Sterilization in the Philippines: the score after half a decade

Since the initial use of sterilization in the Philippines in 1973 as a family planning method, it has become more and more widespread. A bar graph, giving yearly percentages of acceptors for 5 family planning methods, for the years 1974 -- 1977, shows sterilization increasing steadily in popularity, from 3% in 1974, to 12.7% in 1977. Objections to sterilization generally stem from sociocultural and religious considerations as well as misconceptions and fear. People have feared that sterilization is a form of mutilation and castration. Due perhaps to the male fears of castration, female sterilization acceptors account for 90.6% of sterilizations in the Philippines. In 1974, the Philippine government's Commission on Population set guidelines for the training of physicians and the setting up of sterilization centers. The guidelines also stipulated that the procedure would be undertaken on a voluntary basis, would not include abortion, and that clients would be informed of all medical implications, particularly the irreversibility of sterilization. Programs for sterilization in the Philippines have different requirements for acceptors; most stipulate parity of 2 to 4. Difficulties have also arisen from the uneven distribution of sterilization providers throughout the country as well as a lack of physicians trained in both male and female sterilization methods. The need to create effective linkages among the various agencies engaged in sterilization work is noted.     

Pakistan: re-organization at the top

New measures for population program planning have been introduced in Pakistan. 3 wings were added in the Population Planning Council: administration, coordination, and planning; operation; and technical. New elements in the program include: 1) setting up of new directorates; 2) opening of more family welfare clinics, model clinics, and sterilization centers; and 3) expansion of training facilities for medical and paramedical personnel. 2 national training institutions have been established: the Population Training Centre at Lahore, and the National Institute of Advanced Training at Hyderabad. 16 centers have training courses for doctors performing sterilization. There has been a restructuring of the information, education, and communication aspects of the program. The commercial distribution of contraceptives has become an important element. There are efforts to relate the program to other development programs.     

Comprehensive services at Fabella Center

The Jose Fabella Memorial Hospital Comprehensive Family Planning Center was the 1st family planning center to conduct minilaparotomy in the Philippines. It was also the 1st center to conduct research on family planning and to offer training in family planning to nurses, doctors, midwives, and medical students. The center is funded by the Philippine government with about 85% of hospital funds going to salaries of the staff. Supplementing the funding are medicine, equipment, and subsidies for sterilization given by the Commission on Population (Popcom). Research on chemical sterilization requires patients to take oral contraception (OC) or use the condom while under observation for about 4 months. In the case of female patients, this means until the fallopian tubes have been blocked due to the injection of an opaque solution. The patients are then checked for effects on health, sexual practices, and the regularity of menstruation. Dr. Apelo expects to implement this new sterilization method within 5 years. The center's objective is to support the National Population Program in its effort to reduce the country's population growth rate and promote family welfare. When the center was started, it occupied only 1 room of the hospital and was staffed by 1 full time doctor, 4 nurses, 4 midwives, 2 social workers, and 3 support staff. After 1 year of operation, the center recruited only 75 family planning acceptors. Information about the center's family planning services spread solely by word of mouth. During the 1st half of 1982, the center recruited 3490 acceptors of surgical and nonsurgical contraception, representing 96.94% of its 3600 target for the period. Minilaparotomy had the highest number of acceptors, 1742 or 49.92% of the total number of acceptors during the period. This was followed by the IUD with 1356 acceptors, OC, 245 acceptors; and other methods, 147 acceptors. In information and education, the center had 1882 motivational activities consisting of group discussions, ward lectures, field lectures, and mothers' classes. In training, the center conducted 10 courses, representing 100% of its target for the whole year. It trained doctors in performing voluntary surgical contraception and paramedics in assisting doctors in sterilization operations. The training courses were conducted under a subsidized contract with Popcom. The center also offers training in IUD insertion. In research, the center is active in investigating prospects for new contraceptive applications in the Philippine setting.     

Republic of Korea. Country feature

The Government of Korea's 5th 5-Year Economic and Social Development Plan (1982-86) seeks to reduce the population growth rate from its 1982 level of 1.58% to 1.49% by 1986; it is assumed that the population replacement level of fertility (total fertility rate, 2.1) will be attained in 1988. The task of achieving these demographic targets is expected to be made more difficult by factors such as the impact of the 1950s baby boom and widespread son preference. New population control policy measures announced in 1981 call for improvements in the current family planning program management system; a new social and institutional support system to inculcate the small family size norm; strengthened information, education, and communication activities for family planning; and establishment of coordination among the government organizations involved in population-related activities. Numerous social support measures have already been put into effect, including income tax exemptions for up to 2 children, inclusion of population education in the school curriculum, priority in alloting public housing to sterilization acceptors with 2 or fewer children, and provision of IUD services through the medical insurance system. The number of contraceptive acceptors in the government program increased 78.3% from 1981-83, from 614,000 to 1,094,600. Sterilization and menstrual regulation services have shown particularly sharp increases. Program achievement for 1983 was equivalent to 19% of eligible women ages 15-44 years. The total fertility rate stood at 2.7 in 1982. Major efforts now must be directed toward eradicating the strong parental son preference and ensuring better family planning program efficiency and effectiveness.     

A diagnostic study of Department of Health training courses for family planning providers

A study in the Philippines sought to observe and describe the family planning (FP) training program in two regions. This program trains physicians, nurses, and midwives as a team and includes a Basic/Comprehensive (B/C) course in FP with didactic and practicum elements, training in interpersonal communication skills (ICS) for those who have completed with B/C course, and a Preceptors Course for those who will supervise the practicum phase of the B/C course. The study gathered specific information on 1) trainee absenteeism and drop-out rates, 2) course content and effects, 3) the trainee selection process, 4) the practicum requirement for the B/C course, and 5) service delivery values and quality of care. Data were collected through observations, questionnaires, exit interviews with clients during the practicum phase, interviews with supervisors and public officials (mayors), and focus group discussions with regional trainers. This assessment led to the following recommendations: 1) maintain the current team approach; 2) reserve basic orientation-type subjects for office-based training to allow more time for FP topics in the training programs; 3) use caution in making a switch to "competency-based" training because of the possibility that supervision is inadequate for such a training method; 4) improve scheduling; 5) enforce the prerequisites for participation in the ICS and Preceptors Courses; 6) assign only one trainee to a preceptor area during the practicum and reduce the quota of IUD insertions to reduce pressure to obtain IUD acceptors; 7) create a "model" FP clinic each time a preceptor is trained; 8) pay more attention to natural FP methods; and 9) maintain an emphasis on quality of care.     

Bangladesh: progress of the intensive sterilization campaign

The President of Bangladesh announced a governmental population policy which aims at checking the country's population explosion. In line with this newly-announced policy, the national family planning program, aided by the Bangladesh Association for Voluntary Sterilization,, launched an intensive sterilization compaign in mid-1977. In the 1st 3 months of the program operation, 128 doctors were trained at 15 rural health centers. During this same period, more than 50,000 vas and more than 25,000 tubectomies were performed. It is estimated that each of these sterilizations will avert 1.8 births on an average.     

Bicol hospital reaches out to rural folk

The Ago General Hospital in Legaspi City of the Philippines was opened in 1965, antedating the national family planning movement by 5 years. The 180 bed hospital integrates family planning into the overall hospital service; sterilization is the main method used. Of the 3600 patients per year, 15% are family planning acceptors. The hospital employs 3 family planning strategies: inhospital, out patient and supportive. Inhospital strategies center on sterilization counseling and motivation. The counseling sessions include patient education. Primary targets include high risk pregnancies and young couples with a lot of children. Outpatient strategies include a referral system involving hospitals and agencies with family planning programs, lectures for community organizations and personal visits to other clinics and rural health units. The hospital's mobile clinic, staffed mainly by students, provides information, deworming, and pediatric services to the community. Supportive program strategies consist of mass communication, and an acceptor's club for previous acceptors of sterilization. These clubs meet regularly to share and discuss experiences.     

Upholding the freedom of couples to use a method of their choice

A recent review of the Philippine Population Program's 5-year plan, ended in December 1982, showed that in 1980, natural family planning (NFP) users were only about 12.5% of couples practicing family planning. This figure doubled by 1982. Based on these responses the decision was made to intensify the NFP program as early as 1982. The 1st step was to put more money into the NFP program. The program includes the modern scientific techniques such as cervical mucus, basal body temperature, and sympto-thermal. The program also will fund the training of doctors and other clinic personnel and the production and distribution of appropriate training and information material. Other family planning methods, such as sterilization, oral contraception (OC) and the condom, also will be promoted. Promotion of NFP will depend on the choice of the family planning practitioners themselves. The program's community based services are being intensified. NFP, together with the other family planning methods such as sterilization and OC, will always be made available to couples in the community based services. All agencies in the population and family planning program will be promoting NFP. Knights of Columbus doctors have been invited to assist the program and share their own training modules for the training of trainers. An agreement has been entered into with the Gabriel M. Reyes Memorial Foundation based in Aklan. The goal is for trainers who need further knowledge and skills in NFP to learn from the foundation's wealth of organized orientation and training techniques in NFP. NFP is emphasized at this time because it is acceptable to a great number of couples.     

Bangladesh: sterilization program

The National Sterilization Campaign was launched in mid-February 1977 in Bangladesh. The goals were to sterilize 60,000 people in 2 months, to demonstrate the capabilities of the health services, to provide some visible results from the Population Control and Family Planning Division program, and to test the surgical facilities of 150 health centers. 75,000 plus candidates were recruited for sterilization. The campaign mobilized 300 doctors attached to 150 district health centers. During the 1st 2 weeks of operation, 50 centers reported the performance of 4428 vasectomies and 2113 tubectomies. Each acceptor received cash, food, and transportation incentives. The demand for birth control is great, and little basic motivational work was required. Following the campaign, sterilization services are being made available on a regular basis at health centers, but the financial incentives may be discontinued.     

A sensitive approach to family planning motivation in Malaysia

The goals of the Malaysian Family Planning Program are not only to reduce population growth from 3% to 2% by 1985 and to bring the crude birth rate to 28.2 from 30.3, but to generally improve the health of the family, and to enhance the government's efforts to raise the per capita income. The work program is divided into the Creative Unit, the Media Unit, the Production Unit, and the Field Diffusion Unit. The objectives are to build up strong support from political, community, and opinion leaders, and to run educational campaigns aimed at motivating potential acceptors. The program also runs centers training medical and paramedical personnel. The program is combined with development programs for women, especially useful among the rural population.     

The participation of non-governmental organizations in the Philippine population program

In 1957 the National Council of Churches in the Philippines (NCCP) established the Family Welfare Center, offering an educational program in family planning; it was subsequently expanded and reorganized into the Planned Parenthood Movement of the Philippines. Since its creation in 1970 the Philippine Population Program has brought together government, private, and religious activities. Under the 1987-92 development plan nongovernmental organizations (NGOs) will be taking a more active role in the implementation of the population program by contributing to the maternal and child health/family planning and the information, education, and communication (IEC) components. There are more than 50 private organizations engaged in such population activities. These include national women's organizations and development NGOs with a mass base. The Family Planning Organization of the Philippines is carrying out a 3-year comparative study of the effectiveness of community volunteers in the acceptance of natural family planning. The Reproductive Health Philippines has completed a follow-up of Depo Provera defaulters in a previous clinical study of Depo Provera acceptors conducted in 1985-87. IEC support from various medical and social organizations also helped advance family planning and population awareness of the program. The Mary Johnston Hospital and Iglesia ni Kristo have been front-runners in sterilization through their mobile teams and regular clinics. On the negative side, funding constraints are threatening the very existence of some NGOs. Even those that do not face such constraints face problems related to cost effectiveness, priority setting, capability building, and staff development. A survey of the Population Center Foundation identified some urgent concerns: sharing experience in self-reliance, enhancement of the managerial skills of staff, and funding problems. NGOs complement the family planning services of the government as well as focus on the smooth flow of IEC activities.     

India: New family planning program direction outlined

The focus of the current Family Welfare Program in India is education and active community involvement rather than coercion and compulsion. The government is totally committed to the program and has indicated that it will spare no efforts to motivate people to voluntarily accept family planning. However, there is a need for family planning efforts to include all aspects of family welfare, particularly those designed to promote the health of mothers and children. All family planning methods will be made available, and the family will be free to choose the method they prefer. As part of the program, employees of the Union government, State governments, autonomous and local bodies are expected to set an example and adopt the small family norm. The policy statement made by Mr. Raj Narain, Minister of Health and Family Welfare, revealed the government's decision not to legislate, either at the national or the State level, for compulsory sterilization. Sterilization services will be available free of charge to those who voluntarily choose this method. A plan for training indigenous midwives will be implemented as part of the program in order that maternity services may be available to all expectant mothers. Additionally, in recognition of the direct correlation between illiteracy and fertility and between infant/maternal mortality and age at marriage, the government will introduce legislation to raise the minimum age at marriage to 18 years for girls and to 21 years for boys. The plan is for trade unions, Chambers of Commerce, cooperative societies, women's organizations, teachers' federation, district councils, and other voluntary institutions to be associated intimately with the educational campaign launching the Family Welfare Program.     

Perceived factors of family planning clinic performance and service quality

As part of a larger operations research project, this 1990 study analyzed the performance of the Philippine Department of Health's (DOH) family planning (FP) clinics. Specific study objectives were 1) to measure acceptor targets, servicing capacity utilization, outreach, and costs; 2) to determine what providers believed affected performance; 3) to record which quality indicator providers use; and 4) to determine the perceptions of acceptors about clinic personnel, the clinic as a FP outlet, FP service processing, and FP service quality. Data were gathered from clinic records and from sample surveys in 25 clinics in four specified locations. Eight clients were sampled from each of the 100 clinics. It was found that clinic staff accepted low attainment of FP acceptor targets and that clinic capacity utilization levels were at 25% of capacity. Providers were unaware of the number of potential FP acceptors in their areas and had no information about the costs of running their clinics. The FP clinic managers identified 34 major determinants of clinic performance, but more than half reported that they had very little control over these determinants. The providers described quality service from the point of view of the acceptors and described the quality of a clinic in terms of the minimal physical characteristics required. The acceptor survey revealed that acceptor satisfaction depends upon 1) clinic accessibility and lay-out, 2) intensive personal contact, and 3) clinic infrastructure. The study uncovered a need for the DOH to institute management training programs for clinic managers and to provide managers with the resources and personnel to shift priorities in favor of FP coverage and prevalence. Managers, who are resource allocators, must also receive information about the costs of FP services in their clinics. In addition, the DOH's determination that its FP program would be facility- rather than community-based should be modified to incorporate community outreach elements. The DOH can also make a big impact on perceptions of quality (of both providers and acceptors) by improving clinic conditions to meet basic standards. Once these basic needs are met, additional needs of acceptors can and must be addressed.     

The population program shifts to 'high-scenario' targets

The Philippine Population Program would like to achieve a replacement level of 1 daughter per childbearing woman by the year 2000 to reduce the population growth rate to 2% by 1992. Laing projected that high performance by the National Population Program would mean continued increase of sterilization prevalence at an average 1978-1983 rate. Strategies have been adopted to strengthen information-education-communication efforts, to attain higher contraceptive prevalence rates and use-effectiveness, to develop manpower, to achieve self-reliance, and to effect better program coordination, monitoring, research use. Effective service delivery will be a key to achieving the high-scenario targets. Effective use of natural family planning (NFP), will help in achieving the high-scenario goals. Apart from the heavy demand on NFP follow-up, need for prompt delivery of supplies, and lack of doctors and nurses, other factors may impede the high-scenario targets. Saniel believes that program workers should be allowed to insert IUDs and to dispense pills. Under the cost-recovery and cost-sharing schemes of the high-scenario targets, only sterilization will be done for free. It might affect the campaign for increased acceptors, but the start for self-reliance must happen now.     

NFP update: researcher cites need to improve instruction

In the Philippines more and more couples are practicing natural family planning (NFP), but there is a need to improve instruction on this method to increase its effectiveness. Calendar rhythm has been the most popular technique of NFP, but failure rates have been high. This could be changed by improved calendar rythm instruction and the introduction of newer, more effective natural techniques like the basal body temperature, cervical mucus, and symptothermal methods. Dr. John E. Laing, in a paper entitled "research on Natural Family Planning in the Philippines," examines the trends in NFP and summarizes major findings of past research related to NFP and the status of current research. It also discusses the implications of such findings for the National Population Program and the needs for current research. Cting World Fertility Survey (WFS) data on 19 developing countries, Laing states that the Philippines is second only to Peru in current and past use of the rhythm method. He also indicates that since the start of the National Population Program in 1971, rhythm has been offered as an official program method. Yet, in the early years of the program rhythm was not promoted as actively as the other family planning methods. In the last few years, program, officials have become more interested in NFP. 1976 National Acceptor Survey (NAS) data showed that rhythm reduced fertility by 78% compared to the condom's 79%, oral contraceptive's 94%, and the IUD's 98%. A comparison of data from the 1972, 1974, and 1976 NAS indicated a decline in continuation rates and an increase in overall pregnancy rates for all methods except rhythm. The overall pregnancy rate of rhythm declined, but there was no significant change in continuation rate. Laing suggests that probably, while the national population program was increasingly recruiting less motivated couples to try other methods, the rhythm acceptors, who were largely self initiated, mantained earlier levels of motivaton. Evidence points to the widespread use of crude formulas that do not take into account individual variations in cycle length. Many users do not even fully understand the mechanism by which rhythm affects fertility. There is also little knowledge among acceptors of the new and more reliable techniques of NFP for identifying the safe and unsafe periods. Despite problems, a considerable number of acceptors still prefer rhythm to other methods. The commission on population has embarked on a solution to some of the problems by committing itself to the training of volunteers of community-based organizations, particlarly lay leaders. 3 large scale projects are planned for this purpose.     

Low fertility and limited diffusion of modern contraception in Italy during the second half of the twentieth century

During the last two decades of the twentieth century, Italy, Greece, Spain, Portugal, and Japan were characterized by very low fertility levels and limited diffusion of the pill, IUD and sterilization for contraceptive purposes. This paradox is discussed for Italy by revisiting the history of contraception and reproduction during the second half of the twentieth century, and by using new data for the end of that century and the early twenty-first century. The main results are: (1) it has been possible to maintain low rates of planned and unplanned fertility without resorting to more effective contraceptive methods thanks to a careful use ofcoitus interruptus; (2) the pace of diffusion of the pill and IUD was so slow because of the opposition to contraception of the Catholic Church, a gender system emphasizing traditional male and female roles, and a medical culture that made physicians reluctant to prescribe the pill for their patients; and (3) the contraceptive patterns of Italian women born after 1960 are more similar to those of their Western counterparts, although new peculiarities appear, for example, substantial reliance on the condom by people living as couples as well as sexually active singles.     

Understanding calendar rhythm

Rhythm has been among the family planning methods endorsed since the start of the National Population Program in the Philippines, but it has not been given as much emphasis as the other methods such as oral contraception (OC), the IUD, and sterilization. For several years, no systematic effort was made to promote the effective use of rhythm. The 1978 Community Outreach Survey (COS) tried to determine the extent to which contraceptive methods were being used in the Outreach Project areas. The project covered 2,000 barangay service points (BSPs) with 1.76 million married couples of reproductive age (MCRA), representing 32% of the estimated total MCRA in the Philippines. The COS findings revealed that, of the total sexually active married women aged 15-49, 48% were using contraceptive methods. Of these, only 11.4% were using modern methods, 20% were using other program methods (rhythm, condom, and combination of rhythm and condom); and 16.7% were using nonprogram methods (withdrawal, abstinence, and others). When used in combination with other methods, rhythm had a monthly continuation rate of 96%; when used alone, 94%. The COS data showed that the rhythm method is practiced by a large number of Filipino couples. With the renewed interest in rhythm, it became imperative for the program to help rhythm acceptors use the method more effectively and thus reduce user failure. There continues to be need for data on the "product image" of rhythm. These include the emotions that come into play in the acceptance or rejection of rhythm, the perceived side effects as well as advantages of the method, the ways women communicate their "safe" and "unsafe" days to their husbands, the manner in which couples prevent sexual contact during "unsafe" days, and the attitude of couples toward abstinence. Among important study findings were the following: couples choose rhythm because it does not disturb the sexual act, has no side effects, and poses no religious objections; 1 of the problems of rhythm users is that they get varied explanations and instructions from service delivery personnel on the correct way to practice rhythm; and many rural women do not have a clear understanding of the menstrual cycle. Requirements of successful rhythm practice include cooperation, regular cycle, and the couple's age.     

Population education: a life experience course for the young

The Philippines is the 1st country to adopt an extensive population education program at an early stage of its national population program. Population education is a "life experience" course with the following 5 areas of study: 1) demography, 2) determinants of population growth, 3) consequences of population growth, 4) human sexuality and reproduction, and 5) planning for the future. Many institutions in the Philippines are teaching the course materials and training teachers for the course. Difficulties encountered in initiating the course are: 1) lack of administrative support, 2) lack of cooperation from conservative parents, and 3) an overcrowded curriculum. It has been decided to integrate the aspects of this course into existing areas of the curriculum. Topics for future research in population are outlined. Use of the research was also covered.     

"Katiwala": trustee of community health

The setting up of a medical cooperative in a squatter community in Davao City, Philippines, and the training of women from the community to serve as paramedical health visitors and family planning workers, is described. The clinic charges each family a small fee and sells drugs at cost. The health visitor program was initiated by the poor families themselves to reach those who could not come to the clinic. The 1st groups trained chose the name Kaunaunahang Katiwala ng Kalusugan, or First Trustees of Health, and they are called katiwala for short. Since 1973 about 80 of these women, usually about 30 years of age, with home and family responsibilities, and of low educational background, have bee n trained. The dialogic method of Paolo Fraire of Brazil is used, which focuses on the native intelligence of the student and emphasizes a mutual learning process on the part of both teacher and student. Upon graduation the katiwala take care of minor ailments, refer major problems to the clinic, distribute family planning information, and encourage sanitation and good health practices. The barrios are divided into districts and 2 katiwala assigned to each. They receive some compensation. The program has proved it is possible to train persons with little education to be effective health workers and free physicians and nurses for more serious cases.