Family planning as preventive health measure

The link between health and family planning efforts in the Philippines goes back to the beginnings of the National Population Program. In this interview, Dr. Dumindin of the Ministry of Health (MOh) discusses the impact of family planning on health. The family planning program of the MOH, since its inception in 1970, has undergone expansion and taken new initiatives and directions to meet the changing needs of the target clientele. Family planning information, education, and motivation is provided and maintained during routine prenatal, natal, and postnatal clinic and field activities. As of January 1986, the MOH had a total of 2100 clinics--rural health units, medical centers, hospitals, mobile clinics, and special clinics--all over the country. It is estimated that the Ministry's family planning activities have averted around a million births. It is hoped to extend the coverage of the programs to areas that have not been reached before, through further community involvement, by enlisting the participation of more workers in the community, training them on integrated health and family planning services, setting up more service facilities and clinic extensions, and by improving contraceptive use-effectiveness. Hopefully, the Philippine people will become less program-dependent and more self-motivated, and they will recognize the need for birth spacing, birth limiting, and total health care--not as suggested from the outside, but coming from within themselves.     

Village family planning: the Indonesian model

The goal of the Indonesian National Family Planning Program is to reduce the 1970 birthrate by 50% by the year 2000. Since the late 1960s the government has taken an active role in family planning. The National Family Planning Coordinating Board initially concentrated on offering family planning services through health clinics on Java and Bali, but, as of 1974, family planning has been expanded to 10 provinces in the outer islands. Early in 1975 the family planning program was extended to the village through the establishment of village contraceptive distribution centers and sub-village family planning groups. The experience generated from the initiation, development and evaluation of the village family planning scheme is useful in many aspects which may be adapted in other countries of the region. The guiding concepts of Java and Bali village family planning have been non-standardization, maintaining a link to the clinic in the movement to the village, and focusing 1st on contraceptive resupply. The following conclusions can be drawn on the basis of the Indonesian experience with village family planning: 1) family planning at the clinic level alone is insufficient in the long run; 2) the village must become involved in the process of providing services; 3) the enthusiasm and imaginative response to the movement in the village has exceeded expectations; and 4) rural people are, in fact, future oriented.     

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.     

Corporate clinics take on a new role

The Philippines Department of Labor, in conjunction with the U.N. Fund for Population Activities, is sponsoring a pilot family planning program. The industrial program, supervised by the Labor Management Coordinating Council, aims at integrating family planning services into the health services or clinics of 1000 corporations with at least 200 employees within the 2-year period ending June 1977. Family planning seminars are conducted at 3 levels within the corporations and include training sessions for medical personnel. Companies have found that provision of family planning services is more economical in the long run than provision of family welfare services for employees and families.     

Integrating family planning with nutrition and parasite control

At the Inter-Governmental Coordinating Committee Workshop on an Integrated Approach towards Family Planning and Health Programs held at Kuala Lumpur from March 23 to 25, 1977, the feasibility of integrating family planning with nutrition and parasite control through the proper planning of motivational considerations, resource allocation and coordination was studied in detail. Discussion focused on the experience of participating countries in generating community participation in total health programs. Malaysia reported that in the expansion of the national program into the rural areas functional integration has been the approach. In Indonesia nutrition has been an important objective of maternal and child health services. A total integrated development approach has been the objective in the Philippines where family planning information-education-communication has been integrated with nutrition programs and a pilot project on integration of family planning and parasite control has been conducted. Thailand reported on the introduction of an integrated family planning and parasite control program, while Sri Lanka reported on an integrated approach that included family planning with maternity and child health services. A recommendation of the meeting was that experimental pilot projects be established which include nutrition and parasite control elements within the framework of family planning services.     

Total maternal and child care: an approach to the population problem

This article describes the Bohol Province Maternal Child Health/Family Planning Project, a 5-year project financed by the United Nations Fund for Population Activities and the Philippines Department of Health. The objectives of the project are to improve general health services, introduce family planning services in the context of the MCH program, improve training of personnel and evaluated the results of the program. 88 barrio health centers have been established, offering a range of maternal, child health and family planning services. 34 boticas (drugstores) have been set up in local variety stores, dispensing drugs at low cost. A strong research unit collects data for program evaluation and has so far published 23 reports, which are listed at the end of this article. Community acceptance of the program has, in general, been good; midwives have been welcomed. The program has encountered problems of religious conservatism and insufficient contraceptive supplies and has learned the need for good relations with the barrio leaders and residents. The 5-year limit needs to be extended. Progress in health services has been excellent. The effect on family planning, while encouraging, cannot yet be evaluated.     

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.     

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.     

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.     

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.     

计划生育家庭福利政策改革思路研究

随着经济体制变革、社会结构变动、利益格局调整等不断深化,传统家庭功能面临严峻挑战,计划生育家庭问题尤为突出。家庭是国外为数不多的福利扩张领域,也应是我国福利"增长"的优先领域。计划生育家庭福利改革框架包括三个层面:一是针对因执行计划生育国策而产生的确定性风险或不足,在养老保障个人账户下建立计生子账户,实现国家补贴直接送达家庭;二是针对因特有概率事件而形成的不确定性风险建立政策性生育保险,并覆盖农村育龄群体;三是明确计划生育/生殖健康服务作为国家基本公共服务的属性。     

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.     

Sri Lanka: current status of family planning

In Sri Lanka the family planning program is closely related to socioeconomic and cultural variables. The expectation is that in the near future family planning will be included as a component of a network of social services. The official program is a response to the economic necessities and welfare demands of individuals and families. The method of family planning most frequently requested is female sterilization, and no attempts are being made to direct people to other methods. 12 United Nations Fund for Population Activities assisted projects have provided the framework and basis for the institutional coverage of family planning activities in Sri Lanka. However, the experience of these projects revealed a lack of facilities, shortage of personnel and management inadequacies, all related to the delivery of family planning services. The following steps are suggested as a means of overcoming the current problems and expanding the program: 1) establish a pattern of interacting relationship between the mass media, community health education and the available services; 2) provide an operational approach to program management, monitoring and periodic reviews of the program; 3) involve the private sector health facilities; and 4) incur additional capital cost to increase the capacity for delivery of better health facilities and personnel.     

Malaysia implements the integrated approach

Malaysia has implemented an integrated approach in providing family planning services to eligible couples. In 1964 the government of Malaysia adopted a national family planning program, and implementation began in the urban areas and extended into the rural areas. Other agencies are involved in providing family planning services and information including the Federation of Family Planning Associations, the Ministry of Health, the National Family Planning Board, and the Federal Land Development Authority. The number of women practicing contraception has increased from 20,726 in 1967 to 533,646 by 1976. and other methods, 3.9%, respectively. There has been an increase in the percentage of acceptors between ages 15-29 from 56% in 1968 to 71.3% in 1975. The 2nd Malaysian national plan will use a multidisciplinary approach to the problem.     

Pakistan: FPAP projects reflect integrated approach

The Family Planning Association of Pakistan has conducted a number of projects reflecting the government's integrated approach to family planning. The youth project aims at alerting young people to the need for family planning. A full-scale feasibility scan was conducted prior to implementation of the project to determine the best way to reach people. Volunteers were recruited among college students. The project's strategy for 1979 included organization of a youth leadership national workshop and oratorical contest on the topic, "Whatever your cause, it is a lost cause without population planning." Other FPAP projects include a group of "better living projects" which aim to educate young mothers in child care and family nutrition. Projects in the organized sector include a program at the Pakistan Mint, where a motivation center and clinic are set up. Training projects concentrate on fieldworkers and traditional birth attendants (dais). A 3-day course for dais includes reorientation on septic deliveries, child care, maternity care, and record keeping. In the cities, FPAP has a network of multipurpose centers in slum areas, where adult education and income generating activities are integrated with family planning.     

To the barrios] The new course charted by the national population program

In order to reduce the Philippine birthrate to 2% by 1980, the number of rural women practicing contraception must be trebeled. To facilitate such an effort, a large-scale reorganization and reorientation in all areas of family planning activity--delivery, training, research, information, education, and communication--is proposed, shifting the delivery of family planning services from clinics to the 36,000 barrio bases. A goal of 16,000 extension workers in family planning is set for 1976; these workers will be the ones to make the initial contacts with potential acceptors. Then full-time family planning workers will try to make potential acceptors into bonefide ones, giving advice or prescribing the method and providing follow-up. Family planning workers will be supervised by nurses and midwives in health stations, who in turn will be supervised by the physician in the rural health unit. Acceptability among community residents is the most vital characteristic of a family planning worker, with the country's 27,000 hilots (birth attendents) seen as leading candidates. Attracting and training manpower in the field is a major challenge, as is lack of personnel in the area of research. Several possible avenues for the development of research interest and manpower for the population program are explored.     

Integrated family planning/parasite control project: a different approach to community health problems

An obstacle to the acceptance of family planning is the fact that its advantages are not immediately apparent or tangible. A way to get around this obstacle is through the use of "entry points"--projects which yield tangible results in a relatively short time. Through these entry points, the fieldworker builds credibility and wins the confidence of the people in the community he or she is serving. Thus, when the time comes, the people will be receptive to the family planning message. This strategy of the use of entry points is common to integrated projects with a community development program becoming a sort of entry point for family planning fieldworkers. 1 such project, begun quite recently by the Family Planning Organization of the Philippines (FPOP) in 4 pilot sites, uses deworming as an entry point. It is officially known as the Integrated Family Planning/Parasite Control/Nutrition Project. It is 1 of several projects cosponsored and financed by the Japanese Organization for International Cooperation in Family Planning (JOICFP) and the Asian Parasite Control Organization (APCO) in almost a dozen other Asian and Latin American countries. The immediate objective of the project is to establish or increase the credibility of family planning fieldworkers among the people in a target area. Fieldwork connected with family planning is conducted alongside a related community health effort that can produce immediate and visible results. The ultimate goal is to encourage community participation to such an extent that there will no longer be a need for the fieldworker. Strategic planning involves thinking up the "backbone" and molding the "skeleton" of the project, i.e., its concept and basic policies. As the project goes into the design and development stage, additional people are drawn into it. Project experience in Thailand underscores the need to consult with local leaders. The earliest projects were initiated in 1976, but some are already showing successful results. The overall Philippine experience provided support to JOICFP Director Kunii's reiteration of his belief in the effectivity of parasite control as an entry point for population planners. Integration of the nutrition element in the project is regarded as essential.     

Focus on family planning measures

A blueprint for responsible parenthood titled "The Tokyo Initiative" was drawn up at a conference sponsored jointly by the Japan Science Society and the Population Crisis Committee in April 1977. Representatives of several U.N. agencies and nongovernmental organizations participated. The blueprint urges additional resources to make family planning services available in rural areas and unserved areas of cities. Expanded social and economic roles for women were also recommended since it was felt that unless women were allowed to participate in family and community decision-making, "programs for responsible parenthood will be doomed to failure." Adolescents should be educated about reproductive behavior, stressing the adverse effects of early pregnancy. Integrated family planning services which serve the cause of infant and child health and total responsibility for program design be placed as close as possible to people affected. The conference then issued a call for action to implement these family planning objectives.     

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.