Quality of care in Peru: measuring its impact. Field report

A report published in 1995 by the Population Council described the impact of the quality of family planning services on the incidence of unplanned pregnancy in Peru. This report followed a 1994 study that assessed the impact of quality on contraceptive usage by linking data from Peru's 1991-92 Demographic and Health Survey (DHS) and a 1992 Peru Situational Analysis study of the status of family planning (FP) services at 3000 individual service delivery points. The 1995 study added data from a follow-up survey of a sample of the DHS respondents. The 1994 study used an innovative quality of care index that measured the quality of FP services available in a geographic area to women with partners living nearby. This index was then assigned to every woman in the area and correlated with her use of modern contraceptives. The analysis revealed that availability of high-quality FP services greatly increased the number of women using modern contraception. The 1995 study analyzed the impact of quality of care on rates of unintended pregnancy and found that the percentage of unwanted births was significantly higher in areas with low-quality FP services. The researchers note that these results only hint at a relationship between quality of care and reproductive behavior and that the findings should be interpreted conservatively. However, the studies support the importance of investing in quality FP care.     

中国生殖健康方案的推进和已婚育龄人口避孕模式转变——ICPD 10:避孕方法的医控模式和自控模式有变化吗

避孕节育是生殖健康极为重要的内容。文章利用国家人口和计划生育委员会1988年至2001年全国生育节育抽样调查和全国计划生育/生殖健康调查数据,分析了已婚育龄人口在避孕模式上的时空变化特征,在此基础上进一步研究了在已婚育龄人口的年龄、子女数和生活的不同区域环境等方面避孕模式的时空变化。结果表明,在我国人口转变的过程中,低生育水平下的避孕模式以及推行避孕节育知情选择后已婚育龄人口的避孕模式,特别是医院控制的避孕方法与自己控制的避孕方法的构成已经发生了变化,有必要进一步改善生殖健康服务的技术服务等。     

Family planning for new mothers in the Philippines

From November 1997 to February 1998, a survey was conducted to evaluate postpartum family planning (FP) services in the Philippines. Data were gathered from records at 86 clinics in 28 provinces and from interviews with 338 FP providers and 3452 clients who began to use FP within 6 months of delivery. Only 7% of women began using FP within 6 months of delivery, and most postpartum attention was devoted to child care issues. Among the women surveyed, most resumed sexual intercourse at 2.4 months postpartum and experienced a return of menses at 4.4 months postpartum despite breast feeding for 6.2 months. The most commonly recommended method to space births was the IUD followed by the injectable contraceptive. Very few providers recommended use of barrier methods. The results indicate that many breast-feeding women are receiving hormonal contraceptives too soon and that IUD insertion may not be occurring at the ideal time postpartum. While a significant percentage of providers recommended use of the lactational amenorrhea method (LAM) and 16% of the women relied on it, the providers lacked sufficient understanding of LAM. In addition, many women switched or discontinued methods. The study led to the recommendations that postpartum FP services be promoted as an essential part of maternal-child health care and that FP providers receive improved training about contraception and LAM.     

Falling fertility in Indonesia: success in national family planning

This publication summarizes the findings of the National Indonesia Contraceptive Prevalence Survey (NICPS), which revealed a rapid decline in Indonesia's fertility rate. This article also describes how the successful Indonesia family planning program is designed and maintained. Since 1975, fertility rates have dropped from 5.5 to 3.3 children per woman. Those practicing contraception during the same period has risen from 400,000 couples to 17 million. Contraceptive education is high (e.g. 95% of all married Indonesian woman are familiar with a modern contraceptive method). The Indonesia family planning program cooperates with other government activities designed to improve people's health and welfare. It emphasizes access to contraceptive methods and promoting the idea small family. The program was structured to us extensive community involvement, and cultural beliefs were incorporated into program policy; Islamic leaders were consulted before program implementation. The program is flexible so that the differing needs of each region can be effectively met by the family planning program. The future main goal will be to contain a potential population boom when the 40% of the present population which is under 15 years of age becomes reproductively mature.     

India's population: second and growing

Attention in this discussion of the population of India is directed to the following: international comparisons, population pressures, trends in population growth (interstate variations), sex ratio and literacy, urban-rural distribution, migration (interstate migration, international migration), fertility and mortality levels, fertility trends (birth rate decline, interstate fertility differentials, rural-urban fertility decline, fertility differentials by education and religion, marriage and fertility), mortality trends (mortality differentials, health care services), population pressures on socioeconomic development (per capita income and poverty, unemployment and employment, increasing foodgrain production, school enrollment shortfalls), the family planning program, implementing population policy statements, what actions would be effective, and goals and prospects for the future. India's population, a total of 684 million persons as of March 1, 1981, is 2nd only to the population of China. The 1981 population was up by 136 million persons, or 24.75%, over the 548 million enumerated in the 1971 census. For 1978, India's birth and death rates were estimated at 33.3 and 14.2/1000 population, down from about 41.1 and 18.9 during the mid-1960s. India's current 5-year plan has set a goal of a birth rate of 30/1000 population by 1985 and "replacement-level" fertility--about 2.3 births per woman--by 1996. The acceleration in India's population growth has come mainly in the past 3 decades and is due primarily to a decline in mortality that has markedly outstripped the fertility decline. The Janata Party which assumed government leadership in March 1977 did not dismantle the family planning program, but emphasis was shifted to promote family planning "without any compulsion, coercion or pressures of any sort." The policy statement stressed that efforts were to be directed towards those currently underserved, mainly in rural areas. Hard targets were rejected. Over the 1978-1981 period the family planning program slowly recovered. By March 1981, 33.4 million sterilizations had been performed since 1956 when statistics were 1st compiled. Another 3 million couples were estimated to be using IUDs and conventional contraceptives.     

After the demographic transition: policy responses to low fertility in four Asian countries

In the low fertility countries of South Korea, Taiwan, Singapore, and Thailand, policy-makers are concerned about the consequences of low growth. In South Korea, a family planning (FP) program was instituted in the early 1960s, and fertility declined to 1.6 by 1987. Rural fertility is still higher at 1.96, and abortion rates are high. 32.2% of fertility reduction is accomplished through abortion. South Korean population will not stabilize until 2021, at 50.6 million people. The elderly are expected to increase and strain housing, energy, and land resources. Government support for FP is being reduced, while private sector services are being enhanced. Government sterilization programs have been reduced significantly, and revisions in the Medical Insurance Law will cover part of contraceptive cost. Integrated services are being established. Many argue for an emphasis on birth spacing, child and family development, sex education, and care of the elderly. In Taiwan, replacement level fertility was reached in 1983. Policy in 1992 recommended increasing fertility from 1.6 to 2.1. The aim was to stabilize population without pronatalist interventions. Regardless of policy decisions, population growth will continue over the next 40 years, and the extent of aging will increase. In Singapore since the 1960s, the national government focused on encouraging small families through fertility incentives, mass media campaigns, and easy access to FP services. Fertility declined to 1.4 in 1988. Since 1983, government has established a variety of pronatalist incentives. In 1989, fertility increased to 1.8. The pronatalist shift is viewed as not likely to succeed in dealing with the concern for an adequate work force to support the elderly and economic development. In Thailand, fertility declined the fastest to 2.4 in 1993. The key factors were rapid economic and social development, a supportive cultural setting, strong demand for fertility control, and a successful FP program. The goal is to reduce fertility to 1.2 by 1996. Replacement level may be reached in 2000 or 2005. Future trends are not clear.     

Adding choice to the contraceptive mix: lessons from Indonesia

Researchers asked 1945 women of reproductive age living in East Java, Indonesia what contraceptive method they preferred during the women's 1st visit to a government family planning clinic. Soon after field workers introduced them to a method, the researchers asked the women what method the field workers suggested and what method the women planned to use. They again spoke to them 1 year later to determine contraception continuation. The field workers granted 86.3% of the women their method choice. Only 9% of these women had stopped using their chosen method while 72% of the women who were not allowed to use their chosen method stopped using the method assigned to them. Thus choice was a key factor in sustained use of contraceptives. Further if family planning workers stick to a mutual participation of both themselves and their clients, they respect clients' method choices and, by informing clients about the chosen method, they strengthen clients' decision making. In the early 1990s, another researcher had developed a system to determine contraceptive needs at various stages of the reproductive period (before 1st marriage, after 1st marriage but prior to 1st birth, after 1st birth but prior to last birth, and after last birth). She applied observed contraceptive preferences for women using contraception within each life cycle stage to the age specific contraception need, derived from data from the 1987 Contraceptive Prevalence Survey for Indonesia, to determine the ideal contraceptive mix. Her calculations demonstrated that oral contraceptive use was high, IUD use was low, particularly among older women, and too few sterilizations had occurred, particularly among older women. Thus Indonesia needed to broaden the contraceptive mix to encourage methods that better meet women's reproductive life cycle needs.     

The comparative analysis of the dynamics of childbearing women's birth at Yanging County, Beijing]

At the end of 1981 Yanging County had 26 communes, 375 production brigades and a total population of 211,098. A random sampling of 5.07% of the production brigades was taken, which included teams from the plains as well as mountainous regions. The sample had a population of 10,888, or 5.16% of the entire county, among whom 189 subjects were interviewed. These 189 women, whose ages ranged from 35-67, were divided into 5 birth year cohorts (1914, 1920, 1930, 1940, 1946). Findings include: 1) Age at marriage: the average age at marriage (about 17 years) between the 1914 and 1946 groups rose 1.82 years, indicating that early marriage was the norm. The time between marriage and 1st birth has shortened. 2) Fertility data: from 1914 to 1946 the lifetime fertility rate tended to decline from 4.60 to 3.70, but the 1930 cohort was the highest (6.42), followed by the 1920 cohort (6.26). The fertility rate of the 1914 cohort tended to rise in the 1950s after already having reached a peak in the early 1940s, probably because after Liberation fertility rose due to a higher standard of living and a stablized society. The fertility of the 1930 cohort was highest around 1963 when they were already 30 years old. The fertility of the 1940 cohort was also highest beginning around 1963. In both cases, the reason probably was because the national economy improved at this time. Indeed, the national fertility rate rose from a 1960 low of 20.9/1000 to 43.6/1000 in 1963. 3) Contraceptive use: prior to 1972 before there was an offical birth control policy, a sizeable number of women already desired to use contraceptives, the reason being most of these women felt they already had enough children. However, many women did use contraceptives in response to the call to do so. 4) Factors influencing fertility standards: in general, the less a woman's education and the lower her income, the higher was her standard of fertility, and vice versa. 5) The percentage of women who had children who died before the age of 15 ranged from 35.9% of the 67 year olds to 12.6% of the 35 year olds.     

Studying the fertility peak in Beijing]

Beijing, China, is experiencing a baby boom in response to 2 periods of large population increase in the mid-1950s and early 1960s. The average number of annual births was 220,000 in the first period and 269,000 in the second period. The causes of the large increase in the population in the first period were an improvement of health conditions which led to a reduction in mortality, immigration flow, and an erroneous population policy. The causes in the second period were recuperative fertility after three years of natural calamity and increased fertility among immigrants. Net migration had an important role in population growth these two periods; it also will have an important impact in future population changes. According to population projections, another baby boom is expected to occur before the end of the end of the century. During the up-coming baby boom period, 1.54 million births are expected, 190,000 per annum. The average increase in population size is expected to 127,000 per year. In the peak year, it may be around 200,000. Thanks to the family planning (FP) program the occurrence of the third baby boom in Beijing has been postponed and the duration will be shortened. From 1972 to 1982, 2.57 million births was averted due to FP, which drastically reduced pressure on the demand for resources and on the momentum of the next baby boom. Another baby booms is not expected during the early half of the 21st century, although an elevated birth rate within the range of normal fluctuation is predicted. The projection was based on the assumption of restricted migration and the enforcement of the FP program. The realization of the projected population will depend on deferred marriage, deferred child-bearing, prolonged birth spacing, the prevention of high parity fertility, the maintenance of the current population policy, and control over the reproductive behavior of the new migrant population.     

The determinants of the duration of contraceptive use in China: A multilevel multinomial discrete-hazards mdeling approach

Often in demography, individuals may change state over time for a variety of reasons. Competing-risks hazards models have been developed to model such situations. This paper describes the extension of the discrete-time competing-risks hazards model to a multilevel framework that allows for data at different levels of aggregation. The model is illustrated with data from the 1988 Chinese National Survey of Fertility and Contraceptive Prevalence, which collected complete contraceptive histories. Women may stop using a method of contraception for a number of reasons; this paper describes how one can control for correlations between the outcomes of repeated spells of contraceptive use.     

India well prepared for meeting future goals

In India many of the past goals for reduction in birth rates have not been achieved for various reasons, and although contraceptive usage has increased it has not been sufficient to overtake the reduction in death rates. From 1971-80 about 1/2 of the population of the country was subject to a decline in growth rate, and the number of eligible couples using effective contraception was 10.6% in 1971 and 22.7% in 1981 in spite of an increase in the number of such couples. The death rate declined from 27.4 in 1941-51 to 14.8 in 1971-81 with a corresponding increase in life expectancy from 32-52 years. However the growth rate has reached a plateau during 1971-81. Since its inception the Family Welfare Program in India is estimated to have averted 49 million births including 5 million in 1981-82. Future goals are: 1) reduction in birth rate from 35 in 1981 to 21, death rate from 14 to 9 and infant mortality rate from 125 to 60 by the year 2000 along with reductions in maternal mortality and morbidity, and 2) an increase in the percentage of couples protected from 23.6 in 1982 to 60 in 2000, and 3) population size of 950 million by the year 2000 and the commencement of population stabilization leading to a population of about 1200 million by the middle of the 21st century. Future strategies for the promotion of planned parenthood include information, education, and communication programs, incentives and disincentives, involvement of nongovernmental agenices, provision of services and supplies, linkages with other sectors, and monitoring and evaluation activities. Emphasis will be put on interpersonal communication channels to promote the program as a mass movement.     

The current situation and tasks of China's population control

During the 10 years from the late 1960's to the late 1970's, China's birth rate declined by 50%. Currently, however, China is in the midst of a baby boom. 3 statements characterize the birth rate: The growth rate is high (birth rate is 21.04/1000 in 1987 and natural increase was 14.39/1000); unplanned births are common; and population growth is varied in different areas of the country (10 provinces show 3rd or higher parity births at an average rate of 20%; the highest rate in a province is 45%). Several measures are suggested to deal with these population problems; increase nationwide awareness of population control; stabilize current family planning policies with only special case exceptions; expand contraceptive services and increase scientific research in the area of family planning; and enact economic and social welfare policies in line with population control.     

The marketing of the condom

The Commercial Contraceptive Marketing Program was developed by the Population Center Foundation in the Philippines to increase participatio n of private commercial firms in promotion and distribution of nonclinical contraceptives. The program was started to eliminate ignorance concerning contraceptive methods, to increase contraceptive acceptance, and to decrease dropouts from the program. It is hoped that all 200,000 sari-sari stores in the Philippines will eventually become involved in marketing contraceptives. This will free government personnel for the work of extending family planning services to the rural areas. The history of the development of a plan for commercial marketing of condoms in the Philippines is discussed.     

Initially analyzing the characteristics and evaluated indexes in rural areas and making relative policies]

20% of rural family planning (FP) programs in China have an unsatisfactory performance. A study was conducted in four townships with poor FP program performance in Pengxi County, Sichuan Province. Some common characteristics of these townships are as follows. Lack of concern about the FP program on the part of the local leadership. 2) Resistance of local people to FP communication and education; 96% of 426 families interviewed wanted to have 2 children, and only 3.7% wanted 1 child. 3) Lack of enforcement of the incentives and disincentives stipulated in the FP policy. 4) Lack of service delivery back-up in FP programs with a shortage of trained professional staff to provide clinical services and a shortage of the necessary medical facilities or equipment to meet the needs of FP service delivery. 5) The large number of early marriages, early child-births, extra-marital child-births without quota. At the present time, there is not specific quantitative standard to evaluate the FP program performance in a particular district. 3 indicators are appropriate for comparison of program performance. 1) Has the annual birth control target for the district been met? 2) The percentage of births with in the FP quota. Under 60% of births within the quota should be considered poor performance. 3) Over 20% of unplanned pregnancies reflect poor performance in the areas of birth control education, and contraceptive service delivery. The following are suggestions for solving the problems of poor program performance. 1) Community leaders should be evaluated on a per capita production output value rather than on total value. Their achievements should also be linked with their salary increases, promotions and bonuses. 2) One-child families should have a priority in receiving financial aids for development. 3) Governmental and non-government organizations should work together to promote the implementation of FP policies. 4) Service delivery systems should be strengthened by promoting population and FP education to families and in schools. Funding should be made available to increase the capability of birth control service delivery in terms of staff training, provision of equipment and housing and improvement in the quality of services. 5. Full use should be made of the potential of village leaders to take personal responsibility for every aspect of the FP.     

A multilevel model of family planning availability and contraceptive use in rural Thailand

This paper assesses the ways in which the availability of family planning program outlets influences the likelihood of contraceptive use in rural Thailand. It focuses on a village-level measure of actual availability of sources rather than respondent perceptions of availability. Individuallevel and village-level data collected as part of the second Thailand Contraceptive Prevalence Survey are used to test three hypotheses about the effects of actual availability: that (a) availability of family planning outlets increases the likelihood of contraceptive use; (b) it enhances the effect of a desire for no more children on the likelihood of use; and (c) it weakens the positive relationship between education and the likelihood of use.     

Birth rate of Beijing population drops nearly 60% in 20 years

The birthrate of the Beijing (China) population dropped by 60% in the last 20 years. Consequently, population reproduction is characterized by a pattern of low birthrate, low mortality rate, and a low growth rate. The birthrate of the Beijing population was 36.30/1000 in 1950 and rose to 43.41/1000 in 1963. During the 1950-63 period, the average annual birthrate of Beijing population reached 36.71/1000 and the number of births was 2.23 million. Since the beginning of the 1970s, the rapid population growth has been effectively checked by great efforts made in practicing family planning. Over the 1970-83 period, the average annual birthrate dropped to 14.9/1000 and the number of births totaled 1.75 million. With the advance of the family planning effort, particularly acceptance of the concept of practicing family planning for the modernization drive, the people's reproductive notion has changed for the better. At this time, more and more men and women of reproductive age have broken away from the influence of old ideas such as "the earlier the couples have their sons, the soonner they will be helped." By 1982, the average age at 1st marriage was 25.8 years for males and 24.7 years for females. This was a remarkable change as compared with the 1960s. According to the 1982 population census, Beijing women over 60 years had 4.83 children, while those in the age groups 55-59, 50-54, 45-49, 40-44, 35-39, 30-34, and 25-29 has 4.81, 4.50, 3.72, 2.95, 2.32, 1.58, and 0.57 children respectively. Today, 0.66 million couples in Beijing volunteer to have only 1 child.     

The role of contraceptive supply and demand in Mexican fertility decline: evidence from a microdemographic study

This paper uses retrospective life history data to assess the impact of family planning services on contraceptive use in a rural Mexican township. Between 1960 and 1990 contraceptive use rose and fertility declined dramatically. Both contraceptive supply and demand factors were influential in these trends. The start of the government-sponsored family planning programme in the late 1970s was associated with a sharp rise in female sterilization and use of the IUD. However, once we controlled for the changing socio-economic and demographic characteristics of the sample, the presence of family planning services had no significant effect on the likelihood that women used modern reversible methods compared to traditional methods. Men and women expressed concerns about the safety of modern methods such as the pill and the IUD. Efforts to increase modern contraceptive use should place greater emphasis on communicating the safety of these methods and improving the quality of services.     

The Role of Contraceptive Supply and Demand in Mexican Fertility Decline: Evidence from a Microdemographic Study

This paper uses retrospective life history data to assess the impact of family planning services on contraceptive use in a rural Mexican township. Between 1960 and 1990 contraceptive use rose and fertility declined dramatically. Both contraceptive supply and demand factors were influential in these trends. The start of the government-sponsored family planning programme in the late 1970s was associated with a sharp rise in female sterilization and use of the IUD. However, once we controlled for the changing socio-economic and demographic characteristics of the sample, the presence of family planning services had no significant effect on the likelihood that women used modern reversible methods compared to traditional methods. Men and women expressed concerns about the safety of modern methods such as the pill and the IUD. Efforts to increase modern contraceptive use should place greater emphasis on communicating the safety of these methods and improving the quality of services.     

The World Fertility Survey: charting global childbearing

Interviewing some 350,000 women in 42 developing countries and 20 developed countries representing nearly 40% of the world's population, the World Fertility Survey (WFS) is in a unique position to document the historic 1970s slowdown in global population growth. This Bulletin describes efforts begun in 1972 to ensure high quality, internationally comparable, accessible data, the data's importance for policymakers, planners and researchers, and major findings available by early 1982 from directly assisted WFS surveys in 29 developing countries and contraceptive use data from WFS-type surveys in 16 developed countries. Marital fertility has declined in all developing regions except Africa but still averages from 4.6 children/woman in Latin America to 6.7 in Africa, while preferred family size ranges from 3.0 children in Turkey to 8.9 in Senegal--far above the average 2.2-2.5 children/woman needed to end developing countries' population growth in the long run. However, women ages 15-19 prefer nearly 2 children fewer than the oldest women ages 45-49; 3.8 vs. 5.7 on the average. Nearly 1/2 (48%) of married women surveyed in 27 countreis said they wanted no more children. Preventing all unwanted births would reduce birth rates up to 15 births/1000 population in these countries. Overall, 32% of married, fecund women in developing countries are using contraception compared to an average 72% in 16 developed countries. Education, literacy, and more available family planning services increase contraceptive use. Age at marriage is rising in Asia, but this factor alone has little effect on fertility. Infant mortality is higher in many developing countries than previously thought. Breastfeeding is an important restraint on fertility in most developing countries but is declining among more educated, employed, and urban women which could raise fertility if not compensated for by gains in contraceptive use.     

Communique of the State Family Planning Commission on a nationwide fertility sampling survey of every person per thousand

In 1982, the Chinese State Family Planning Commission conducted a nationwide fertility survey of 1 person/1000 in 28 provinces, municipalities, and autonomous regions. 815 sample units were selected and 310,462 women aged 15-67 were interviewed, 99.9% of those identified. 252,094 (24.77%) were of childbearing age (15-49) with 24.76% 15-19 years old. Among women of fertile age, 31.46% were unmarried, 64.53% were married to their 1st husbands, 2.89% were remarried, .19% were divorced, and .94% were widowed. Average age of 1st marriage increased from 18.4 in the 1940s to 22.8 in 1981. Total fertility rate dropped from 5.44 in the 1940s to 2.63 in 1981. In 1981, the birth rate was 85/1000 women of fertile age. Fertility was much higher among minority nationalities. 118 million of China's 170 million married couples of reproductive age (69.46%) use birth control at present; 50.2% use the IUD, 25.4% tubal ligation, 10.0% vasectomy, 8.2% oral contraceptives, and 2.0% condoms. About 21 million married women should have begun using contraception but have not. 14 million or 42.3% of 33 million 1 child couples have pledged to have only 1 child. If the fertility level of 1981 is maintained and the average woman continues to have 2.63 children, 2.91 in rural areas, China's population will reach 1.2 billion by 1993 and will exceed 1.3 billion by 2000. The Central Committee has a target population of 1.2 billion by 2000.