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.     

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.     

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.     

A diagnostic study of Department of Health training courses for family planning providers

A study in the Philippines sought to observe and describe the family planning (FP) training program in two regions. This program trains physicians, nurses, and midwives as a team and includes a Basic/Comprehensive (B/C) course in FP with didactic and practicum elements, training in interpersonal communication skills (ICS) for those who have completed with B/C course, and a Preceptors Course for those who will supervise the practicum phase of the B/C course. The study gathered specific information on 1) trainee absenteeism and drop-out rates, 2) course content and effects, 3) the trainee selection process, 4) the practicum requirement for the B/C course, and 5) service delivery values and quality of care. Data were collected through observations, questionnaires, exit interviews with clients during the practicum phase, interviews with supervisors and public officials (mayors), and focus group discussions with regional trainers. This assessment led to the following recommendations: 1) maintain the current team approach; 2) reserve basic orientation-type subjects for office-based training to allow more time for FP topics in the training programs; 3) use caution in making a switch to "competency-based" training because of the possibility that supervision is inadequate for such a training method; 4) improve scheduling; 5) enforce the prerequisites for participation in the ICS and Preceptors Courses; 6) assign only one trainee to a preceptor area during the practicum and reduce the quota of IUD insertions to reduce pressure to obtain IUD acceptors; 7) create a "model" FP clinic each time a preceptor is trained; 8) pay more attention to natural FP methods; and 9) maintain an emphasis on quality of care.     

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.     

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.     

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.     

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.     

Beyond population,beyond family planning: the Commission on Population's total integrated development approach

The Philippine Commission on Population (Popcom) after 5 years of operation has succeeded in reducing the national population growth rate from 3.01% in 1970 to 2.66% by the middle of 1975. More than 50% of the country's eligible couples are practicing family planning or have received services at some time. New acceptors recruited during the fiscal year 1974-1975 totaled 716,650 as compared with 191,426 in 1970. As of December 31, 1975, continuing users amounted to 22% of the population. Despite the accomplishments, however, the following operational problems exist: 1) 57 out of every 100 married women of reproductive age have not been reached by the program; 2) in all regions, only 2 out of 3, or even fewer, women are aware of the existence of a family planning clinic to serve them; 3) there is a definite shift from the more effective to the less effective methods of contraception; and 4) there is a large disparity between knowledge and practice of family planning among both urban and rural women. Additionally, the clinic-based system limits the program's outreach to urban areas, and the doctor-centered approach limits the provision of services. In response to these problems, Popcom developed the Total Integrated Development Approach in 1975. This approach is currently being implemented in 7 pilot provinces and under the auspices of this approach, various strategies have been developed to improve service delivery and to expand coverage of the rural areas. 1 such strategy is the establishment of barrio resupply points which are complemented by mobile clinics which service remote and inaccessible areas. Eventually, depending on the success of the program, the approach will be implemented in all provinces within the next 3 or 4 years. Each Total Integrated Development Approach will include the 4 components of services delivery, IEC (mass and interpersonal communication and special projects), training, and research and evaluation.     

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.     

Is it possible to incorporate evidence-based professional midwifery practices into public health services in Mexico?

Problem and backgroundDuring the past two decades, Mexico has launched innovative maternal health initiatives to improve maternal and neonatal outcomes, placing emphasis on the incorporation of professional midwifery practices into the healthcare system. This study explored the perceptions of healthcare providers and women using public birth care services regarding professional midwifery practices and how can the inclusion of evidence-based midwifery techniques improve the quality of service.MethodologyWe conducted a qualitative, cross-sectional study of three healthcare networks in Mexico. A content analysis was performed of data collected through 109 semi-structured interviews: 72 with healthcare providers and 37 with women.ResultsHealthcare providers and women had minimal knowledge of the competencies and skills of professional midwives. Medical personnel accepted the incorporation of some evidence-based midwifery practices. Women had experienced fear and anguish during childbirth so they considered that incorporating professional midwifery practices into maternal health services would be favourable in that it would render birth care more respectful.Discussion and conclusionsHealthcare providers are willing to consider the inclusion of some evidence-based midwifery practices in health services and regard assistance from professional midwives. They believe that structural conditions will complicate their incorporation. Although the women interviewed had experienced fear, anxiety and loneliness during childbirth, most of them admitted to feeling “safer” in a hospital (secondary-care health centre) setting where possible complications could be resolved. This perception of safety served to justify the delivery of healthcare in a manner that is inattentive to women’s needs, which go beyond biomedical issues and include emotions and the positive experience of childbirth.     

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.     

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.     

Technical information via print

The amount that the staff of family planning clinics learn through technical publications is discussed in this article on the Philippine Population Center Foundation's Study of the flow of scientific information. The main questions raised include to what extent doctors, nurses and midwives learn from publications sent to their clinics, or from colleagues who have read the journals. If the latter is true, do the staff members teach one another or merely refer each other to the technical information available? 99 copies of "Population Reports" were sent out to various clinics throughout the Philippines. A 3rd of the issues were on the pill, a 3rd were on the IUD, and a 3rd were on the condom. 6 weeks after the information was sent out, tests on all 3 contraception methods were given to all staff members who were part of the survey. Ideally clinic staffs would perform best on the tests of the method on which they had received information. Tables giving breakdowns on the individual areas tested show that while clinics which had been sent information on the IUD scored best on the IUD test, clinics which had been sent pill and condom information did not do better on their respective tests than the others. Nurses and midwives from clinics with good interpersonal relations scored higher on the tests on which they had been sent information. Results also showed that the more involved a professional was with a contraceptive, the more he/she read about it. While encouragement and referral occurred between colleagues, teaching did not. A 2nd study was then run on how levels of interpersonal communication could be determined. A multiple regression analysis showed that the best predictors of intraclinic communication were age difference among clinic staff, similarity in clinic staff's length of family planning service, family planning caseload, similarity of clinic staff's reading of professional literature, average length of service of staff members in the medical profession, and average age of clinic staff.     

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.     

Contraceptive practice required to meet a prescribed crude birth rate target: a proposed macro-model (tabrap) and hypothetical illustrations

TABRAP (TArget Birth Rate Acceptor Program) is a computer programmed model that provides a direct solution to the problem of determining the total annual numbers of contraceptive acceptors required to achieve a prescribed crude birth rate target path. Applied to an initial population for which age structure, the fertility schedule, and expected trends in life expectancy and age-specific proportions of females married are known, TABRAP incorporates the following factors: age at acceptance, with acceptors drawn from currently married nonusers; age-method-specific attrition rates of users; a potential fertility schedule of acceptors that allows for aging and sterility; and allowance both for postpartum anovulation and nine months for gestation to time properly the averted births. TABRAP generates annual data on acceptors, couple-years of use, births averted and age-specific fertility rates that meet the crude birth rate target. Resulting changes in population size, age structure and crude vital rates, also yielded, are invariant with respect to acceptor age and method mix. Assuming a target to reduce the crude birth rate from 45 to 30 in ten years, TABRAP is illustrated for seven mixes of acceptor age-method combinations applied to a population approximately that of Thailand, circa 1965.     

Implementing the birth policy to village as the grass-roots unit]

At the present time, the emphasis of the birth control program in China is in the rural areas where it is harder to implement a birth control policy. A new initiative taken in Liaoning Province to certify rural villages in family planning (FP) practice has proved to be successful. 6 criteria have to be met by a rural village to be qualified for certification: 1) an adequate FP organizational network, 2) comprehensive coverage of publicity and education program activities, 3) satisfactory FP program implementation, 4) extensive usage of contraceptive methods, 5) good quality service delivery, and 6) efficient program management. Specific regulations on organizational structure, educational activities, policy implementation, contraceptive supply, data collection and reporting, and management of finances have also been formulated to promote the certification process. Packages of incentives and disincentives have been established to integrate FP program implementation with the responsibilities, decision-making powers, and personal benefits of the leaders and the village community. The sense of birth control practice as a communal endeavor in villages has also been created under these regulations. Over 80% of villages in Liaoning province have now been certified. Various birth control model villages have been set up to promote the FP program elsewhere.