Comprehensive services at Fabella Center

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

Sterilization in the Philippines: the score after half a decade

Since the initial use of sterilization in the Philippines in 1973 as a family planning method, it has become more and more widespread. A bar graph, giving yearly percentages of acceptors for 5 family planning methods, for the years 1974 -- 1977, shows sterilization increasing steadily in popularity, from 3% in 1974, to 12.7% in 1977. Objections to sterilization generally stem from sociocultural and religious considerations as well as misconceptions and fear. People have feared that sterilization is a form of mutilation and castration. Due perhaps to the male fears of castration, female sterilization acceptors account for 90.6% of sterilizations in the Philippines. In 1974, the Philippine government's Commission on Population set guidelines for the training of physicians and the setting up of sterilization centers. The guidelines also stipulated that the procedure would be undertaken on a voluntary basis, would not include abortion, and that clients would be informed of all medical implications, particularly the irreversibility of sterilization. Programs for sterilization in the Philippines have different requirements for acceptors; most stipulate parity of 2 to 4. Difficulties have also arisen from the uneven distribution of sterilization providers throughout the country as well as a lack of physicians trained in both male and female sterilization methods. The need to create effective linkages among the various agencies engaged in sterilization work is noted.     

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

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

Sterilization: the barriers are being crossed

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

The participation of non-governmental organizations in the Philippine population program

In 1957 the National Council of Churches in the Philippines (NCCP) established the Family Welfare Center, offering an educational program in family planning; it was subsequently expanded and reorganized into the Planned Parenthood Movement of the Philippines. Since its creation in 1970 the Philippine Population Program has brought together government, private, and religious activities. Under the 1987-92 development plan nongovernmental organizations (NGOs) will be taking a more active role in the implementation of the population program by contributing to the maternal and child health/family planning and the information, education, and communication (IEC) components. There are more than 50 private organizations engaged in such population activities. These include national women's organizations and development NGOs with a mass base. The Family Planning Organization of the Philippines is carrying out a 3-year comparative study of the effectiveness of community volunteers in the acceptance of natural family planning. The Reproductive Health Philippines has completed a follow-up of Depo Provera defaulters in a previous clinical study of Depo Provera acceptors conducted in 1985-87. IEC support from various medical and social organizations also helped advance family planning and population awareness of the program. The Mary Johnston Hospital and Iglesia ni Kristo have been front-runners in sterilization through their mobile teams and regular clinics. On the negative side, funding constraints are threatening the very existence of some NGOs. Even those that do not face such constraints face problems related to cost effectiveness, priority setting, capability building, and staff development. A survey of the Population Center Foundation identified some urgent concerns: sharing experience in self-reliance, enhancement of the managerial skills of staff, and funding problems. NGOs complement the family planning services of the government as well as focus on the smooth flow of IEC activities.     

Community-based contraceptive distribution: a Korean success story

The results of a community-based contraceptive distribution program using village women canvassers in Cheju Island province, Korea, are evaluated. This rural province had the highest fertility and lowest contraceptive use before the project began. After pre-testing in another area, township-level family planning field workers recruited 365 new female canvassers per 150 women at risk of pregnancy, compared to 10,000-25,000 per worker in the previous scheme. The canvassers were to contact every household, offering them pills or condoms, or vouchers for an IUD or sterilization from the clinic. The former target system, which in reality had limited the numbers of acceptors, was suspended, necessitating an increase in budget outlays for family planning in Cheju province. By 1985 the contraceptive prevalence had doubled, and fertility fell 40.1 and 32.4% in the 2 Cheju counties. Costs per couple-year for the Cheju program were lower than those in other areas. The results of this project suggested that increasing the number of community workers or canvassers in rural areas helps reduce barriers to the use of contraceptives.     

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.     

Upholding the freedom of couples to use a method of their choice

A recent review of the Philippine Population Program's 5-year plan, ended in December 1982, showed that in 1980, natural family planning (NFP) users were only about 12.5% of couples practicing family planning. This figure doubled by 1982. Based on these responses the decision was made to intensify the NFP program as early as 1982. The 1st step was to put more money into the NFP program. The program includes the modern scientific techniques such as cervical mucus, basal body temperature, and sympto-thermal. The program also will fund the training of doctors and other clinic personnel and the production and distribution of appropriate training and information material. Other family planning methods, such as sterilization, oral contraception (OC) and the condom, also will be promoted. Promotion of NFP will depend on the choice of the family planning practitioners themselves. The program's community based services are being intensified. NFP, together with the other family planning methods such as sterilization and OC, will always be made available to couples in the community based services. All agencies in the population and family planning program will be promoting NFP. Knights of Columbus doctors have been invited to assist the program and share their own training modules for the training of trainers. An agreement has been entered into with the Gabriel M. Reyes Memorial Foundation based in Aklan. The goal is for trainers who need further knowledge and skills in NFP to learn from the foundation's wealth of organized orientation and training techniques in NFP. NFP is emphasized at this time because it is acceptable to a great number of couples.     

Republic of Korea. Country feature

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

Indonesia: family planning target stepped up for 1980; twofold success of integrated project

The recruitment of 3 million additional family planning acceptors for the fiscal year 1979/80 was the target of Indonesia's family planning program. Available data shows that Indonesia was the 1st country in the world to have consumed 200 million cycles of contraceptive since the program's inception 9 years ago. The achievement of a lower birth rate of between 20 and 22 per 1000 (present rate is approximately 38/1000) is possible within the next 10 years should the program maintain its present pace. Education of women; health of pregnant mothers, and nutrition of children are factors which strongly affect family planning. Current conditions are such that 30% of children aged 0 to 6 years and a large proportion of mothers are malnourished. A coordinated family planning-rural development project launched by the Indonesian Planned Parenthood Association and Indonesian Women's Association was launched 2 years ago and has proved successful. The project's core activity is the organization of income-generating projects such as poultry-raising, vegetable cultivation, handicrafts and small industries. Family planning and other health measures (eg, environmental sanitation) were also promoted. The project utilized selected cadres of married women who were then trained in community development. These women became trainers in their own villages. The project proved to be successful in terms of income-generating activities for the women and in terms of gaining 623 new family planning acceptors within a period of 5 months.     

Fresh impetus to family planning programmes planned in India. APPN interviews Mr. B. Shankaranand Union Minister for Health and Family Welfare,India

Mr. B. Shankaranand, Union Minister for Health and Family Welfare in India, speaking on new policy measures planned to give family planning a major boost, stated that programs related to population and family welfare should be interwoven with the minimum needs program so that the message of the small family norm becomes attractive to acceptors. The new incentive measures, outlined by Shankaranand, are based on the understanding that the existing infrastructure for service delivery must be fully utilized. The new package of incentives places equal emphasis on state level campaigns which will be suitably dovetailed with services and supplies. Monetary rewards in the form of community assets will be given to organized and identifiable groups actively engaged in the implementation of the Family Welfare Program. Cash awards will be given to the best performing states. A new incentive scheme will be introduced for industrial labor groups in the organized sector. Innovative publicity campaigns in selected areas will be conducted. Reorganization of the service delivery outreach system will include establishing health posts staffed by nurse midwives and health workers in urban slums and congested areas. A scheme is in preparation to issue green cards to acceptors of terminal methods after 2 children. The card holders will be entitled to priority attention and preferential treatment in schemes where such practices are feasible. Currently, there are 5000 Primary Health Centers and 50,000 subcenters offering integrated health services. Family planning statistics provide supportive evidence of programmatic response to the achievement of longterm goals of population stabilization. During the 1st 10 months of the current financial year 2,800,000 sterilizations were performed, a 43% higher achievement rate than the corresponding period last year. The number is likely to rise to 4,000,000 by the end of this financial year. Similarly, the number of IUD acceptors is 760,000, 35% higher than last year. Another encouraging sign has been the formulation of a National Health Policy.     

Withdrawal in Pakistan: new insight into an old method

Although family planning programs pay almost no attention to the validity of coitus interruptus (withdrawal), it is a traditional method of family planning widely used to regulate fertility in Pakistan. Large-scale quantitative studies conducted in recent years in Pakistan by the Population Council have indicated that withdrawal is the most popular temporary method of fertility regulation in the country, second among all methods only to female sterilization. Pakistani couples use withdrawal mainly because they believe that modern methods are unsafe for women and unreliable. They have some fears and misconceptions about modern methods. The method may work well in Pakistan also because users seem to feel that they own it. Withdrawal is therefore a reasonable option given Pakistanis' beliefs and circumstances. Those who use withdrawal in Pakistan practice the technique with considerable efficacy and tend to continue using it. Furthermore, couples which use withdrawal have discussed their family planning preferences and decided together to use the method. However, in order to improve the use of modern methods of contraception, information provision, counseling, and interpersonal communication must be improved.     

India: New family planning program direction outlined

The focus of the current Family Welfare Program in India is education and active community involvement rather than coercion and compulsion. The government is totally committed to the program and has indicated that it will spare no efforts to motivate people to voluntarily accept family planning. However, there is a need for family planning efforts to include all aspects of family welfare, particularly those designed to promote the health of mothers and children. All family planning methods will be made available, and the family will be free to choose the method they prefer. As part of the program, employees of the Union government, State governments, autonomous and local bodies are expected to set an example and adopt the small family norm. The policy statement made by Mr. Raj Narain, Minister of Health and Family Welfare, revealed the government's decision not to legislate, either at the national or the State level, for compulsory sterilization. Sterilization services will be available free of charge to those who voluntarily choose this method. A plan for training indigenous midwives will be implemented as part of the program in order that maternity services may be available to all expectant mothers. Additionally, in recognition of the direct correlation between illiteracy and fertility and between infant/maternal mortality and age at marriage, the government will introduce legislation to raise the minimum age at marriage to 18 years for girls and to 21 years for boys. The plan is for trade unions, Chambers of Commerce, cooperative societies, women's organizations, teachers' federation, district councils, and other voluntary institutions to be associated intimately with the educational campaign launching the Family Welfare Program.     

The population program shifts to 'high-scenario' targets

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

Natural family planning works in a Bukidnon town

Natural family planning is being actively promoted in a pineapple plantation of the Philippine Packing Corporation (PPC) located in northern Bukidnon province. Prospective acceptors attend 4 seminars which cover sex education and instruction on natural family planning methods. The goal of the program is family life and marriage enrichment rather than family size limitation. Thus, there is no target number of acceptors. Early acceptors used the basal body temperature method, but this was subsequently replaced by the sympto-thermal method. Participants report that the close observation of physical changes required by the natural family planning method has enabled them to be more aware of their bodies and more appreciative of themselves. Laypersons work closely with acceptor couples. There are 6 fulltime grassroots motivators and 23 camp motivators. Affiliated with the Family Life Commission of the Catholic Bishops Conference of the Philippines, the program is also supported by the Phillips Memorial Hospital and is part of the PPC's barrio assistance program. The corporation actively supports self-help projects in the plantation areas.     

Integrating reproductive health services into family planning programs

A recent Population Council publication, Reproductive Health Approach to Family Planning, discusses integration of reproductive health into family planning programs in a series of edited presentations that Council staff and colleagues gave at a 1994 meeting of the US Agency for International Development (USAID) cooperating agencies. The presentations reflect the Council's view that family planning programs ought to help individuals achieve their own reproductive goals in a healthful manner. The report discusses four areas of reproductive health: reproductive tract infections (RTIs), including sexually transmitted diseases; prevention and treatment of unsafe abortion; pregnancy, labor, and delivery care; and postpartum care. Christopher Elias (Senior Associate, Programs Division) argued that family planning programs ought to provide services that target RTIs, given that these illnesses afflict a significant proportion of reproductive-age women. The family planning community has an ethical responsibility to provide services to women who experience an unwanted pregnancy. They must have access to high-quality postabortion care, including family planning services. Professional midwives are ideally suited to serve as integrated reproductive health workers trained to combat the five major maternal killers: hemorrhage, sepsis, pregnancy-induced hypertension, obstructed labor, and unsafe abortion. This was demonstrated in a highly successful Life-Saving Skills for Midwives program undertaken in Ghana, Nigeria, and Uganda, and soon to start in Vietnam in conjunction with the Council's Safe Motherhood research program. Family planning services should be viewed as part of a comprehensive set of health services needed by postpartum women, which include appropriate contraception, maternal health checks, well-baby care, and information about breastfeeding, infant care, and nutrition. Family planning programs should incorporate breastfeeding counseling into their services. When programs aim to help individuals meet their own reproductive goals in a healthful manner, this implies that services will not increase clients' risk of morbidity.     

Men and family planning: toward a policy of male involvement

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

Control of population by economic means]

Education alone cannot effectively control population growth. Benefit to the individual must be coordinated with the benefit to the community and the country. It is absolutely necessary and possible to control population by economic means. The economic policy in Tienjing includes: 1) give preference to single child families in child care, health benefits, education, and employment, and financially punish families with more than two children; 2) establish a better rationing policy, one not based on a per capita ration, and give preference to single child families; 3) establish retirement benefits and guarantee higher living standards for retirees who have either no children or only 1 or 2 children, and give paid sick leave to people experiencing complications following sterilization operations; 4) establish equal inheritance rights for both male and female offspring; and 5) give bonuses to units with excellent family planning results and to medical personnel with fewer complications during sterilization operations, and financially punish groups with poor family planning results. In order to effectively implement the economic means, coordinate bonuses with punishment, and coordinate local policies with those of the entire society. The key is strong leadership, but the voluntary and active involvement of the public insures success.     

Family planning among the Maranaos

An effort has been made to introduce population education concepts and family planning practice to the Maranaos of Lanao del Sur province in the southern Philippines. A survey conducted in 1969 revealed that an overwhelming majority were opposed to family planning, because of the belief that it ran counter to the teachings of the Koran. In 1969, Dansalan College 1st opened a maternity clinic and, subsequently, established a family planning clinic on campus, the only one of its kind in the province. Since the clinic began operations, a total of about 1370 acceptors have been recruited. The oral contraceptive is the most preferred method among the acceptors, accounting for 60%, followed by the injectable. Additionally, the college has integrated family planning and population education into its Community Service Program. Despite several years of effort by Dansalan College, however, Maranaos have failed to respond significantly to practicing family planning. College officials continue to be optimistic, recognizing that the effort will take years of motivating and education.     

Sri Lanka: current status of family planning

In Sri Lanka the family planning program is closely related to socioeconomic and cultural variables. The expectation is that in the near future family planning will be included as a component of a network of social services. The official program is a response to the economic necessities and welfare demands of individuals and families. The method of family planning most frequently requested is female sterilization, and no attempts are being made to direct people to other methods. 12 United Nations Fund for Population Activities assisted projects have provided the framework and basis for the institutional coverage of family planning activities in Sri Lanka. However, the experience of these projects revealed a lack of facilities, shortage of personnel and management inadequacies, all related to the delivery of family planning services. The following steps are suggested as a means of overcoming the current problems and expanding the program: 1) establish a pattern of interacting relationship between the mass media, community health education and the available services; 2) provide an operational approach to program management, monitoring and periodic reviews of the program; 3) involve the private sector health facilities; and 4) incur additional capital cost to increase the capacity for delivery of better health facilities and personnel.