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.     

Female genital mutilation: Conditions of decline

Female genital mutilation (or femalecircumcision) has been experienced by over 100 millionwomen in sub-Saharan Africa and the Nile valley.Efforts to suppress the practice were made in theearlier decades of the present century, especially bymissionaries in Kenya in the 1920s and early 1930s.Successful indigenous opposition to this activity ledto a cultural relativist attitude toward FGM beingdominant among governments and international bodiesfor the next half century. This situation has changedover the last 20 years as the women's movement has ledan attack on the practice, so that by the mid-1990sall relevant major international bodies andgovernments without exception had committed themselvesto its suppression. Nevertheless, efforts to counterFGM have often been weak and there has been littleevidence of their success. This paper draws on acontinuing research program among the Yoruba peopleof southwest Nigeria to show not only that FGM hasbegun to decline but that this occurrence can beexplained wholly by programs organized by theMinistry of Health and women's organizations. Thefocus of this paper is on the determinants of thischange. These are shown to be: (1) a reduction inceremonies associated with the practice, (2) itsincreasing medicalization, (3) indigenous secularcampaigning based on the provision of information, and(4) a focus on individuals, especially women. There islittle belief that the campaign is an assault on theculture, but rather a growing feeling, especiallyamong those influenced by it, that it would be moreappropriate once such a campaign has begun for it tobe whole-hearted rather than lukewarm.     

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.     

Secrecy and silence: why women hide contraceptive use

A recent Population Council survey of 1860 married women and 1056 of their husbands in urban Zambia found that many women who use contraception do so without their husbands' knowledge and that those women who hid their practice of contraception from their husbands did so because they found it very difficult to bring up the subject of family planning with them. These findings indicate that low levels of contraceptive use are not the result of a simple communication matter. Sex and sexuality are often the exclusive domain of African husbands. As such, if a wife initiates a discussion of family planning, she may threaten her husband's sense of control and create discord within the family. The culture of silence about sex and sexuality is very strong in Africa. 57% of women stated that were they to propose contraceptive use with their husbands and the husband opposed such practice, they would nonetheless use them without his knowledge. 7% of the women stated that if their husbands disapproved of contraceptive use, they would nonetheless openly use a method against his wishes. The majority of women correctly perceived their husbands' views on family planning use and fertility preferences. In focus groups, both men and women said that they did not believe that women have the right to independently act upon their reproductive preferences. A husband's inadequate financial support of his children could, however, justify clandestine contraceptive use. These findings point to the need to include easily hidden methods in the mix of contraceptives family planning programs offer. Moreover, service providers should not automatically encourage husbands' involvement. A client's right to privacy should always be respected.     

Tools and training strengthen African AIDS groups

Recent estimates indicate that AIDS has stricken approximately 21 million adults and children in sub-Saharan Africa. Many grassroots organizations were born during the early 1990s in response to the pandemic. Two Population Council researchers undertook four collaborative interventions to strengthen such organizations. Their efforts showed that providing simple, carefully chosen forms of technical assistance can greatly improve the ability of grassroots organizations to achieve their goals. Modest investments of time and expertise can yield considerable positive results. In Uganda, the National AIDS Control Program's Community Counseling Aides (CCA) Project sends trained volunteers to conduct AIDS education and provide basic nursing care. KIWAKKUKI, a women's group in Moshi, Tanzania, provides AIDS education and care for people affected by AIDS. In Ndola, Zambia, the INDENI Petroleum Refinery's HIV/AIDS Committee conducts educational activities, provides condoms and medical care, and addresses the needs of employees' families. In Lusaka, Zambia, the women of the KWASHA MUKWENU care for children orphaned by AIDS. Population Council interventions in each of these programs is described.     

Rural Egyptian women bear heavy disease burden

In 1998, a multidisciplinary group of researchers investigated women's reproductive health in two rural villages in Giza, Egypt using data from clinical examinations and laboratory tests. In addition, a questionnaire supplemented with in-depth interviews illuminated women's perceptions of illness and the sociocultural context of the community. Examining a random sample of 509 married, nonpregnant women, the researchers found that the vast majority of these women suffer from a spectrum of gynecological and related conditions. Beyond reproductive tract infections, which affect roughly half of the women, genital prolapse afflicts 56% and anemia 63%. Suspicious cervical cell changes (11%) and cervical erosion (22%) in women were noted. Moreover, related conditions were also highly prevalent: women suffered from urinary tract infections (14%), obesity (43%), and hypertension (18%). The team also discovered that two-thirds of women with symptoms had not sought care. Factors other than the physical accessibility, inadequacy in the quality and nature of available health services, and low priority that women place on their health have all contributed to women's lack of seeking treatment. This study suggests that a multidisciplinary approach to medical provision, taking women's perceptions into account is the most effective way to address reproductive health and ill health in communities of the developing world.     

The Differential Mortality of Undesired Infants in Sub-Saharan Africa

With high rates of infant mortality in sub-Saharan Africa, investments in infant health are subject to tough prioritizations within the household, in which maternal preferences may play a part. How these preferences will affect infant mortality as African women have ever-lower fertility is still uncertain, as increased female empowerment and increased difficulty in achieving a desired gender composition within a smaller family pull in potentially different directions. I study how being born at a parity or of a gender undesired by the mother relates to infant mortality in sub-Saharan Africa and how such differential mortality varies between women at different stages of the demographic transition. Using data from 79 Demographic and Health Surveys, I find that a child being undesired according to the mother is associated with a differential mortality that is not due to constant maternal factors, family composition, or factors that are correlated with maternal preferences and vary continuously across siblings. As a share of overall infant mortality, the excess mortality of undesired children amounts to 3.3 % of male and 4 % of female infant mortality. Undesiredness can explain a larger share of infant mortality among mothers with lower fertility desires and a larger share of female than male infant mortality for children of women who desire 1–3 children. Undesired gender composition is more important for infant mortality than undesired childbearing and may also lead couples to increase family size beyond the maternal desire, in which case infants of the surplus gender are particularly vulnerable.     

对我国育龄妇女生育健康状况的分析——个体指标的应用实例

本文利用 1997年全国人口与生殖健康调查数据 ,应用作者提出的育龄妇女生育健康个体指标 ,从人口、社会、经济几个方面对我国育龄妇女生育健康状况的部分影响因素进行了定量分析。分析结果显示 ,我国育龄妇女的生育健康状况及存在主要问题与妇女年龄、文化程度、居住地及社区环境密切相关。文章最后根据分析结果 ,对改善我国育龄妇女生育健康状况提出了几点建议     

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.     

Is mass schooling essential for fertility decline to begin?

The article explores the significance of mass schooling in fertility decline. Population Council researchers have investigated these links in 17 sub-Saharan African countries. Using data from the Demographic and Health Surveys for these countries, three indicators of the extent of mass schooling for 15-19 year olds were investigated: the percentage ever in school, the percentage completing 4 years, and the percentage completing primary education. Results showed that only six countries in which at least 90% of the 15-19 year olds have ever attended school; at least 75% in 8 of the countries had attended school for 4 years; and at least 60% in Botswana, Ghana, Kenya, South Africa, Tanzania, and Zimbabwe completed primary school. For the fertility transition, two indicators were taken into account for the 17 countries: the percent decline in fertility from 1960 or 1965 to the present, and the percent of currently unmarried women practicing contraception. 7 of the 17 countries have had fertility declines of less than 10%; 3 countries had less than 10%. In comparing the fertility data and schooling data, investigators found a strong statistical relationship between the percentage of 15-19 year olds completing 4 years of schooling and the phase of the fertility transition. However, other factors have played a role in the fertility decline in certain countries.     

SHORT REVIEWS

Books reviewed in this article: Rashmi Dube Bhatnagar , Renu Dube , and Reena Dube Female Infanticide in India: A Feminist Cultural History Charles Blackorby , Walter Bossert , and David Donaldson Population Issues in Social Choice Theory, Welfare Economics, and Ethics Josef Gugler (ed .) World Cities Beyond the West: Globalization, Development and Inequality Panel on Urban Population Dynamics , National Research Council , M. R. Montgomery , R. Stren , B. Cohen , and H. E. Reed (eds .) Cities Transformed: Demographic Change and Its Implications in the Developing World UNAIDS/WHO AIDS, Epidemic Update: December 2005 The World Bank Improving Health, Nutrition, and Population Outcomes in Sub‐Saharan Africa: The Role of the World Bank     

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.     

Effects of education on reproductive behavior: lessons from Pakistan

Evidence from the Pakistan Demographic and Health Survey 1990/91 (PDHS) and a 1987 study by Zeba A. Sathar and Karen Oppenheim on women's fertility in Karachi and the impact of educational status, corroborates the correlation between improved education for women and fertility decline. PDHS revealed that current fertility is 5.4 children/ever married woman by the end of the reproductive period. 12% currently use a contraceptive method compared to 49% in India, 40% in Bangladesh, and 62% in Sri Lanka. The social environment of high illiteracy, low educational attainment, poverty, high infant and child and maternal mortality, son preference, and low status of women leads to high fertility. Fertility rates vary by educational status; i.e., women with no formal education have 2 more children than women with at least some secondary education. Education also affects infant and child mortality and morbidity. Literacy is 31% for women and 43% for men. 30% of all males and 20% of all females have attended primary school. Although most women know at least 1 contraceptive method, it is the urban educated woman who is twice as likely to know a source of supply and 5 times more likely to be a user. The Karachi study found that lower fertility among better educated urban women is an unintended consequence of women's schooling and deliberate effort to limit the number of children they have. Education-related fertility differentials could not be explained by the length of time women are at risk of becoming pregnant (late marriage age). Fertility limitation may be motivated by the predominant involvement in the formal work force and higher income. The policy implications are the increasing female schooling is a good investment in lowering fertility; broader improvements also need to be made in economic opportunities for women, particularly in the formal sector. Other needs are for increasing availability and accessibility of contraceptive and family planning services and increasing availability and accessibility of contraceptive and family planning services and increasing knowledge of contraception. The investment will impact development and demography and is an adjunct to child health an survival.     

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.     

The heterogeneous effects of socioeconomic and cultural factors on fertility preferences: evidence from Rwanda and Kenya

Journal of Population Research - This research uses the latest Demographic and Health Surveys to investigate the heterogeneity of effects of socioeconomic and cultural factors on fertility...     

Interplay of rights,technology, and services explored

Recent developments in the field of reproductive health and family planning have featured key intersections among technology, services, and rights. In May 1999, the Population Council hosted a two-day meeting on rights, technology, and services in reproductive health to examine more deeply the philosophical underpinnings of the council's work. In many countries, planning pregnancies and exercising reproductive rights have been central tenets of feminist thinking and activism for decades. In other settings, fertility-regulation technologies were introduced primarily for the purpose of controlling population growth rather than facilitating the exercise of individual rights. Much of the critique of population programs has centered on violations of rights and the need to protect women in the process of testing and delivering reproductive technologies. Despite a diversity of opinions on the ethics and appropriateness of specific technologies, there is a growing consensus that women and men have a basic right to control their bodies, reproduction, and sexuality. In many places, however, people have faced barriers as they attempt to exercise these rights. Some obstacles are primarily economic, while others are physical or institutional in nature. During the meeting, participants raised many additional questions, and their exploration of these questions highlighted the ways that rights, technology, and service influence each other.     

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.     

A chronology of the study of older women's health: data, discoveries, and future directions

Women have been traditionally ignored in health and medical research. Some reasons for this mentality include a fear of harming a woman's reproductive ability, fear that variations in the menstrual cycle could confound results, fear that a woman's body could not withstand the rigors of clinical research, and an assumption that male and female body chemistry is similar. Thankfully, these fears and assumptions are being challenged and several major data-bases, designed specifically to study women's health, have emerged. The purpose of this paper is to: (1) characterize the major longitudinal studies on women's health, (2) summarize the major discoveries from these studies that are relevant to older women, and (3) pose several future directions for research throughout the paper.     

Does female circumcision affect infertility and fertility? A study of the central African Republic, Côte d’Ivoire, and Tanzania

This study explores the association between female circumcision and infertility and fertility, using information from the Demographic and Health Surveys (DHS). In Côte d’Ivoire and Tanzania, circumcised women had lower childlessness, lower infertility by age, and higher total fertility rates than women who were not circumcised; the reverse pattern prevailed in the Central African Republic. In all three countries, however, circumcised women grouped by age at circumcision did not have significantly different odds of infertility nor of having a child than did uncircumcised women, when the effects of covariates were controlled. Thus we find evidence suggesting that the practice of female circumcision does not have a statistically discernible effect on women’s ability to reproduce.