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.     

Family planning programs in industrial establishments: an operations research study

An operations research study in the Philippines sought to uncover determinants of the sustainability of employment-based family planning (FP) programs offered in industrial settings where the Philippine Center for Population and Development (PCPD) had provided assistance in implementing Responsible Parenthood/FP-Maternal Health (RP/FP-MH) Programs. Qualitative data were gathered through observations and interviews with the target population and with company management and program implementers. Based on this study, the following recommendations were made: 1) training outputs should be echoed to employees immediately; 2) RP/FP-MCH team members should be recruited from each level of the work force; 3) an appropriate IEC (information, education, and communication) strategy should be devised to respond to the short time-frame in which employees can participate; 4) team-building training should be incorporated as a regular activity early in the contract period; 5) sectoral targeting should be used within a given company; 6) training programs should be designed for each of the three types of team members and should overlap the basic topics; 7) teamwork and mutual assistance should be encouraged; 8) the work of the teams should be rewarded; 9) commendable initiative of liaison officers should be sustained; 10) representatives of the PCPD should maintain a close relationship with the teams through PCPD staff visits to the companies; 11) management requires more intensive orientation on the RP/FP-MH program; 12) PCPD support should be withdrawn gradually until the companies are able to sustain the program themselves; 13) it may be helpful to require a company to meet rigid criteria in order to take part in the PCPD project; 14) OR should be continued; and 15) the concept and practice of quality of care should be introduced to service delivery and training of staff and motivators.     

A diagnostic study of the DOH health volunteer workers program

A 1993 study in the Philippines sought to 1) examine the characteristics of the Barangay (village) Health Workers (BHWs), 2) describe their recruitment and training, 3) reveal what their work entailed and how they felt about it, 4) identify the factors affecting their ability to deliver FP services, and 5) determine clients' attitudes towards them. Data were collected from structured interviews with 100 active BHWs and 150 clients in each of two regions. Most of the BHWs were women who had at least some high school education. They were longterm residents of their villages, were not gainfully employed, and their family incomes were below the poverty level. They were in favor of FP but considered three or more children ideal. Most had been BHWs for at least six years after being recruited (most often by a midwife). Most BHWs spent an average of 1.7 days assisting in the health centers and 2.0 days in the field. Their FP training was sketchy and largely centered on the use of various methods. The BHWs expressed a desire to learn more about natural FP, the IUD, and newer methods. Most received some monetary or other incentive for their work and were supervised directly by local midwives. FP service delivery was positively associated with education, experience, acquaintance with local residents, and cultural homogeneity with the clients. About half of the clients reported that they had consulted a BHW about FP, but an additional third were not familiar with the BHW program. The image of the BHW in the community was of a friendly, well-intentioned but not terribly knowledgeable person. The BHWs tended to provide follow-up services but often failed to refer clients to the health centers in the first place. Clients also reported that the BHWs gave them no choice about which method to use. This study points out the shortcomings in the BHW program. Improvement in outreach objectives could be reached by improved recruitment and training activities, the provision of more generous incentives, and improved logistics (such as contraceptive supply). The FP record-keeping system should also be improved.     

Quality of care and family planning drop-outs in Bukidnon province: a survey study

A study was undertaken in the province of Bukidnon in the Philippines to determine the actual percentage of family planning (FP) acceptors who become dropouts, the reasons they drop out, and the factors most strongly associated with this phenomenon. Data were collected through interviews with married women of reproductive age who had been recorded as being a FP acceptor during 1992. The sample size was set at 400 using a probability-proportionate-to-size sampling technique. In examining the extent of the drop-out problem, it was found that the actual FP status of each respondent agreed with the clinic records in 73.4% of cases and that 22% of those thought to be dropouts had actually switched methods. Most of the women who stopped using oral contraceptives said they did so because of side effects. The drop-out problem was most acute among women who were poorer, less educated, and of higher parity. The attitude of a husband towards use of a method was a better predictor of continuation than the wife's attitude. Clients who felt their provider was approachable and friendly were significantly less likely to drop out. Despite the fact that the FP program is modeled on a "cafeteria" approach which provides choices to acceptors, 9.5% of acceptors in this survey claimed they were not offered a choice. Women who received limited information were more likely to become drop-outs. Clients who had to return to clinics frequently for resupply of OCs or condoms were most likely to become drop-outs. While the number of dropouts identified in this study was only half the official estimate for the province, the short time between FP acceptance and the survey may have reduced the number of dropouts. The program implications of these findings are that 1) the occurrence of side effects needs study, 2) groups characterized by high drop-out rates should receive immediate attention, 3) favorable attitudes should be fostered in husbands, 4) women must receive more information on their options, 5) quality of care must be improved, 6) the use of the IUD should be promoted, and 7) resupply procedures should be revised to reduce trips to the clinic.     

An analysis of the determinants of family planning volunteer workers' performance in Iloilo City

This report analyzes data from a survey of 106 Barangay (village) Service Point Officers (BSPOs) associated with the City Population Office and 106 Barangay Health Workers (BHWs) associated with the City Health Office to compare the family planning (FP) service delivery performance of these voluntary workers in Iloilo City in the Philippines and to quantify the effects of the factors which influence their performance. Both the BSPOs and the BHWs assist in the delivery of health and FP services at the grassroots level. The survey data were supplemented with interviews with key informants, focus group discussions with married couples of reproductive age, clinic records, and observations of the BSPOs and BHWs at work. The analysis compared the sociodemographic characteristics of the two groups; the recruitment procedures followed (if any); FP training; actual FP-related work; involvement in community organizing; incentives received; supervision of the volunteers; attitude towards their work; FP knowledge, attitude, and practice; time allocated to FP activities; number of clients served; and number of clients counseled. Correlation analysis of factors influencing volunteer performance indicated that FP training had the largest positive influence on FP activities. The output of the workers was also positively affected by the amount of time spend in FP activities and by their involvement in community organizing. The commitment of the workers had a significant impact on the number of clients they resupplied with contraceptives. Variation in the FP performances of the two groups was caused by the fact that delivery of FP services is a major role of the BSPOs and only one of many responsibilities of the BHWs. These findings reinforce the planned restructuring of Iloilo City's FP program which would once again designate the Population Office as the lead agency. Increasing the knowledge of these volunteers about the side effects and contraindications of various methods should have a positive effect on continuation rates. Recruitment of volunteers should be based on the individual's level of interest and commitment.     

FP client-worker interaction as an ingredient of quality of care

In order to contribute to the improvement of the clinic-level management of the family planning (FP) programs of the Philippine FP Program, an assessment was made of client-staff interactions. Data were collected during May-June 1990 from 107 FP personnel and 1440 clients using a purposive sampling procedure which identified project sites on the basis of their FP performance; evenly divided the sample between government-sponsored programs and nongovernmental organizations; and randomly drew a sample of clients which included past users, never users, and current users. Data were gathered from a survey and from observations of at least 27 client-staff interactions in each of the four project sites. The observations were followed by in-depth interviews. While the interactions were positively viewed by the clients, some of the service providers (perhaps coping with an overly large case load) tended to shorten the duration of the interaction. The recommendations which arose from this study include: 1) FP personnel in this study, who indicated a preference for recruiting new acceptors rather than motivating past users, should be given a travel allowance and time to use the effective technique of home visits to try to reduce the number of drop-outs; 2) specific topics and counseling techniques should be included in the training courses for FP personnel; 3) the clinic setting must be improved to conform to quality standards and provide privacy for clients; and 4) clinic visits should be personally satisfying for the client as well as efficient.     

Family planning and resilience: associations found in a Population,Health, and Environment (PHE) project in Western Tanzania

Using 2016 household survey data from Tanzania, we define and measure resilience within the context of Population, Health, and Environment programming and quantify the link between resilience and family planning. We created a multicomponent model using confirmatory factor analysis in a structural equation modeling context. Factor loadings for eight defined latent factors of resilience were statistically significant (p?<?0.001). We created a factor called “FP-MCH” reflecting awareness, attitudes, and access to family planning (FP) and health care services and use of maternal and child health care (MCH) facilities. Analysis, with controls, shows that a 1 standard deviation (SD) increase in FP/MCH was associated with a 0.68 SD increase in resilience (p?<?0.01), suggesting that the association between FP/MCH and resilience is robust across a range of factors. Analyses showed that the association between FP/MCH is broadly related to the construct of resilience and not through any single component. This study supports the importance of including FP/MCH as part of integrated projects to enhance resilience.     

Do stepping-stone jobs exist? Early career paths in the medical profession

In the Netherlands, students who want to become a medical specialist have to enrol in a training program which is in limited supply. During the search for a position as trainee (or “junior medical specialist”), they may accept a temporary job as a medical assistant. We use a micro data set to investigate whether such work experience increases the probability of becoming junior medical specialist. To deal with selectivity, we simultaneously model the transitions from unemployment to trainee, from unemployment to medical assistant, from medical assistant to trainee and from medical assistant to unemployment. We find that a job as medical assistant helps to become a medical specialist. Received: 27 July 2000/Accepted: 31 January 2001 All correspondence to Gerard J. van den Berg. Responsible editor: John F. Ermisch.     

A literature review to determine midwifery students’ perceived essential qualities of preceptors to increase confidence and competence in the clinical environment

BackgroundMidwifery students’ experiences with preceptors in the clinical environment plays an integral role in developing the confidence and competence of students. As up to 50% of the midwifery program is taught in the clinical environment, an analysis of the preceptorship role in the context of midwifery student confidence and competence may be important to inform future practice and policy.AimTo discover, whilst on clinical placement, what is required by preceptors to suitably equip midwifery students to develop confidence and competence in the clinical environment.MethodsA search of the literature was undertaken using health and midwifery related electronic databases of PubMed, CINAHL, Intermid, SCOPUS and Web of Science. Grey literature, and reference lists from studies were also part of the thorough search process.FindingsAfter critical reading of the 15 included studies, there were a number of themes identified as the preceptor qualities that contributed to student confidence and competence. Those themes include ‘belongingness’, ‘hands on experience/skill development’, ‘students’ development of professional identity’ and ‘preceptor characteristics that impact student learning’.DiscussionStudent confidence and competence can be dependent on the preceptor who supports them. There are preceptors who enable students to flourish in their confidence and competence, and there also appears to be preceptors who do not possess these qualities, which requires further enquiry.ConclusionAs the evidence appears to find that trained preceptors are optimal for student confidence and competence, further enquiry is warranted to inform policy and practice around the concept of preceptorship training for midwives.     

Perceived factors of family planning clinic performance and service quality

As part of a larger operations research project, this 1990 study analyzed the performance of the Philippine Department of Health's (DOH) family planning (FP) clinics. Specific study objectives were 1) to measure acceptor targets, servicing capacity utilization, outreach, and costs; 2) to determine what providers believed affected performance; 3) to record which quality indicator providers use; and 4) to determine the perceptions of acceptors about clinic personnel, the clinic as a FP outlet, FP service processing, and FP service quality. Data were gathered from clinic records and from sample surveys in 25 clinics in four specified locations. Eight clients were sampled from each of the 100 clinics. It was found that clinic staff accepted low attainment of FP acceptor targets and that clinic capacity utilization levels were at 25% of capacity. Providers were unaware of the number of potential FP acceptors in their areas and had no information about the costs of running their clinics. The FP clinic managers identified 34 major determinants of clinic performance, but more than half reported that they had very little control over these determinants. The providers described quality service from the point of view of the acceptors and described the quality of a clinic in terms of the minimal physical characteristics required. The acceptor survey revealed that acceptor satisfaction depends upon 1) clinic accessibility and lay-out, 2) intensive personal contact, and 3) clinic infrastructure. The study uncovered a need for the DOH to institute management training programs for clinic managers and to provide managers with the resources and personnel to shift priorities in favor of FP coverage and prevalence. Managers, who are resource allocators, must also receive information about the costs of FP services in their clinics. In addition, the DOH's determination that its FP program would be facility- rather than community-based should be modified to incorporate community outreach elements. The DOH can also make a big impact on perceptions of quality (of both providers and acceptors) by improving clinic conditions to meet basic standards. Once these basic needs are met, additional needs of acceptors can and must be addressed.     

Program evaluation: the experience in population education

The Population Education Program (PEP) of the Department of Education and Culture in the Philippines takes pride in a built-in evaluation system which assesses accomplishments primarily in light of objectives laid out and gathers feedback useful in improving future training programs. Its evaluation theoretically serves to measure 3 training dimensions -- before, during, and after each training course. Evaluation of both the 5- and 1-week training programs follows the same pattern. Pretraining evaluation is done by administering a pretest at the beginning of each course, which quantitatively measures trainees' baseline knowledge and attitudes. It is intended for the use of trainers in determining how the course should proceed. Assessment made while training is in progress (formative evaluation) is done through a steering committee meeting held at the end of a week or a day for the 5- and 1-week courses, respectively. The meetings focus on identifying weaknesses requiring immediate or future course revisions. At the end of the course, a posttest is given to measure positive or negative changes in the trainees' knowledge and attitudes. These changes are assumed to have been caused by training. Additional qualitative information is collected through an evaluation sheet containing open-ended questions on different aspects of the course. Problems of "who" should evaluate and "how to" evaluate are among current problems evident in practice, and a revised training scheme has been implemented to deal with these problems.     

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.     

Low fertility and limited diffusion of modern contraception in Italy during the second half of the twentieth century

During the last two decades of the twentieth century, Italy, Greece, Spain, Portugal, and Japan were characterized by very low fertility levels and limited diffusion of the pill, IUD and sterilization for contraceptive purposes. This paradox is discussed for Italy by revisiting the history of contraception and reproduction during the second half of the twentieth century, and by using new data for the end of that century and the early twenty-first century. The main results are: (1) it has been possible to maintain low rates of planned and unplanned fertility without resorting to more effective contraceptive methods thanks to a careful use ofcoitus interruptus; (2) the pace of diffusion of the pill and IUD was so slow because of the opposition to contraception of the Catholic Church, a gender system emphasizing traditional male and female roles, and a medical culture that made physicians reluctant to prescribe the pill for their patients; and (3) the contraceptive patterns of Italian women born after 1960 are more similar to those of their Western counterparts, although new peculiarities appear, for example, substantial reliance on the condom by people living as couples as well as sexually active singles.     

Assessing the impact of a family planning nurse training program in Egypt

In 1991 the Egyptian Ministry of Health introduced a new training program for family planning nurses. The training program stressed the development of nurses' counseling skills. As part of the Operations Research Program, sponsored by Family Health International in collaboration with the Egypt National Family Planning Board, managerial staff from family planning agencies designed and implemented a study to evaluate the impact of the new training program. The study objective was to assess the impact of nurse training on nurse performance in the clinic and on clients' family planning knowledge, attitudes and contraceptive use. The study was designed to provide usable information to family planning managers in the field within a time period of less than one year. The study results indicate that there is an association between improved family planning training for nurses and positive changes in family planning knowledge, attitudes and behavior among women attending MoH clinics in this study. The greatest relative change occurred in knowledge. Women in the experimental group, relative to the control group, displayed increased knowledge about contraceptives, particularly the pill and the IUD. Attitudinal change was less pronounced. Favorable attitudes toward oral contraceptives and condoms became more prevalent, and reports of husband-wife communication about family planning also increased. Finally, although contraceptive use was already high prior to the nurse training, IUD use increased significantly among women in one governorate.     

Iud retention in West Pakistan and methodology of assessment

In 1967 there was a sample survey of women who had had IUD insertions in West Pakistan during the first 18 months of the Pakistan National Family Planning Program which began in July, 1965. The 12 month retention rate, including reinsertions, per 100 respondents was 56. Certain gross relationships between respondent characteristics and IUD retention were found. Respondents age 35+ and with 5+ living children and respondents who had insertions within two months postpartum had relatively high retention rates. Respondent characteristics associated with low retention rates included: age 35+ with 0–4 living children; reasons other than family planning reported as reasons for insertion; less than one-half hour travel time required to obtain insertion; not informed at time of insertion about side-effects of IUD; and insertion during last six months of 1966. Consistency of response was evaluated by reinterviewing a sample of respondents. The significance of the 43 percent non-response rate was evaluated by making further attempts to interview a sample of non-respondents.     

A complex and demanding situation – Midwifery preceptors and midwifery students’ experiences of teaching and learning prevention of severe perineal trauma

BackgroundMany high-income countries have seen an increase in severe perineal trauma. Teaching strategies and conditions for learning during the active second stage of labour are scarcely described.AimTo describe midwifery preceptors and midwifery students’ experiences’ of teaching and learning how to manage the second stage of labour, with the specific aim of preventing severe perineal trauma.MethodsA qualitative study with focus group discussions and individual in depth-interviews with preceptor midwives (n = 23) and student midwives (n = 10). Data were analysed by qualitative content analysis.Results“A complex and demanding situation with mutual need for feedback, reflection and safety” was the overall theme describing the conditions. Three sub-themes were identified. “Adapting to a unique situation” refers to the difficulty of teaching and learning the aspects needed to prevent severe perineal trauma, and to provide care during this stage. “Hindering and limiting circumstances” describes teaching strategies that were perceived negatively, and how midwifery students tried to adapt to the preceptors rather than the birthing women. “A trustful and communicative relationship” describes the importance of the relationship between the student and the preceptor, where communication was a central, but not obvious part.ConclusionAn increased awareness among preceptors is needed to optimize teaching strategies, enabling the students to focus on learning the art of the second stage of labour; supporting the woman, preventing severe perineal trauma and ensuring the safety of the unborn baby. Future research should address how existing prevention models can include training to increase preceptors’ confidence in teaching.     

A survey of China's birth control among women of child-bearing age

To further implement China's family planning policy of "prevention first, birth control first," a study of the current family planning situation was conducted. A survey of the birth control methods employed by women of childbearing age and by men was based on a nationwide randomized sampling of 1/1000. In the different age groups, ranging from 15-49 years old, IUD users accounted for over 50%, tubal sterilization 25%, and vasectomy 10%. The main IUD users were women in the 20-24 age group. Tubal sterilization was more prevalent among the women in the 35-39 age group. The use of oral contraceptives (OCs) was more common among younger women but accounted for less than 10% of the total. The survey was based on the replies to questionnaires from 172,788 married women of childbearing age; 120,022 of them practiced contraceptive methods for a birth control rate of 69.46%. The breakdown was as follows: IUD, 34.84%; tubal sterilization, 17.63%; vasectomy, 6.94%; OCs, 5.86%; condom users, 1.39%; and other methods (including chemical suppositories, rhythm, or safe period method and withdrawal before ejaculation), 2.78%. There was a higher percentage of OC users in urban areas, and a marked preference for IUDs in the rural communities. The rural birth control rate was 68.58%; the urban rate was 74.17%. The use of the IUD has priority in all the areas; its percentage approaches the national average level. The use of vasectomy as a birth control method varies considerably according to area as does the use of OCs, condom, and tubal sterilization. Rural minority groups prefer the IUD and OCs; tubal sterilization, the condom, and vasectomy are preferred by the Han nationality. The birth control rate differed according to the different occoupation groups: 77.85%, workers; 76.01%, farmers; 85.15%, cadres; 59.52%, housewives; and 66.67%, others. The birth control rate was higher among those who received a college education than the illiterates, but statistics did not show a significant difference in the rate of those with a high school education and the illiterates. Mothers of 0-1 children generally preferred OCs; tubal sterilization was preferred by mothers with 2-3 children. The nonusers of contraception accounted for 30.54% among married women of childbearing age. A breakdown gives the following figures: menopause and infertility, 6.17%; divorced and widowed, 1.64%; planned parenthood, 10.51%; nonusers who should have practiced contraception, 12.22%. On a national level, the estimated number of nonusers of contraception among those who should be practicing contraception comes to about 20,000,000 women.     

Use of the intra-uterine contraceptive device in rural West Pakistan

This paper presents selected aspects of experience with the intra-uterine contraceptive device (IUD) in rural West Pakistan. There were 1,162 IUD cases analyzed with respect to retention or non-retention. Retention rates were estimated, using life table methods, to be between 55 and 75 percent at one year; the smaller figure was obtained when theIUD was considered to be in situ only until the last examination, when it was observed to be in place. The latter or larger figure was obtained when the IUD was considered to be in situ unless known to be out.The extent of follow-up greatly affects estimates of the length of time the IUD remains in situ. Retention also varies with the type of I UD employed; exclusive use of Loop 3, which has the best retention record of those used,may be expected to yield higher retention rates by as much as 5 to 10 percent for one year. A number of other factors were examined that might explain non-retention. The objective variables that were examined in this experience, such as age, previous contraception, and husband's illiteracy, were on the whole rather poor predictors of IUD retention. Expulsion and other medical complications appear to account for most discontinuance of use of the IUD.     

Family planning operations research in the Philippines

This essay introduces an issue of the Philippine Population Journal dedicated to the presentation of the results of operations research (OR) studies undertaken for the Philippine Family Planning (FP) Program as part of a program coordinated by the Population Council which seeks to improve FP services. The concept of OR was introduced to program managers and researchers at two workshops held in 1992. Five of the seven diagnostic proposals developed during these workshops were funded and are covered in this Journal. The results of earlier OR studies conducted under the sponsorship of the UN Population Fund are also included. The concept of OR was developed to provide managers with timely answers to their everyday problems through appropriate research. OR forces social scientists to overcome prejudices against this kind of applied research and forces program managers to learn to rely on research findings instead of on hunches. OR also forces both parties to work as a team. An important intent of this Journal is to encourage the dialogue which must precede the institutionalization of OR and to indicate to social scientists and program managers that OR has a personal relevance to their work. The research reported in this Journal will contribute to the building of theories through the many convergences in the conclusions reached about such issues as home visits, suboptimal clinic conditions, inadequate provision of FP information, and the role of outreach workers.     

Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia

Problem

There is increasing demand for capacity building among the Aboriginal and Torres Strait Islander (Indigenous) maternal and infant health workforce to improve health outcomes for mothers and babies; yet few studies describe the steps taken to mentor novice Indigenous researchers to contribute to creating a quality evidence-base in this space.