Injectable contraceptives: how safe are they?

Controversy still surrounds the use of the injectable contraceptive, Depo-Provera, in 3rd world countries, when it has yet to be approved in the US, Canada, Japan, and other developed nations. Some medical professionals maintain Depo is both safe and effective and could curb rapid population growth worldwide. With no conclusive decision made, some countries have approved Depo while others have not yet decided. Originally approved for a variety of uses, Depo is approved in the US only as a treatment for advanced endometrial cancer; however, it is now available in 65 countries and is used as a contraceptive in the Philippines. Depo and its companion Norigest are both progestonogenic injectables and were developed in the late 1950s. Injectables inhibit ovulation and thicken cervical mucus, thereby preventing fertilization. The reservoir usually lasts from 3-6 months, and its action cannot be reversed until the body has completely absorbed the drug. Injectables are highly effective; most accidental pregnancies occur shortly after the 1st injection before the drug has taken effect or at the end of an interval when its effect is wearing off. Overall the rate of fertility return corresponds to the rates for the pill and the IUD. Injectables have the advantage of preventing side effects brought on by estrogens; thus they would be beneficial to women desiring to use contraception but who cannot manage pill side effects. They do not interfere with lactation and have the lowest failure rate of the reversible methods. Important to developing countries is that injectables require no effort on the part of the user. Injectables do disrupt the menstrual pattern and Depo use often results in weight gain. Little is known about the longterm risks of Depo; however, in 1973 the US Food and Drug Administration withdrew approval of Depo for pregnancy-related uses because of links to birth defects. Other recent studies have uncovered other possible effects including uncertainty about whether injectables affect the composition of breastmilk or whether they raise blood glucose levels. Ethics have entered into the controversy with the "contraceptive double standard" where Depo has been exported to 3rd world nations when it has been ruled unsafe for American women. Campaigns have been organized against the distribution and use of injectables in the developed nations and a few in the 3rd world have begun to organize. While the Philippines has approved Depo, it is not yet considered an official method of the National Population Program. Policymakers await a more thorough analysis of factors for and against the promotion of the drug.     

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.     

The population program shifts to 'high-scenario' targets

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

Family planning in choiseul province,Solomon Islands

The results presented are from a rural prevalence survey on family planning in Choiseul Province, Solomon Islands. Married women aged 15–49 years with at least one living child and married men whose wife met the same criteria, provided data on knowledge, attitudes and practices of contraceptive use. Fifty one per cent of the female sample were using some form of contraception, 26 per cent reversible and 25 per cent non-reversible methods. Sixty-five per cent of men claimed that they or their spouse were using a method of family planning. Tubal ligation was the most common currently used method (25 per cent in the female survey). Desired family size was four for both males and females. Knowledge and approval of family planning was high, with 83 per cent of females and 81 per cent of males knowing of at least one method. Problems in accessing information and services for family planning include cultural and logistical constraints. Religious affiliation was the major variable affecting knowledge, use and approval of contraceptive methods. Nearly a quarter of the sample lived further than two hours travel time from the nearest health clinic supplying contraceptive methods. These clinics often have only an intermittent availability of supplies. A strong interest in family planning was demonstrated by both respondents and service providers.     

Breastfeeding women and family planning programs: special needs and opportunities

Although breastfeeding makes a major contribution to fertility control and child spacing in many developing countries, the implications of this are not widely recognized. Terminology may be part of the reason. Contraception may imply something modern, whereas the contraceptive effect of breastfeeding is a natural biological mechanism. Also, many family planning program managers are educated in the West, where breastfeeding is of little contraceptive importance. Regardless of where they were educated, they may consider the pregnancy-postponing effects of breastfeeding as mythology, or may consider breastfeeding as sufficiently effective at the individual level. Breastfeeding as a family planning method cannot be "delivered" to women by family planning methods, and requires an educational approach rather than a clinical or medical approach. A women might use breastfeeding more confidently in avoiding an unplanned pregnancy if she begins using a contraceptive method as soon as she resumes menses, when she begins giving her baby food supplements, or by 6 months post partum--whichever comes first. She can achieve high effectiveness in avoiding pregnancy by keeping the baby nearby and feeding on demand, feeding frequently, sleeping near the baby and maintaining nightfeedings, not giving the baby bottles or pacifiers, and giving the baby only breastmilk for at least 4 months. Breastfeeding can only be used by new mothers and cannot be used to postpone the 1st birth. Nor is it appropriate for women who have attained their desired family size, or who wish to avoid or postpone pregnancy at any cost.     

Estimating unmet need for contraception by district within Ghana: an application of small-area estimation techniques

The importance of meeting the unmet need for contraception is nowhere more urgent than in the countries of sub-Saharan Africa, where the fertility decline is stalling and total unmet need exceeds 30 per cent among married women. In Ghana, where fertility levels vary considerably, demographic information at sub-national level is essential for building effective family planning programmes. We used small-area estimation techniques, linking data from the 2003 Ghana Demographic and Health Survey to the 2000 Ghana Population and Housing Census, to derive district-level estimates of contraceptive use and unmet need for contraception. The results show considerable variation between districts in contraceptive use and unmet need. The prevalence of contraceptive use varies from 4.1 to 41.7 per cent, while that of the use of modern methods varies from 4.0 to 34.8 per cent. The findings identify districts where family planning programmes need to be strengthened.     

Why women who don't want to get pregnant don't use contraception

In the developing world about 120 million women have an unmet need for contraception. They want to postpone childbearing, yet they do not use contraception, often because of the unavailability of services and supplies. However, according to a recent article by John Bongaarts, the primary factors are lack of knowledge about a contraceptive method, concern about side effects, and the disapproval of the male partner in developing countries. Lack of knowledge means inability to describe the uses of a contraceptive, its side effects, and the locale of its availability. An approximate knowledge index was calculated for such women, which showed that knowledge level positively correlated with contraceptive prevalence. Countries where the index was below 50% had a contraceptive prevalence of 8% only. The determinant reasons why women were reluctant to use the pill, IUD, and sterilization had to do with health and the fear of side effects, such as nausea and increased bleeding. The contraceptive prevalence among these women was reduced by 71% for the pill, 86% for the IUD, and 52% for sterilization. In Sub-Saharan countries nearly 70% of women cited partner disapproval of contraception, although they had never discussed family planning with their partners. The central concept for reducing unmet need is access with quality, which means that services are voluntary, safe, and appropriate in delivery. Some of the recommendations to reduce the unmet need for contraception include: one-on-one same-sex discussions to increase contraceptive knowledge and acceptability; sensitive responses by programs to their client's health concerns; support by service providers to women negotiating with male partners in order to mitigate male disapproval; and sex education and family planning services to reduce unwanted and early sexual contact and pregnancy while girls develop identities apart from mothering roles.     

The dynamics of contraceptive adoption in Bohol,Philippines: 1976-1978

A researcher analyzed 1976 and 1978 data on 414 rural women who had never used a family planning method to prevent pregnancy and lived in the predominantly Catholic island province of Bohol in the Philippines to look at the influence certain aspects of the family planning program, begun in 1976, as predictors of changes in contraceptive behavior. 34.5% accepted contraception between 1976-1978. The researchers learned that couple traits (e.g., age, income, education, and religiosity) had only an indirect effect on change in contraceptive behavior. A desire to stop, limit, or space births (motivation) was a strong predictor of family planning method acceptance (p.001). Further couples who clinic providers contacted the most often or who had received more family planning services (services) were much more likely to use contraceptives (p.001). Indeed a significant relationship existed between motivation and services (p.001). Moreover couples who were truly motivated to use family planning methods did not let distance to family planning services prevent them from seeking these services (p.001). On the other hand, couples who confronted personal obstacles to family planning including social, psychological, and other subjective costs (cost index) tended not to accept family planning methods (p.001). A negative association existed between services and location of households vis a vis the intervention program (p.001) which indicated that the program did have an effect in the area of the province where it was located. In conclusion, the strongest predictors of change in contraceptive behavior included motivation, services, and cost index. Services and cost index indicated the great importance of interpersonal and/or client staff contact, especially since they were more important in influencing behavior change than distance and family planning site.     

Men and family planning: toward a policy of male involvement

The stated aim of this discussion is to examine the extent of male use of family planning and the nature of men's role in family planning in developing countries. Case studies are presented which are successful examples of strategies for involving men in family planning. Policies that aim to increase male involvement must be sensitive to cultural values, apply to a decentralized government approach toward information and supplies, include adequate political will, and consider the costs and benefits of changing values. A male family planning policy would not always be compatible with all fertility values in developing countries or traditional values of the older population. A policy should stress the value of male individuals contributing as much as possible for their own and others' welfare. Community participation is considered important in order to create a feeling of mutual support. A sizeable investment will be required for mass distribution of contraceptive information. Schools are viewed as an ideal place for educating youth about the problems of high fertility and about use of family planning methods, such as the condom. Religious organizations should be used to educate people about responsible parenthood and to minimize barriers to use of modern contraception. Comic books on how to use condoms are suggested as a good source. Local authorities who are trusted are useful in influencing acceptance among local populations. Local personnel may be trained as information disseminators. Adequate contraceptive information needs to be supplied to a wide audience. Lack of supply and inadequate information are given as two key reasons for insufficient use of male contraception. Condoms should be priced to be affordable to the average person and free to those with no income. Program strategies that proved successful are cited for Thailand's Mechai Viravaidya program and Bali's grass-roots program. The vasectomy program in Bangladesh is also noted for its success. Low levels of condom use are attributed to factors such as price, education, availability, accessibility, culture, religion, and economic conditions. Male sterilization levels can be enhanced with wider availability of clinics and provision of correct information for challenging beliefs that vasectomy is a form of castration.     

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.     

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.     

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.     

Reducing unsafe abortion in Kenya

In Kenya, where abortion is permitted only to save a woman's life, unsafe abortion accounts for over one-third of maternal deaths and hospital emergency rooms are overcrowded with women suffering complications of induced and spontaneous abortions. Postabortion care, a service linking emergency treatment of abortion complications with family planning counseling and comprehensive reproductive health care, is under review by the Population Council as a method of reducing maternal mortality and morbidity as well as the incidence of repeat unsafe abortion. An operations research study conducted by the Kenyan Ministry of Health identified several obstacles to such care: lack of information on abortion management, limited service provider skills, inconsistent supplies, and a lack of empathy for women presenting with incomplete abortion. Although 86% of abortion patients from 6 Kenyan hospitals expressed an interest in contraceptive counseling, only 5% reported actually receiving such information. As part of the operations research, these 6 hospitals introduced postabortion care, including, in 3 hospitals, use of manual vacuum aspiration. All 6 hospitals provided contraceptive counseling and psychosocial support. Based on the success of this experience, the Ministry of Health is considering introducing postabortion care to all hospitals in Kenya.     

The child survival hypothesis

Summary Because of current interest in the child survival hypothesis, we have reviewed available evidence bearing upon the relationships of infant and child mortality to fertility and contraceptive behaviour. The evidence is drawn from time series data for local and national vital events, from special in-depth studies of the infant mortality-fertility relationships in family formation, and from service statistics from health and family planning programmes. As a result of this review, we suggest five clarifications which should be made in redefining the child survival hypothesis and assessing its potential programme implications. The child survival hypothesis states that improved child survival will contribute to increased family planning motivation and consequent fertility decline. The evidence presented here suggests that the effect is not automatic and probably not a necessary pre-condition for fertility decline. There is certainly not a reflexive one-to-one replacement, but a partial effect may still be important. In the clearly demonstrated reduction in inter-pregnancy intervals after a child death, the major component is undoubtedly the removal of the biological protection of lactational amenorrhoea. A separate but somewhat smaller effect has been demonstrated in situations where lactation did not seem to have been the explanation. It is expected that increased child survival will contribute to fertility decline mainly in countries experiencing rapid mortality decline and population growth. The replacement of children who die is probably not so much 'volitional' as a result of alterations in sub-conscious expectations. It is apparent that in traditional agrarian populations, few direct and manipulable means of influencing motivation for fertility limitation are available, and, therefore, it must be stressed that integrated health and family planning programmes do provide opportunities for immediate programme development. By making parents aware of improved changes of survival through health services in which they develop confidence, the spontaneous linkages between mortality and fertility can presumably be reinforced. Family planning services must be provided as an essential initial step in programme development, but they can be made more effective, as well as politically more acceptable if appropriately integrated with maternal and child health and nutrition services.     

Age-old methods of contraception

Folk methods of contraception have been used in Philippines from immemorial times, especially in the rural areas. Some methods seem to be practical while others are mystical. The popularity of methods are due to their low cost and the trust women in the community feel for the traditional healer. Herbs are the most commonly method used. For external application, pounded and heated leaves are placed inside a bag. Traditional practitioners believe that when the "charm" is worn during intercourse, the semen will "dropout" of the vagina. For internal application a beverage is prepared with seeds of the plant and drunk before sexual intercourse. For contraceptive purposes other herbs used in rural communities could induce abortion, which is illegal in Philippines. A projected study by the University of the Philippines' College of Medicine will try to establish the pharmacological effectiveness of local plants to determine the validity of some methods of family planning reported by medical students who have talked to rural herbalists and patients. The one which seems most relevant for this study is the herb Kibatalia Gitingesis, which is supposed to contain "progesteronal-like principles." Other methods of contraception are abdominal massage, which involves manual manipulation of the uterus, chemicals, like asoge (mercury), salt, and tablets, and the use of inanimate objects, such as the bato-balani or magnetic stone. If herbs and other folk methods of contraception are proven to be effective, the possibility to have them incorporated into the National Population Program has to be considered. The untrained hilots (nurse midwives) could become trained program workers, and because of their influence in the community the number of acceptors would increase.     

Expanding contraceptive choice: findings from Zambia

The Population Council's Expanding Contraceptive Choice program works to increase the contraceptive options available to women and men in developing countries. To achieve this goal, the Council is pursuing a new approach, one which begins with an assessment of contraceptive needs from which recommendations for upgrading contraceptive services are based. This new approach was tested in four countries including Zambia in which Stage I--contraceptive needs assessment--was completed. Results of the assessment indicated that despite the efforts of the national family planning program, 33% of Zambian women who do not want to get pregnant do not practice contraception. Only 9% of women use a modern contraceptive method. These results suggest that there is a need for introducing new contraceptive technologies and for expanding utilization of existing methods in the country. Also, stage I assessment yielded other positive outcomes which are enumerated in this paper. In response to this report, the Zambian government decided to proceed with stage II research on the viability of introducing new and underutilized contraceptive methods into the national family planning program.     

Full-time workers reach out to the villages

The Philippine Commission on Population (Popcom) has fielded 2721 fulltime outreach workers (FTOWs). The FTOWs are the outcome of a shift from a clinic-based, motivation-oriented family planning effort to the Rural Outreach Program which is part of the new Total Integrated Development Approach (TIDA). Organizationally, the workers are under local government supervision and their purpose is to make the family planning program more responsive to community needs. This article profiles the average FTOW, describes recruitment and training procedures and discusses problems of the program -- funding, transportation, inadequate training, lack of educational materials, shortage of contraceptive supplies -- and possible solutions.     

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.     

A sound population program

A sound population program must respond to real human needs, must be rooted in values, must generate results, must be administered in an integrated manner, must be based on the ethic and goal of self reliance and on the belief that it must operate and grow on its own steam, and must release human resources for productive economic endeavors. To make any sense at all, population must be linked to the gut level needs of the individual. People should not be viewed as demographic statistics, and the word human should be used in the basic sense of hunger and poverty. If the goal is to bring about lasting change in the way that Filipinos manage their lives and their living, it is necessary to probe their values. If social change is the goal, tradition must be challenged. In the area of family planning, persons who can communicate the fact that the program seeks to enrich life more than prevent birth must be chosen. There has been some criticism that the population/family planning program is "too contraceptive oriented" and too mechanistic in the approach to population. Contraception is behavior, a good measure of acceptance and an effective measure of commitment. The delivery of welfare must be horizontally integrated. Thus it is necessary to learn to work in teams, teams of development workers. The value of self determination and the conscious practice of planning and shaping one's life is the very logic of family planning. The program needs to implant the values of family planning firmly in the community, or, more accurately, in the small face to face primary groups where social norms are set and where change must take place if it is to last. The answer to how to achieve a sound population program lies less in what is done than how it is done.     

Comprehensive services at Fabella Center

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