality, and school enrollment on program and household variables yielded the following findings. 1) The presence of maternal and child health clinics reduced fertility but not mortality. 2) The presence of public health centers strongly reduced mortality but not fertility. 3) The presence of contraceptive distribution centers had no effect on fertility. 4) School attendance rates were influenced positively by the availability of primary and secondary schools. 5) Health and family planning programs had no effects on schooling. 6) The availability of public latrines reduced fertility and mortality. 7) The water supply variable did not affect the dependent variables when ordinary least squares techniques were applied but had statistically significant impact when logit methods were used. 8) Electricity supply had little effect on the dependent variables. 9) The mother's schooling had a strong positive correlation with children's schooling but no effect on fertility or mortality. 10) Household expenditures were related positively to school attendance and negatively to mortality. 11) There was little or no interaction between household variables and presence of government programs. 12) Subprovincial area measures of service availability appeared more appropriate for public health and family planning services, while village-level measures appeared more appropriate for schooling.
Some attributes of LAM are unquestionably positive, such as the fact that it is effective. Clinical trials of LAM have upheld the Bellagio Consensus that the chance of pregnancy is less than 2% in the first 6 months postpartum in amenorrheic women who are fully or nearly fully breastfeeding. Secondary data analyses in numerous settings have drawn the same conclusion. Whether as a strategy or a method, used correctly or even if used imperfectly, LAM is a reliable way to avoid pregnancy. To the extent that LAM represents an additional contraceptive option, this is also clearly positive since a broad array of contraceptive options maximizes the likelihood of finding a good fit between user and method, and increases contraceptive use. Other characteristics of LAM represent potentially positive impacts. If LAM is shown to be an effective conduit to other modern methods, the implications are profoundly positive. If LAM is cost effective, for households and/or for programs, this will also make the method extraordinarily attractive. Conversely, some aspects of LAM are negative, such as the fact that it affords no protection against STDs, it requires counseling from a well-informed provider, and intensive breastfeeding can make heavy demands on the woman's time. Many of the remaining attributes of LAM may not be important to a policy decision about LAM promotion. For example, whether LAM is actualized as a strategy or a method may not be important to a decision to promote LAM, although it has a huge impact on how services are delivered. Some factors may be profound on a local or individual level. For example, one simple factor, such as the absence of full/nearly full breastfeeding, can rule out the method as an option, while another, such as the fact that it provides the needed waiting period during vasectomy counseling, can make LAM the method of choice. Although LAM seems unlikely to have widespread popularity in societies like the United States, within such settings are breastfeeding women for whom other contraceptive choices are not satisfactory and to whom LAM is attractive. Although clinicians cannot be expected to directly provide LAM education in every setting, women should be informed about LAM as an effective contraceptive choice, and clinicians should be prepared to make referrals to competent sources. The future of LAM, especially in terms of formal, programmatic initiatives, may continue to be focussed in transitional and less developed settings. Comparative cost/benefit analyses for both the family planning program and the household will contribute meaningfully to decisions about whether to use LAM and whether to include LAM in national and local family planning policies and programs. The most important call to action is to implement operations research designed to determine what factors, if any, will maximize the uptake of a second modern contraceptive method after LAM protection expires among never-users of family planning, to compare this with other contraceptive strategies, and to evaluate the cost aspects. If the potential of LAM to be a conduit to other modern contraceptive methods is effectively realized, the method can be profoundly important in the development of communities and in family formation. Because LAM is effective in preventing pregnancies, and because it extends the range of contraceptive choices, considering LAM on the policy level is always appropriate. Despite the array of drawbacks to LAM, as with any other family planning method, the potential assets of LAM, especially the promise to introduce nonusers to contraception, are sufficiently important to warrant the introduction of LAM within an operations research framework to both capitalize on its intrinsic strengths and determine its programmatic robustness. In the 10 years since the concept of LAM was pronounced as the Bellagio Consensus, claims have been made both for and against its use. During this time, program and policy leaders have been giv
Government-sponsored family planning services in developing countries have traditionally provided free contraceptives to couples who choose to contracept. The advisability of and need for such extensive subsidization is brought into question in this article, based on studies that have compared free and fee-for-service family planning programs. Little difference in demand exists between free and moderately priced services. The importance of price in determining family planning demand is also explored through studies of demand shifts in response to changes in contraceptive prices. Contraceptive price increases in established programs have generally had a minimal effect on utilization. Price reductions in established programs, however, have led to increases in contraceptive demand. These findings suggest that moderate fees can be imposed for family planning services without affecting demand; however, full cost recovery may pose a deterrent to low- and moderate-income couples.
A program designed to improve the availability of vasectomy in public-sector clinics trained physicians at 43 facilities in no-scalpel vasectomy between 1993 and 1995. Among the 38 clinics that responded to a follow-up survey in 1996, the number of clinics providing vasectomies rose from 23 to 32, an increase of almost 40%, while the number of vasectomies performed rose by 18%. Seventeen of the 32 clinics performed more vasectomies after the training; 10 of the 17 had not previously provided the procedure. In-depth interviews with staff from seven sites that experienced large caseload increases and from seven that experienced decreases identified three elements for the successful establishment or expansion of vasectomy services-sufficient numbers of trained providers, funds to subsidize vasectomies for men who cannot afford them and activities to raise awareness about the availability of low-cost or free vasectomy.
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Teen pregnancy has declined throughout North America in the 1990s. In Yukon Territory, Canada, teen pregnancy in the late 1990s was almost 40% lower than in the early 1990s. This rate of decline is significantly greater than most recently reported national rates of teen pregnancy decline in Canada and United States. Identifying possible causes of the Yukon decline may help policy makers and program managers plan and implement teen pregnancy prevention strategies. Data on Yukon teen pregnancy prevention initiatives were collected through numerous discussions and interviews with Yukon service providers, teens, and the general public between 1994 and 2001. Analysis of data demonstrates that multiple new initiatives spanning many sectors were implemented in the mid and late 1990s that could have contributed to the decline in Yukon teen pregnancy. A multi-dimensional approach to teen pregnancy prevention that included researching and evaluating family planning programs and policies before, during, and after implementation, increasing access to longer-acting hormonal contraceptives, providing continuing family planning medical education to health care providers and other youth service providers, subsidization of contraceptives, delivery of innovative family planning mass media campaigns, and delivery of ongoing sexual health education programs may have significantly contributed to the decline in Yukon teen pregnancy. Collaboration among service providers across many service sectors (clinical, public health, education, First Nations, government communication and policy, grassroots) facilitated coordination of the multi-dimensional approach.
Using participant observation data on worker-client exchanges from Bangladesh, this article examines the interface between a government family planning program and the rural women it serves. Case material focuses first on the program function typically identified in the literature: meeting unmet demand for contraception by providing convenient supply. Functions that have been less recognized are then illustrated: (1) the worker's role in reducing fear of contraceptive technology; (2) her effort to address religious barriers, child mortality risks, and high fertility preferences; and (3) her role in mobilizing male support. The range of functions performed by the female family planning worker in the cases discussed here demonstrates that her role transcends the boundaries of what is conventionally implied by the concept of supply. She acts as an agent of change whose presence helps to shift reproductive decision-making away from passivity, exposing women long secluded by the tradition of purdah to the modern notion of deliberate choice.
Records on 36,062 maternity cases admitted to 12 teaching hospitals throughout Indonesia between 1977 and 1980 were analyzed. A hospital maternal mortality rate of 37.4/10,000 cases (39.0/10,000 live births) was derived that was about ten times higher than rates reported from developed countries in the early seventies. Hemorrhage, infection and toxemia accounted for 91.2% of deaths resulting from direct obstetric causes and for 86,1% of total deaths. It is postulated that if all pregnant women received adequate antenatal care, and if all women wanting no additional children were sterilized, maternal mortality would be cut in half. It is recommended that maternal health services in Indonesia be integrated into its successful family planning program.
Data from the 1984 Malaysian Population and Family Survey were matched with birth registration records for 1985-87 to determine the accuracy of statements regarding desired family size that were reported in a household survey in predicting subsequent reproductive behavior. The findings of this study were that stated fertility intention provides fairly accurate forecasts of fertility behavior in the subsequent period. In other words, whether a woman has another child is predicted closely by whether she wanted an additional child. Informational, educational, and motivational activities of family planning programs would, therefore, have greater success in reducing family size if fertility intentions were taken into account.
A diagnosis was conducted of management information systems (MIS) for maternal and child health and family planning programs in 27 African, 5 Asian, and 8 Latin American and Caribbean countries. The diagnosis covered the collection and use of information on physical infrastructure, human resources, equipment/supplies, services provided, coverage attained, and program quality and impact. It was found that many programs do not produce certain basic input and output indicators and that even among those that do, information is too infrequently brought to bear on management decision-making. Constraints under which the MIS operate in these countries are identified, and some rudimentary calculations of what would be required to improve MIS functioning are made.
Although richer in natural resources than many developing countries, Morocco's economic development has been plagued by repid population growth, along with declines in the world price of its main export, phosphate, and a costly war in Western Sahara. Situated on the northwest corner of Africa, the Kingdom of Morocco is dominated geographically by its long coastline and the rugged Atlas mountain range to the east ans south. Abour 1/3 of the population live in remote mountain villages and speak Berber rather than the official language, Arabic. Despite large expanses of desert, agriculture has always been an economic mainstay. Morocco has hab near self-sufficiency in foodstuffs, but is now threatened by the burgeoning population, growing at 2.9% annually. The Moroccan governemnt officially recognized the role of population in development as early as 1966 and initiated a family planning program the following year. In 1979-80, a nationwide survey was conducted in conjunction with the World Fertility Survey program in part to assess the progrss of the family planning and health delivery systems. The newly published results show that contraceptive use is higher than expected. About 23% of the married women use birth control, and almost 20% use one of the more reliable methods. The pill is the most popular method, accounting for 71% of all users, followed by withdrawal, the IUD, and rhythm. Large families are valued, women want about 5 children each, but actual fertility exceeds even these levels. The Total Fertility Rate (TFR) for the 1974-79 period was 5.9 children per woman. This indicated a significant decline in childbearing among younger women, since women aged 40 and over reported an average total of 7 children. The WFS results support evidence of decline in birth rates indicated by the 1982 Moroccan census. Declines in infant mortality also measured by the WFS have not been as dramatic, but do show constant improvement, falling from 130 in the 1950s to about 93 in 1975-80. In general, the WFS results show real movement towards the government's goal of lowering fertility rates.
An examination of the characteristics of contraceptive acceptors in a family planning program in rural Bangladesh revealed trends of declining age and number of living children among new acceptors. A time series analysis of the age-specific acceptance rates confirmed the observation, indicating that over time the program succeeded in attracting younger and low-parity women. The high use prevalence rates resulted in fertility levels that were 25 percent lower in the program area than in the comparison area. The decline in the fertility levels during the first program year was mainly due to a large decline in fertility among women over age 35, but in the second year, the contribution made by women 30-35 years old was substantial.
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In 1970, enactment of federal legislation created a national family planning program funded under Title X of the Public Health Services Act. Since the enactment of this legislation, clinics funded entirely or partially by Title X have been the primary source of subsidized family planning services in the United States. Although information characterizing women who receive family planning services at Title X clinics can assist in program planning and operations, such information has not been compiled at the national level since 1981. In 1992, state family planning administrators and CDC, with cooperation from Title X grantees, initiated the Family Planning Services Surveillance (FPSS) project to characterize women receiving family planning services from Title X clinics in 1991. This report presents the findings of FPSS.