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.     

Latin American hospitals improve postabortion care. Maternal health

Approximately 4 million women undergo illegal abortions each year in Latin America and the Caribbean, and hundreds of thousands of women with postabortion medical emergencies or incomplete abortions seek hospital care. Once in an emergency ward, a woman may await treatment for 24 hours, bleeding, frightened, and in pain. A woman in such a situation may also experience nurses who chastise her for becoming pregnant or committing a sin, be examined with several staff members observing, undergo unexplained treatment without anesthesia, and/or leave the service facility without knowing whether she is still fertile or how to avoid pregnancy. INOPAL, Population Council's operations research program on family planning and reproductive health in the region, is working to find the best ways, medically and financially, for hospitals to deliver high-quality, comprehensive services to postabortion patients. Most maternal deaths and injuries could be prevented by access to family planning services and information about contraceptive use. The Population Council and colleagues from hospitals, governments, and nongovernmental organizations are conducting studies in Guatemala, Peru, and Mexico on the emergency treatment of incomplete abortions with the goal of improving and standardizing postabortion services.     

Workshop on long-term contraceptives

The National Population Council Secretariat (NPCS) of Ghana held a three-day workshop on long-term contraceptives in 1996 in collaboration with the Ministry of Health, the Association of Voluntary Surgical Contraception, and the Johns Hopkins Population Communication Services. The session was funded by USAID. The executive director of NPCS, Dr. Richard Turkson, said that the slow rate of contraceptive acceptance was an obstacle to population control despite political concern that rapid population growth exerted an adverse impact on the economy. Only 10% of married women were using long-term or permanent methods of contraception. The hope was voiced that the participants would devise practical and cost-effective education, information, and communication (IEC) strategies to boost the demand for long-term contraceptive methods among sexually active people in Ghana. It was essential that these strategies and activities were based on a realist assessment of the demographic and social situation of the country. The examination of case studies in cultures similar to Ghana would also offer valuable lessons. The factors that hinder the acceptance of long-term methods include misconceptions, myths, and false rumors rooted in a general lack of knowledge among the people. Participants were urged to come up with strategies to counter these problems, and service providers were encouraged to improve their knowledge about contraceptive methods and counseling skills. Male involvement in contraception was also advocated. Statistics show that most Ghanians practicing contraception were using short-term methods such as foaming tablets, pills, and condoms. However, it is necessary to shift to long-term methods such as injectables, implants, and sterilization in order to achieve significant reductions in fertility.     

Trends and determinants of contraceptive use in Kenya

This study uses the 1977-1978 Kenya Fertility Survey and the 1989 Kenya Demographic and Health Survey to examine trends and determinants of contraceptive use in Kenya. A substantial increase in contraceptive use occurred in Kenya over the decade. Yet although the increase was shared by all groups in the country, the amount of change differed greatly. A regression decomposition procedure revealed that shifts in population composition--that is, an increase in better educated women and in the proportion of women who want to cease childbearing--were the primary sources of aggregate change in contraceptive use.     

Assessing the impact of a family planning nurse training program in Egypt

In 1991 the Egyptian Ministry of Health introduced a new training program for family planning nurses. The training program stressed the development of nurses' counseling skills. As part of the Operations Research Program, sponsored by Family Health International in collaboration with the Egypt National Family Planning Board, managerial staff from family planning agencies designed and implemented a study to evaluate the impact of the new training program. The study objective was to assess the impact of nurse training on nurse performance in the clinic and on clients' family planning knowledge, attitudes and contraceptive use. The study was designed to provide usable information to family planning managers in the field within a time period of less than one year. The study results indicate that there is an association between improved family planning training for nurses and positive changes in family planning knowledge, attitudes and behavior among women attending MoH clinics in this study. The greatest relative change occurred in knowledge. Women in the experimental group, relative to the control group, displayed increased knowledge about contraceptives, particularly the pill and the IUD. Attitudinal change was less pronounced. Favorable attitudes toward oral contraceptives and condoms became more prevalent, and reports of husband-wife communication about family planning also increased. Finally, although contraceptive use was already high prior to the nurse training, IUD use increased significantly among women in one governorate.     

“You’re a ‘high-risk’ customer”: A qualitative study of women’s experiences of receiving information from health professionals regarding health problems or complications in pregnancy

BackgroundExperiencing complications in pregnancy is stressful for women and can impact on fetal and maternal outcomes. Supportive encounters with health professionals can reduce the worry women experience. Further research is needed to understand women’s perspectives on communicating with their healthcare providers about their concerns.AimThis study explored women’s experiences of receiving information about pregnancy complications from healthcare providers and their interactions with multiple professionals and services during pregnancy.MethodsThis was a qualitative interpretive study. Semi-structured interviews were conducted with 20 women experiencing pregnancy complications recruited from antenatal services at two hospitals in Sydney. Inductive thematic analysis was used to analyse the data.FindingsWomen had a range of reactions to their diagnoses, including concern for their baby, for themselves and for their labour. Most women reported that communication with healthcare providers was distressing, they were not listened to and staff used insensitive, abrupt language. Women were also distressed by delays in education, receiving contradictory information and having to repeatedly share their stories with different health professionals. In some cases, this damaged the therapeutic relationship and reduced trust towards healthcare providers. Midwives were generally preferred over doctors because they had a more woman-centred approach.ConclusionTo improve women’s experiences of care for pregnancy complications, it is critical to improve the communication skills of maternity service providers. Women’s need for information, resources and support can best be provided by continuity of care with a named health professional, for example, a midwife working within an integrated multidisciplinary antenatal service model.     

Situation analysis: assessing family planning and reproductive health services. Quality of care

This issue of Population Briefs contains articles on researches conducted by the Population Council concerning the delivery of quality of care, contraceptive development, safe abortion, family planning, demography, and medical anthropology. The cover story focuses on a systematic data collection tool called Situation Analysis that helps managers in program evaluation. This tool has a handbook entitled "The Situation Analysis Approach to Assessing Family Planning and Reproductive Health Services" that contains all the information needed to conduct a Situation Analysis study. The second article reports about a new contraceptive method, the two-rod levonorgestrel, which was developed at the Population Council and was recently approved by the US Food and Drug Administration. The third article reports on a medical abortion procedure that was proven to be safe, effective, and acceptable to women in developing countries. Moreover, the fourth article presents initial findings of the Community Health and Family Planning Project conducted in Northern Ghana. The fifth article discusses the paper written by the Population Council demographer, Mark Montgomery entitled "Learning and lags in mortality perceptions". Finally, the sixth article deals with another paper that reports on women's health perceptions and reproductive health in the Middle East.     

知情选择对人工流产影响的验证

利用固定效应模型对1988—2001年全国计划生育／生殖健康调查数据进行了再次分析,以量化考察知情选择政策对中国已婚育龄妇女人工流产行为的影响。研究发现,知情选择与已婚育龄妇女人工流产可能性的降低之间呈现一定的因果关联。知情选择导致了育龄妇女人工流产的可能性降低,并在各个孩次上都有明显的体现。     

Population research and education in Vietnam

Population research and education in Vietnam have expanded in their functions since the early 1980s. There are currently 5 departments conducting demographic studies: the National Committee for Population and Family Planning within the Ministry of Health, the Ministry of Education, and the Institute of Pedagogical Sciences, the Ministry of Labor Fore, the Vietnam Women's Union, and the Youth Union. An overview is provided of each department and its research and educational activities as well as the General Statistics Office (GSO) and the Institute of Sociology. GSO provides statistics on population annually from a variety of sources including the decennial census. The last census was conducted in 1989 and is useful for understanding general demographic trends. Vital rate data are considered too low. The Institute of Sociology uses the sample survey and focus groups to examine social and economic conditions and their effects on norms and values about reproduction. The Institute conducted a knowledge, attitudes, and prevalence (KAP) survey in 1984. Studies have focused on the commune level and the role of government in population regulation. Findings have supported a position that the goal of a 2-child family is not attainable without social and economic change as well as family planning. Migration studies have also been undertaken with the Ministry of Labor. The National Committee for Population and Family Planning is concerned with studies on the biotechnology of contraceptive methods and abortion. A study in 1987 examined health workers attitudes toward and knowledge of a variety of contraceptive methods. In 1988 the Demographic and Health Survey was conducted and data were comparable internationally. Studies have been helpful in designing training programs and in informing decision makers. Forecast data in 1990 were useful in setting targets for the coming decade. The Ministry of Education targets the general public and students. Materials aim to create positive attitudes to family planning and to inform about general population issues. Special groups such as the Women's Union have conducted KAP studies and the Center for Women's Studies has focused on the problems of women in development.     

Abortion in amsterdam

Abstract Mortality from abortion is low in the Netherlands to-day, and approximately equal to mortality at delivery. Calculations suggest that about 4,000 abortions occur in Amsterdam every year, of which about 2,100 are induced. The abortion rate shows a very gradual decline after the Second World War. An investigation of the social background of women with induced abortion showed no relationship between occupational group and the incidence of abortion, but a strong negative correlation between religion and abortion. Abortion was more common among women with disturbed relationships in their own or parental families. Induced abortion usually occurred in pregnancies resulting from failure of contraception; these failures were caused not by lack of knowledge of good contraceptives, but by ineffective practice of contraception. The inability to use contraceptive methods in an effective way is related to a lack of communication between the two partners, and to a negative attitude of the women towards sex. An attempt has been made to formulate a theory of the causes of induced abortion among the women interviewed in Amsterdam.     

Family planning practice and women's fertility decision-making power

This paper investigates the effects of family planning practice on fertility decision-making power in South Korea. The log-linear analysis of the 1981 survey data by the Institute of Population and Health Services Research, Yonsei University, Seoul, Korea, shows that those urban and rural women who practice family planning or have experienced abortion exercise greater influence on a couple's fertility decision making than those who do not practice family planning or who have had no abortion experience. In addition, there is the interactive effect of abortion experience and contraceptive use on fertility decision making among urban women. This finding is significant because regardless of how birth control is available within a society, birth control use enhances women's decision making power where fertility is concerned.     

Fertility in Kenya and Uganda: a comparative study of trends and determinants

Between 1980 and 2000 total fertility in Kenya fell by about 40 per cent, from some eight births per woman to around five. During the same period, fertility in Uganda declined by less than 10 per cent. An analysis of the proximate determinants shows that the difference was due primarily to greater contraceptive use in Kenya, though in Uganda there was also a reduction in pathological sterility. The Demographic and Health Surveys show that women in Kenya wanted fewer children than those in Uganda, but that in Uganda there was also a greater unmet need for contraception. We suggest that these differences may be attributed, in part at least, first, to the divergent paths of economic development followed by the two countries after Independence; and, second, to the Kenya Government's active promotion of family planning through the health services, which the Uganda Government did not promote until 1995.     

Delaying factors for maternal health service utilization in eastern Ethiopia: A qualitative exploratory study

BackgroundIn Ethiopia, maternal health service utilization is still unacceptably low. The societal and cultural factors that constrain women from attending these services have not yet been sufficiently explored. Using qualitative methods, we aimed to explore the factors that delay maternal health service utilization in eastern Ethiopia.MethodA total of 13 audio-recorded focus group discussions were conducted comprising 88 participants. We conducted separate group discussions with reproductive aged women, mothers-in-law, traditional birth attendants, husbands, and Health Extension Workers to capture their knowledge, practices, feelings, thoughts and attitudes towards maternal health service utilization. The recorded sessions were transcribed into the local language and then translated into English for analysis.ResultThe study identified a number of factors that may delay maternal health service utilization. Factors were grouped using the Three Delays model as a framework. Low level of awareness regarding need, poor involvement of husband, perceived absence of health problems, social power, community misperceptions and cultural restrictions, negative attitudes towards male midwives, acceptance of traditional birth attendants and poor social networking were Delay One factors. Lack of physical accessibility and high transportation costs were categorised as Delay Two factors for skilled birth care attendance. Perceived or experienced poor quality of care were categorised as Delay Three factors for both skilled birth and postnatal care utilization.ConclusionDespite the ongoing government measures to improve maternal health service utilization in Ethiopia, numerous factors continue to contribute to delays in service use, which in turn contribute to high maternal mortality.     

Maternity and child health care in urban China

In China the effort to develop maternal and child health (MCH) care has been ongoing. Initially, attention was directed primarily to promulgating a modern method of delivery in an effort neonatal tetanus and puerperal fever. The next stage was the systematic management of MCH care. Pregnant women and puerperants were given a series of checkups and guidance from conception until the 42nd day after delivery. The purpose was to prevent and treat complications. In some cities, perinatal care has developed to the point of health care management of the health of both mother and child. This extensive health care system includes preconception and pregnancy care, puerperant care, and neonatal care. Premarital checks have become the rule in the urban areas. MCH care organizations at the grassroots level and community health workers take responsibility for advising newly married couples about health care. In addition, some medical colleges and their affiliated hospitals provide consultation services for these couples. The Shanghai Railway Medical College uses a computer to make projections on multigenic genetic diseases. It provides information on incidence risk of the next generation to help couples make their childbearing decisions. The majority of pregnant women get their 1st prenatal check prior to the 12th week of pregnancy, followed by 9 re-examinations to screen out high risk factors. Difficult labor, infections, obstetric trauma, postpartum hemorrhage, and fetal distress are prevented at childbirth. Newborns are scored with Apgar comments; those with low marks are specially protected. In some cities, an investigation system has been established to deal with perinatal deaths. Perinatal care is managed at 3 levels: community MCH centers and MCH departments of hospitals, clinics, and industrial enterprises form the 1st level of care; MCH centers of city districts and hospitals at the district level make up the 2nd level of care; and MCH institutes or hospitals at provincial or city levels, hospitals attached to medical colleges, and hospitals under government ministries form the 3rd level of care.     

Fertility in Kenya and Uganda: A comparative study of trends and determinants

Between 1980 and 2000 total fertility in Kenya fell by about 40 per cent, from some eight births per woman to around five. During the same period, fertility in Uganda declined by less than 10 per cent. An analysis of the proximate determinants shows that the difference was due primarily to greater contraceptive use in Kenya, though in Uganda there was also a reduction in pathological sterility. The Demographic and Health Surveys show that women in Kenya wanted fewer children than those in Uganda, but that in Uganda there was also a greater unmet need for contraception. We suggest that these differences may be attributed, in part at least, first, to the divergent paths of economic development followed by the two countries after Independence; and, second, to the Kenya Government's active promotion of family planning through the health services, which the Uganda Government did not promote until 1995.     

Maternity services and the discharge process: A review of practice in Queensland

BackgroundEfforts to increase postnatal support available to women and families are hampered by inadequate referral mechanisms. However, the discharge process in maternity services has received little research attention.AimTo review current discharge practices in Queensland, in order to identify mechanisms to minimise fragmentation in the care of women and families as they transition from hospital-based postnatal care to community-based health and other services.MethodsA survey of discharge practices in Queensland hospitals that offer birthing services (N = 55) and content analysis of discharge summary forms used by those hospitals.FindingsFifty-two Queensland birthing hospitals participated in the study. Discharge summaries were most commonly sent to General Practitioners (83%), less commonly to Child and Family Health Nurses (CFHNs; 52%) and rarely to other care providers. Discharge summaries were usually disseminated within one week of discharge (87%), but did not capture any information about care provided by domiciliary services. Almost one-fifth (19%) of hospitals did not seek women's consent for the disclosure of their discharge summary and only 10% of hospitals had processes for women to check accuracy. Significant gaps in the content of discharge summaries were identified, particularly in psychosocial and cultural information, and post-discharge advice. The format of discharge summaries diminished their readability.ConclusionDischarge summaries (format and content) should be consistent, comprehensive and specific to maternity services. Discharge summaries should be generated and disseminated electronically at the time of discharge from the maternity service. Women should review their discharge summaries and direct and consent to its dissemination.     

Regardless of where they give birth,women living in non-metropolitan areas are less likely to have an epidural than their metropolitan counterparts

QuestionCan differences in Australian birth intervention rates be explained by women's residence at the time of childbearing?.MethodsData were collected prospectively via surveys in 1996, 2000, 2003, 2006 and 2009 from women, born between 1973 and 1978, of the Australian Longitudinal Study on Women's Health. Analysis included data from 5886 women who had given birth to their first child between 1994 and 2009. Outcome measures were self-report of birth interventions: pharmacological pain relief (epidural and spinal block analgesia, inhalational analgesia and intramuscular injections), surgical births (an elective or emergency caesarean section) and instrumental births (forceps and ventouse).FindingsPrimiparous women residing in non-metropolitan areas of Australia experienced fewer birth interventions than women residing in metropolitan areas: 43% versus 56% received epidural analgesia; 8% versus 11% had elective caesarean sections; and 16% versus 18% had emergency caesarean sections. Differences in maternal age and private health insurance status at first birth accounted for differences in surgical birth rates but did not fully explain differences in epidural analgesia.ConclusionNon-metropolitan women had fewer birth interventions, particularly epidural analgesia, than metropolitan women. Differences in maternal age and private health insurance do not fully explain the differences in epidural analgesia rates, suggesting care provided to labouring women may differ by area of residence. The difference in epidural analgesia rates may be due to lack of choice in maternity services, however it could also be due to differing expectations leading to differences in birth interventions for primiparous women living in metropolitan and non-metropolitan areas.     

Meeting health and family planning needs in Latin America and the Caribbean

The operations research and technical assistance (OR/TA) project in The Population Council has concentrated on fertility and infant mortality issues in Latin American and the Caribbean for more than a decade through INOPAL. INOPAL is an acronym for Investigacion Operacional en Planificacion Familiar y Atencion Materno-Infantil para America Latina y el Caribe (Operations Research in Family Planning and Maternal-Child Health in Latin America and the Caribbean). In March 1995, the project entered its third phase, INOPAL III, with the renewal of its contract from the United States Agency for International Development (USAID). To facilitate communication between INOPAL, collaborating agencies, and USAID, INOPAL Director James Foreit moved from Peru to a Council office in Washington, D.C. INOPAL has six objectives: 1) to test the integration of family planning and reproductive health services; 2) to increase access to family planning; 3) to develop strategies to reach special populations; 4) to improve the sustainability of family planning programs; 5) to improve service quality; and 6) to institutionalize operations research capability in the region. INOPAL II conducted 61 subprojects in 12 countries in collaboration with 24 USAID cooperating agencies and other international organizations. The project established new services for postpartum women, adolescents, and rural women; improved program quality and financial sustainability; increased vasectomy promotion and the range of available contraceptives; and developed new modes of service delivery. A key finding of INOPAL II operations research was the importance of increasing cost-effectiveness to ensure program sustainability. INOPAL III will work toward all six objectives, with an emphasis on integrating reproductive health and family planning services. Operations research and technical assistance (OR/TA) subprojects will focus on the prevention and treatment of sexually transmitted diseases, perinatal and postpartum care, and postabortion care.     

India's National Family Health Survey provides new information on maternal and child health and AIDS awareness

Teams surveyed a sample of 88,562 households, drawn from 99% of the population of India in 24 states plus the National Capital Territory of Delhi, between April 1992 and September 1993 to collect a basic set of information on all 500,492 household members, with more details on the 89,777 women in the households who had ever been married and were aged 13-49 years. This National Family Health Survey (NFHS) collected information from the women on a range of health topics including child immunization, women's knowledge of AIDS, services and facilities use during pregnancy and childbirth, infant feeding and treatment for diarrhea, and infant, child, and maternal mortality. Levels of infant and child mortality declined in India, but 8% of all children still die before their first birthday and 11% die before reaching age 5. As for maternal mortality, there are an estimated 420 maternal deaths per 100,000 live births annually. That rate implies that at least 100,000 Indian women die each year due to causes related to pregnancy and childbirth. Survey results indicate the need to strengthen vaccination programs and teach women about proper infant feeding practices. They also highlight the need to increase antenatal care and other medical services. In all of these areas, the NFHS results indicate wide variation among India's regions and states. Furthermore, a general lack of AIDS awareness suggests that the government's AIDS awareness campaign, relying primarily upon electronic media, has not yet reached the majority of India's population.