Integrating reproductive health services into family planning programs

A recent Population Council publication, Reproductive Health Approach to Family Planning, discusses integration of reproductive health into family planning programs in a series of edited presentations that Council staff and colleagues gave at a 1994 meeting of the US Agency for International Development (USAID) cooperating agencies. The presentations reflect the Council's view that family planning programs ought to help individuals achieve their own reproductive goals in a healthful manner. The report discusses four areas of reproductive health: reproductive tract infections (RTIs), including sexually transmitted diseases; prevention and treatment of unsafe abortion; pregnancy, labor, and delivery care; and postpartum care. Christopher Elias (Senior Associate, Programs Division) argued that family planning programs ought to provide services that target RTIs, given that these illnesses afflict a significant proportion of reproductive-age women. The family planning community has an ethical responsibility to provide services to women who experience an unwanted pregnancy. They must have access to high-quality postabortion care, including family planning services. Professional midwives are ideally suited to serve as integrated reproductive health workers trained to combat the five major maternal killers: hemorrhage, sepsis, pregnancy-induced hypertension, obstructed labor, and unsafe abortion. This was demonstrated in a highly successful Life-Saving Skills for Midwives program undertaken in Ghana, Nigeria, and Uganda, and soon to start in Vietnam in conjunction with the Council's Safe Motherhood research program. Family planning services should be viewed as part of a comprehensive set of health services needed by postpartum women, which include appropriate contraception, maternal health checks, well-baby care, and information about breastfeeding, infant care, and nutrition. Family planning programs should incorporate breastfeeding counseling into their services. When programs aim to help individuals meet their own reproductive goals in a healthful manner, this implies that services will not increase clients' risk of morbidity.     

对人口和生殖健康领域的社会性别意识调查与思考

社会性别平等是实现人口与发展的有效途径,相关政府部门管理者的社会性别意识对于推进人口与生殖健康领域的性别平等具有重要意义。对30个省、市、自治区人口和计划生育委员会与卫生厅项目管理者的调查显示,大多数项目管理者能够正视传统性别文化对妇女的影响,从不平等的性别关系分析人口与生殖健康领域的突出问题,对于推进性别平等具有一定的社会责任感。但同时也反映出:一部分项目管理者对中国的性别平等发展形势缺乏了解,对现实生活中两性不平等的权责关系缺乏辨析,对女性参与项目决策的必要性认识不足,这容易造成公共政策与项目管理中的性别缺失。为此,应提升项目管理者的社会性别分析能力,建立性别平等咨询机制和监督机制,以促进人口与生殖健康领域的社会性别主流化。     

对中国县区级计生机构优质服务中社会性别公平程度的探索性研究——基于对M县计划生育管理与服务机构的调查

为探索中国县区级计划生育/生殖健康机构在优质服务体现社会性别公平的程度,对M优质服务项目县的计划生育管理和服务机构进行了2次共9组典型组专题讨论调查。结果表明,在优质服务目标群体的权益保障和责任分担方面,服务领域明显拓宽,社会性别公平程度有了一定改善。但是由于传统计划生育管理模式与服务观念的影响,计生机构主要关注已婚育龄妇女的权益和风险,未婚、更年期女性和男性的生殖健康服务仍然存在欠缺。在两性共同责任分担方面,男性分担避孕生育责任的趋势开始出现,但现有服务资源与规范仍制约着男性参与的程度。     

中国生殖健康方案的推进和已婚育龄人口避孕模式转变——ICPD 10:避孕方法的医控模式和自控模式有变化吗

避孕节育是生殖健康极为重要的内容。文章利用国家人口和计划生育委员会1988年至2001年全国生育节育抽样调查和全国计划生育/生殖健康调查数据,分析了已婚育龄人口在避孕模式上的时空变化特征,在此基础上进一步研究了在已婚育龄人口的年龄、子女数和生活的不同区域环境等方面避孕模式的时空变化。结果表明,在我国人口转变的过程中,低生育水平下的避孕模式以及推行避孕节育知情选择后已婚育龄人口的避孕模式,特别是医院控制的避孕方法与自己控制的避孕方法的构成已经发生了变化,有必要进一步改善生殖健康服务的技术服务等。     

Reproductive health care in India: a new paradigm

India has adopted a new approach to family planning that locates these services within the reproductive health care context. This means that family planning and reproductive health services will be offered as an integrated package. To implement this approach, the government will follow a framework for reproductive health designed by Saroj Pachauri, director of the Population Council's office in New Delhi, to guide the government's new Reproductive and Child Health Project. This initiative marks a significant paradigm shift in India; away from a population-control approach, implemented through a top-down, bureaucratic, target-driven program, towards a gender-sensitive high-quality services responsive to the health needs of clients, especially the women. Considering the geographical variations in reproductive health, the framework contains two service packages: an essential and comprehensive version, each consisting of broad categories of service and matrix of interventions. To support the transition underway, the Council has launched an advocacy project to educate health care providers and policymakers about reproductive health issues and help them translate the framework into effective programs. In order to successfully implement this initiative, partnerships with the nongovernmental sector, especially at the community level are essential.     

Who uses reproductive health services in the Philippines (and who doesn't)?

Data from the 1993 National Demographic Survey and the Safe Motherhood Survey have filled gaps in knowledge about the accessibility and use of reproductive health services in the Philippines. Analysis of the data by the East-West Center's Program on Population has revealed that the number of women using family planning (FP) and maternal health services has risen to 40% in 1993 from 17% in 1973. Modest gains were also seen in the past five years despite disruption to program efforts. Prenatal care showed the greatest maternal care coverage rate increase, but 70% of births occurred at home, with only 51% attended by a trained person, and only 32% of postpartum women received care. Adolescents and women who are over age 40, uneducated, Muslim, and/or live in a rural setting have the most unmet need. In addition, less than half of the women reporting symptoms of a sexually transmitted disease sought treatment from a trained practitioner. Most women use public sector services, including 71% of those using modern contraceptives. While trained midwives provided 58% of prenatal care, traditional birth attendants delivered 52% of all births, and a high incidence of maternal mortality persists (209/100,000). Recommendations arising from this analysis include 1) improving prenatal and delivery care, 2) strengthening postpartum FP services, 3) expanding the program to reach more women, 4) extending the range of reproductive health services offered, 5) integrating traditional practitioners into the reproductive health system, and 6) balancing cost and service variations between the public and private sectors.     

Son preference, use of maternal health care, and infant mortality in rural China, 1989-2000

This study assesses the effects of socio-economic conditions and the interaction between son preference and China's one-child family planning policy on the use of maternal health care services and their effects on infant mortality in rural China, using nationally representative data from the 2001 National Family Planning and Reproductive Health Survey. The results show that while the use of maternal health care services has continued to increase over time, large gaps still exist in the use of these services and in infant survival by mother's education, community income, and parity. Further improvements in the reproductive health of all women and in infant survival will require effective reduction of the obstacles to the use of maternal health care among those women in rural China who are less educated, poor, and of higher parity.     

Use of maternal health services in rural China

We use data from the nationally representative 1997 Demographic and Reproductive Health Survey to examine use of maternity services in rural China. The data indicate that roughly 60 per cent of women had at least one prenatal visit, while 40 per cent had a professionally assisted birth over the period 1988-97. Despite China's shift from a more socialist to a more privatized health care system, use of maternity services increased over this period. These increases are consistent with the push toward integration of reproductive health into family planning that emerged after the 1994 International Conference on Population and Development and the 1995 Fourth World Women's Conference held in Beijing. At the same time, we find indirect evidence that the target-based population policy may well have exerted downward pressure on use of maternity services; differences by parity are marked and multilevel models predicting use of maternity services indicate underdispersion at the individual level.     

New perspectives on population: lessons from Cairo

The lessons from the 1994 World Population Conference in Cairo, Egypt, are summarized in this publication. The topics of discussion include the evolution of population policies, the changing policy environment, demographic trends, and solutions in the form of gender equity, provision of reproductive health services, and sustainable social and economic development. The program of action supported by 180 governments and targeted for 2015 articulated the goals of universal access to a full range of safe and reliable family planning methods and reproductive health services, a specified level of reduction in infant and child mortality, a specified level of reduction in maternal mortality, an increase in life expectancy to 70-75 years or more, and universal access to and completion of primary education. Other features include goals for improving women's status and equity in gender relations, expansion of educational and job opportunities for women and girls, and involvement of men in childrearing responsibilities and family planning. Steps should be taken to eliminate poverty and reduce or eliminate unsustainable patterns of production and consumption. Population policy must be integrated within social and economic development policies. About $22 billion will be needed for provision of family planning and reproductive health services by the year 2015. Costs will increase over the 10-year period due to the increased population to be served. Per person user costs for family planning alone are higher in countries without infrastructure and technical skills. Actual costs vary with the cost of contraceptive supplies, patterns of use, and efficiency of delivery systems. Although the plan offers 16 chapters worth of advice and recommends 243 specific actions, countries will have to be selective due to cost limitations. The 20/20 Initiative is proposed for sharing social service costs between international donors (20%) and host countries (20%). A separate UN projection of need is for 33% of support from international donors for family planning and related programs. The constraints to the implementation of the action plan are identified as the rate of demographic change, the extent of public support for population limitation and provision of family planning services, and potential conflicts of interests and funding between cooperating agencies. The World Bank has developed guidelines for policy development according to a country's identification as an emergent, transitional, or advanced country.     

新疆人口现状

国家统计局的资料表明,2000年新疆人口平均预期寿命已达67．41岁,比1949年增加了37岁。1985年,新疆被国际自然医学会列为世界上4个长寿地区之一,每百万人口中百岁老人的数量居全国之首。     

Gender inequalities and demographic behavior

A summary was provided of the central findings about gender inequalities in Egypt, India, Ghana, and Kenya published by the Population Council in 1994. These countries exhibited gender inequalities in different ways: the legal, economic, and educational systems; family planning and reproductive health services; and the health care system. All countries had in common a high incidence of widowhood. Widowhood was linked with high levels of insecurity, which were linked with high fertility. Children thus became insurance in old age. In Ghana, women's insecurity was threatened through high levels of marital instability and polygyny. In Egypt, insecurity was translated into economic vulnerability because of legal discrimination against women when family systems were disrupted. In India and all four countries, insecurity was reflective of limited access to education, an impediment to economic autonomy. In all four countries, women's status was inferior due to limited control over reproductive decision making about childbearing limits and contraception. In India, the cultural devaluation of girls contributed to higher fertility to satisfy the desire for sons. In India and Egypt, family planning programs were dominated by male-run organizations that were more concerned about demographic objectives than reproductive health. The universal inequality was the burden women carry for contraception. Family planning programs have ignored the local realities of reproductive behavior, family structures, and gender relations. The assumption that husbands and wives have similar fertility goals or that fathers fully share the costs of children is mistaken in countries such as Ghana. Consequently, fertility has declined less than 13% in Ghana, but fertility has declined by over 30% in Kenya. Family planning programs must be aware of gender issues.     

New strategies for slowing population growth

Growth of world population over the next 100 years, until the year 2100, will produce an estimated 11.5 billion people. The past focus on reducing rapid population growth exclusively through family planning has not been sufficient. Population policy needs to be broadened to include health care, education, and poverty reduction. The population policy recommendations of Population Council Vice-President John Bongaarts and Senior Associate Judith Bruce were to reduce unwanted pregnancies by expanding services that promote reproductive choice and better health, to reduce the demand for large families by creating favorable conditions for small families, and to invest in adolescents. The Population Council 1994 publication "Population Growth and Our Caring Capacity" outlined these issues. Another similar article by John Bongaarts appeared in the journal "Science" in 1994. In developing countries, excluding China, about 25% of all births are unwanted; 25 million abortions are performed for unwanted pregnancies. The provision of comprehensive family planning programs will go a long way toward achieving a reduction in unwanted pregnancies. In addition, changes are needed in male control over female sexuality and fertility and in cultural beliefs that are obstacles to use of contraception. Stabilization of population at 2 children per family will not occur unless there is a desire for small families. In most less developed countries, large family sizes are preferred. Governments have an opportunity to adopt policies that reduce economic and social risks of having small families. This can be accomplished through the widespread education of children, a reduction in infant and child mortality, improvement in the economic and social and legal status of women, and provision of equitable gender relations in marriage and child rearing. The rights of children to be wanted, planned, and adequately cared for need to be supported. These aforementioned measures will help to reduce fertility, provide support for small families, and justify investment in social development. Population momentum will keep population growing for some time even with replacement level fertility. Investment in adolescents through enhancement of self-esteem and promotion of later childbearing can lengthen the span between generations and slow population momentum. Population policies will be more effective when human rights are protected.     

Demographic Research in Britain 1936–1986

We use data from the nationally representative 1997 Demographic and Reproductive Health Survey to examine use of maternity services in rural China. The data indicate that roughly 60 per cent of women had at least one prenatal visit, while 40 per cent had a professionally assisted birth over the period 1988–97. Despite China's shift from a more socialist to a more privatized health care system, use of maternity services increased over this period. These increases are consistent with the push toward integration of reproductive health into family planning that emerged after the 1994 International Conference on Population and Development and the 1995 Fourth World Women's Conference held in Beijing. At the same time, we find indirect evidence that the target-based population policy may well have exerted downward pressure on use of maternity services; differences by parity are marked and multilevel models predicting use of maternity services indicate underdispersion at the individual level.     

Redefining family planning programs

The Population Council's issue paper entitled Reconsidering the Rationale, Scope, and Quality of Family Planning Programs calls on family planning programs to focus only on reducing unwanted fertility by helping people meet their own reproductive goals safely and ethically. Many family planning programs have been wrongly handed the extra responsibility of reducing wanted fertility. They have therefore used inappropriate means (e.g., incentives, quotas, and coercion) to boost contraceptive prevalence. If programs do focus on reducing unwanted fertility, they will foster reductions in overall fertility and population growth as well as improvements in clients' health and well-being. A new framework has emerged from this shift in rationale. It sets the stage for expanding the scope, improving the quality, and assessing the impact of family planning programs in terms of client choice, health, and well-being. A program needs to determine the range and quality of family planning services it provides at the local level. Local program managers, policymakers, and consumer interest groups should establish minimum or achievable standards of service based on the local health care capacity. Program items that should be assessed include choice of methods, information for clients, technical competence, interpersonal relations, mechanisms to encourage continuity of care, and appropriate constellation of services. The Population Council has conducted rapid appraisals of the quality of care of family planning services to help local program managers to evaluate the strengths and weaknesses of their programs. The HARI (Helping Individuals Achieve their Reproductive Intentions) Index measures a program's success in helping clients safely prevent unwanted or unplanned pregnancy. Program managers can conduct a self-assessment that revolves around answering four questions. Family planning services are an important social investment and are essential to development.     

黑龙江省穆棱市计划生育村民自治调查报告

计划生育村民自治是我国农村社区计划生育的管理方式。穆棱市早在1999年就进行了计划生育村民自治试点工作。穆棱市在具体推行中以人为本,将维护群众的合法权益作为第一要义,尊重和保护群众的生育权、知情权、计划生育技术服务的获得权以及民主参与权。同时,对于低生育水平下的人口与计划生育工作,穆棱市勇于实践,适时改革,取得显著成效。     

Fertility beyond the frontier: indigenous women,fertility, and reproductive practices in the Ecuadorian Amazon

Recent research suggests that after decades of population decline, indigenous populations of the lowland tropics of Latin America are now experiencing rapid growth. At the same time, conservationists have pronounced indigenous lands as a key to the future of Amazon forests. As such, conservationists should have a good understanding of indigenous demography and impacts on conservation and development. Yet, there is little depth to understanding of these demographic changes and a dearth of quantitative research on the reproductive practices of indigenous populations. This study addresses these gaps through analyses of a household survey of 648 women of reproductive age from five distinct ethnic populations in the Ecuadorian Amazon. We estimate fertility, analyze reproductive intentions and contraceptive use, and determine the unmet need for reproductive health services. The analyses confirm high fertility rates and high levels of unmet need for contraception. With regard to program and policy implications, we conclude by arguing that isolation and cultural barriers present unique challenges to meet the reproductive health needs of these populations. Innovative approaches, such as those merging population–health–environment topics, may be most relevant for meeting these challenges.

Assessment of ASEAN population programme

The objectives of the 5th meeting of the ASEAN Heads of Population Program, held at Chiang Mai during November 1981, were the following: to discuss and consider the midterm reviews of some of the Phase 1 projects; to discuss and consider the ASEAN population experts' views on the progress made in the rest of the phase 1 projects; to discuss and consider the progress made in the implementation of the phase 2 projects; to discuss and consider the ASEAN population experts' recommendations on the ASEAN population program in the 1980s based on the report of the programming exercise submitted by the consultant in the expert group meeting; and to discuss administrative and other problems faced by the program implementors in the operationalization of the ongoing ASEAN population projects and provide appropriate directions to solve such problems. As a result of the programming exercise, the meeting established the directions for the future ASEAN population program and strongly recommended the continuation, intensification, and expansion of the ASEAN population program. A total of 12 projects comprise the ASEAN population program: 5 projects under phase 1 and 7 under phase 2. Under phase 1, 1 project has been completed, and the 1st parts of 2 other projects are in the process of implementation. Phase 2 projects, which started in September/October 1980, are all in the process of implementation. The following phase 1 projects are summarized: integration of population and rural development policies and programs; modular training for trainers of population and development agencies in ASEAN countries; multi-media support for population programs in the context of rural development in ASEAN countries; and migration in relation to rural development. The following phase 2 projects are also summarized: institutional development and exchange of personnel; women in development in ASEAN countries; and migration in relation to rural development. The following phase 2 projects are also summarized: institutional development and exchange of personnel; women in development; developing and strengthening national population information systems and networks in ASEAN countries; population and development dynamics and the human resource balance; studies on health and family planning in ASEAN countries; development of ASEAN social indicators; and population migratory movement and development.     

以人为本 制度创新——对深圳建立城市流动人口计生协经验的思考

在我国现行制度下 ,长期滞留城市的“流动人口”由于没有“身份” ,而缺少正式组织网络和与政府畅通的沟通渠道 ,因此自组织现象比较突出 ,维权的需求迫切 ,成为城市人口管理的一个难点。深圳市通过建立流动人口计生协 ,“以宣传为先导 ,以群众参与为关键 ,以真情服务为根本 ,以提高生育质量、转变生育观念为主题” ,来开展“生产 ,生活 ,生育”服务 ,为流动人口“营造一个家” ,取得了多重社会效益 ,对新时期城市计生协的工作定位以重要启示 ,同时反映了我国未来计划生育事业的发展方向     

Combining vertical service with horizontal service to promote family planning]

How Bazhong County of Sechuan Province, China, carries out family planning through a combination of what are termed vertical and horizontal services is described. Vertical service refers to assistance such as premarital education, prenatal hygiene, child health care, and family planning, while horizontal service refers to household assistance for married women. Premarital education is designed to help young people acquire sufficent knowledge about family planning, hygiene, and eugenics, and stresses the disadvantages involved in marriages between close relatives. Prenatal hygiene provides safe and convenient medical accommodations for delivery of the child as well as maternal care. Child health services assure that the best facilities are to be made available for physical examinations, vaccinations, and medical treatment. The family planning program involves comprehensive measures such as distribution of contraceptives and safe sterilization. In addition, the county provides medical assistance for couples unable to have children. Horizontal service providing household assistance for married women promotes scientific farming (e.g., how to use fertilizer), helps people increase their income by teaching them skills, and provides social services to improve life style and education. These vertical and horizontal services have brought about substantial improvements in the standard of living, family harmony, and population control.