NFP promotion in the Philippines: all program components covered

At least 50 of the 105 agencies in the Philippines listed in the "Directory of Agencies with Population Activities" are actively participating in the promotion of natural family planning (NFP). Of these, 40 offer instruction on its use, 22 provide training to clinic personnel or field workers, 19 conduct information/education/communication (IEC) activities, and 6 undertake research. The Population Center Foundation's (PCF's) Information Support to Population Projects (ISP) has prepared a preliminary inventory of programs and projects on NFP, covering some of those that were done in recent years, are being implemented, or have been proposed. Some projects described in the inventory are reviewed. Recent research or research proposals are showhow related, all leading to how the method can be effectively promoted and how couples can be taught its proper use. Instruction on NFP appears in all training activities of Popcom's regional offices, particularly in their refresher courses. Program managers are being trained in managing and monitoring activities to promote the method. In 1980 outreach workers, doctors, nurses, and midwives were trained by Popcom to motivate couples to practice the method and to teach them how to use it correctly. That same year, Popcom's office in the Ilocos region introduced the rhythm dial calendar, a simplified version of the rhythm slide rule. The Ministry of Health National Family Planning Office incorporates natural family planning instruction in its training seminars for the Ministry's health personnel in the regions. As in training, all regional offices of Popcom promote NFP along with other methods that they make available to prospective acceptors. This is in keeping with the program's "cafeteria approach" to family planning. In 1982 Popcom began intensifying the provision of services in NFP, allocating around 4 million pesos to preparations for its effective promotion. In support of service delivery efforts are IEC activities such as the development, production, and distribution of brochures and other reading material on NFP, schoolroom instruction, and lectures. The intensification of IEC efforts in the private sector to promote the modern and scientific techniques of NFP is most clearly evident in a fairly recent seminar sponsored by the Communication Foundation for Asia. Program agencies with activities in natural family planning are listed.     

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.     

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.     

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.     

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.     

Republic of Korea. Country feature

The Government of Korea's 5th 5-Year Economic and Social Development Plan (1982-86) seeks to reduce the population growth rate from its 1982 level of 1.58% to 1.49% by 1986; it is assumed that the population replacement level of fertility (total fertility rate, 2.1) will be attained in 1988. The task of achieving these demographic targets is expected to be made more difficult by factors such as the impact of the 1950s baby boom and widespread son preference. New population control policy measures announced in 1981 call for improvements in the current family planning program management system; a new social and institutional support system to inculcate the small family size norm; strengthened information, education, and communication activities for family planning; and establishment of coordination among the government organizations involved in population-related activities. Numerous social support measures have already been put into effect, including income tax exemptions for up to 2 children, inclusion of population education in the school curriculum, priority in alloting public housing to sterilization acceptors with 2 or fewer children, and provision of IUD services through the medical insurance system. The number of contraceptive acceptors in the government program increased 78.3% from 1981-83, from 614,000 to 1,094,600. Sterilization and menstrual regulation services have shown particularly sharp increases. Program achievement for 1983 was equivalent to 19% of eligible women ages 15-44 years. The total fertility rate stood at 2.7 in 1982. Major efforts now must be directed toward eradicating the strong parental son preference and ensuring better family planning program efficiency and effectiveness.     

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.     

Combining vertical service with horizontal service to promote family planning]

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

Satisfied users clubs: family planning acceptors as model agents of the program

The National Population Program in the Philippines has encouraged family planning acceptors to shift from their passive role as recipients of family planning services into an active role as program participants. In the mid 1970s the Commission on Population (Popcom) began setting up satisfied users clubs in various regions of the country with the aid of the Ministry of Social Services and Development (MSSD). Other government institutions like the Ministry of Labor and Employment (MOLE) formed similar family planning groups. So did private agencies participating in the Program. There were indications at that time that community based family planning clubs could help the Program in informing couples about family planning and in motivating them to practice contraception. In 1977 a study conducted by the University of the Philippines Institute of Maternal Clinic found that family planning acceptors in Dumaguete City received social and psychological support from local barrio women's clubs. A 1978 Community Outreach Survey indicated that full time outreach workers (FTOWs) found statisfied users clubs helpful in increasing the number of new acceptors in their areas and in bringing down the number of family planning dropouts. Once a decision to create a club is made, club organizers meet with the barangay captain and his council to get their approval and seek their cooperation in inviting people to join the proposed club. Once the approval is given known family planning users in the community or mothers of reproductive age are invited to attend a community assembly. Of 59 clubs surveyed, only 10 had a formal constitution and bylaws. All clubs elected their officers and conducted monthly meetings which lasted from 2-4 hours. The main selling proposition of the clubs is the involvement of members in nonfamily planning activities like income generating schemes, skills training, nutrition seminars, and immunization of children. 81% of the officers of all 59 clubs were family planning acceptors. The majority of officers had undergone voluntary sterilization. Only 8 of the 59 clubs considered themselves single purpose clubs committed to the promotion of family planning. The other 51 were multipurpose organizations, with both family planning and nonfamily planning activities. In the area of family planning, the club's objectives were to increase family planning acceptors, disseminate family planning information, and maintain current users.     

Pakistan: re-organization at the top

New measures for population program planning have been introduced in Pakistan. 3 wings were added in the Population Planning Council: administration, coordination, and planning; operation; and technical. New elements in the program include: 1) setting up of new directorates; 2) opening of more family welfare clinics, model clinics, and sterilization centers; and 3) expansion of training facilities for medical and paramedical personnel. 2 national training institutions have been established: the Population Training Centre at Lahore, and the National Institute of Advanced Training at Hyderabad. 16 centers have training courses for doctors performing sterilization. There has been a restructuring of the information, education, and communication aspects of the program. The commercial distribution of contraceptives has become an important element. There are efforts to relate the program to other development programs.     

NFP update: researcher cites need to improve instruction

In the Philippines more and more couples are practicing natural family planning (NFP), but there is a need to improve instruction on this method to increase its effectiveness. Calendar rhythm has been the most popular technique of NFP, but failure rates have been high. This could be changed by improved calendar rythm instruction and the introduction of newer, more effective natural techniques like the basal body temperature, cervical mucus, and symptothermal methods. Dr. John E. Laing, in a paper entitled "research on Natural Family Planning in the Philippines," examines the trends in NFP and summarizes major findings of past research related to NFP and the status of current research. It also discusses the implications of such findings for the National Population Program and the needs for current research. Cting World Fertility Survey (WFS) data on 19 developing countries, Laing states that the Philippines is second only to Peru in current and past use of the rhythm method. He also indicates that since the start of the National Population Program in 1971, rhythm has been offered as an official program method. Yet, in the early years of the program rhythm was not promoted as actively as the other family planning methods. In the last few years, program, officials have become more interested in NFP. 1976 National Acceptor Survey (NAS) data showed that rhythm reduced fertility by 78% compared to the condom's 79%, oral contraceptive's 94%, and the IUD's 98%. A comparison of data from the 1972, 1974, and 1976 NAS indicated a decline in continuation rates and an increase in overall pregnancy rates for all methods except rhythm. The overall pregnancy rate of rhythm declined, but there was no significant change in continuation rate. Laing suggests that probably, while the national population program was increasingly recruiting less motivated couples to try other methods, the rhythm acceptors, who were largely self initiated, mantained earlier levels of motivaton. Evidence points to the widespread use of crude formulas that do not take into account individual variations in cycle length. Many users do not even fully understand the mechanism by which rhythm affects fertility. There is also little knowledge among acceptors of the new and more reliable techniques of NFP for identifying the safe and unsafe periods. Despite problems, a considerable number of acceptors still prefer rhythm to other methods. The commission on population has embarked on a solution to some of the problems by committing itself to the training of volunteers of community-based organizations, particlarly lay leaders. 3 large scale projects are planned for this purpose.     

Magdamayan: drawing the family into community work

Magdamayan is an old word meaning to help one another; it has been chosen as an acronym for a program currently being undertaken by the Family Planning Organization of the Philippines (FPOP) that addresses itself to family life and community development -- a departure from previous FPOP projects. It aims to reach out to rural villages through 44 chapters covering selected communities in the 3 major island groups. Its main objectives are to reach the majority of the eligible population in each village, increasing the awareness, knowledge and understanding of family planning; to enlist 80% of eligible couples; and to maintain a 90% continuation rate. The 1st cycle of the project activities was begun in July 1975, divided into 3 phases spread over 18 months. Phase 1 involved preparations for the project in the villages, including a baseline survey. Phase 2 was the actual program phase, including a mass information drive, contraceptive promotion, identification of target groups, training of motivators, and provision of backup services. Phase 3 involved the phasing out of FPOP staff and turning the project over to community volunteers, and evaluation. Among the activities employed to facilitate integration of family planning into community life were 57 vocational skills training courses, various income generating activities (dances, sporting events, raffles) and community development projects. Preliminary evaluation of the 1st cycle indicates impressive success, but below the 80% acceptance and 90% continuation rates. Community development activities were seen as much enhanced, and basic health services and vocational skills training were successfully introduced. Constraints identified as limiting the success are discussed, and it is concluded that the program's performance this far is good enough to warrant its use as an alternate or model for similar family planning projects.     

Natural family planning: A comparison of continuers and discontinuers

Little research has been done on social-psychological variables related to the use of natural family planning. The objective of this study was to analyze variables that differentiated between continuers and discontinuers of natural family planning (NFP). Questionnaires were obtained from couples who had received instruction in the sympto-thermal method of natural family planning at a large urban hospital. Subjects who were attempting to become pregnant or who were using other methods of contraception in conjunction with NFP were deleted from the analysis, leaving N of 74. With Pearson correlation, variables significantly related (p<.05) to NFP continuance were: religiosity, planning more children, perceived severity of pregnancy, support from spouse and relatives, dissatisfaction with other contraceptive methods, attitudes toward NFP, perceived effectiveness of NFP, attitudes toward abstinence, and importance of intercourse.     

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.     

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.     

Depo-Provera: clarifying the issues

In this interview, deputy executive director Ester B. Sy-Quimsiam of the Commission on Population talks on Depo-Provera, the latest method officially accepted by the Philippine Population Program. Medically, Depo has been proven to be safe, effective, long-acting, and reversible. A single dose of this drug can prevent a woman from pregnancy for 3 months. In clinics where the nurse or the midwife is trained in comprehensive family planning technology the drug will be introduced. Clinics in areas where prevalence of the more effective method is low must be targeted. Managers, supervisors, trainers of service providers, and fieldworkers will be trained to implement the information and education campaign and generate demand among married couples of reproductive age who are most eligible for Depo. Family planning services will continue to be subsidized by the program, but the cost of contraceptive supplies will be shared by the user. But there will still be subsidized supplies for those who cannot afford them. Service providers must be well informed; they must not only at the contraceptive, they must also consider a prospective client as a total person.     

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.     

Sterilization: the barriers are being crossed

The sterilization program begun in the Philippines by Presidential Decree in 1974 is described. The goals of the program are: 1) training of program practitioners, to equip a corps of physicians with needed skills; 2) recruitment of acceptors to test the acceptability and viability of the approach among eligible groups; and 3) "professionalization" of medical practice in sterilization. The training of program physicians has been taken over by Popcom as part of its 1-year sterilization training program. The institutionalization of the surgical sterilization in medical schools and family planning organizations has been undertaken by the Study and Training Center for Surgical Sterilization. Various types of sterilization clinics are described. The reaction of the population and methods of handling potential acceptors are described. Sterilization techniques and side effects are presented for male and female sterilization. 3 models for information-education-communication in sterilization are reported. The number of births averted by this sterilization program is estimated. Problems encountered are revealed.     

Bangladesh: progress of the intensive sterilization campaign

The President of Bangladesh announced a governmental population policy which aims at checking the country's population explosion. In line with this newly-announced policy, the national family planning program, aided by the Bangladesh Association for Voluntary Sterilization,, launched an intensive sterilization compaign in mid-1977. In the 1st 3 months of the program operation, 128 doctors were trained at 15 rural health centers. During this same period, more than 50,000 vas and more than 25,000 tubectomies were performed. It is estimated that each of these sterilizations will avert 1.8 births on an average.     

Shuangyang County popularizes contraceptive knowledge

Shuangyang County is located in the southeast of the Changchun City, Jilin Province, with a total population of 385,000 and a total area of 2,000 square kilometers. The rural population makes up 96% of the total with 8.2% minorities. As the county government vigorously promoted the family planning program in the period of the 6th Five-Year Plan, the rapid growth of the population was effectively controlled. Since 1982, the county government has put the emphasis of the family planning work on publicizing scientific knowledge, on provviding technical services and on training the working staff at the grass-roots level. In response to the different needs of the community for knowledge about premarriage, preconception, and postnatal cares as well as infant feeding, the county government started a program in 1985 for popularizing knowledge about puberty, hygiene, sexual physiological hygiene, pregnancy care, and birth control. As a result, a number of young people have delayed their former marriage date to the ideal marriage age. Many newlyweds voluntarily chose the most proper age for giving birth. To improve the effectiveness of contraception, the county government promoted widely the use of a new type of IUD. Finally, the county government believes that it is most important to improve the quality of the family planning workers at the grass-roots level. Accordingly, the government worked out a plan to train the community workers regularly.