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.     

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.     

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.     

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.     

Thailand: family planning program exceeds targets

According to Dr. Somboon Vacharothai, Director General of the Ministry of Public Health, the number of people in Thailand who practiced family planning exceeded last year's target. 664,895 individuals used family planning services; this was 62.2% above the planned target for 1976. It was further predicted that 700,000 persons would be recruited by the family planning program in 1977. The preferred method of birth control was the oral contraceptive; it is the method of 800,000 acceptors. Service outlets have been extended rapidly with 5836 medical centers providing family planning services throughout Thailand. Government allocations for family planning have increased from 0.9 million dollars in 1975 to 2.47 million dollars in 1977.     

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.     

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.     

NFP update: researcher cites need to improve instruction

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

A cast of 40: population and family planning agencies at work in the Philippines

This is a compilation of 42 agencies, both government and private, participating in the Philippine population program. Each listing includes: the purpose of the organization; a summary of its activities for fiscal year 1974-1975; the name of the project director; and the address. A large number of these agencies are engaged primarily in population or family planning work. Others, such as the medical schools at the University of the Philippines and the University of Santo Tomas, have family planning programs as part of a broader effort.     

Service station established at villages and towns in Fufeng County pushed forward the family planning program there]

In 1985 the 15 villages and towns of Fufeng County, Shanxi Province, established service stations to promote family planning. The County invested over 90,000 yuan in an x-ray machine, operation table and necessary medical supplies. The service stations provided fluoroscopy, surgical and propaganda rooms. The purpose of each station, staffed by female physicians and family planning cadres, was to develop contraceptive birth control, teach eugenics, and counsel women. The establishment of service stations obviously proved significant and useful, as seen from the following data: for the years 1983-85, the county birth rate fell 2%; the multiple child rate dropped 7.7%; the birth control rate rose by 12.6%; the sterilization rate rose by 1.3%. By October 1986, these figures showed even more improvement. The success of the service stations was also due to: taking its services to the people, their homes, and their workplace; making family planning work a service, rather than a management; systematizing family planning work and making it available at all times.     

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.     

Corporate clinics take on a new role

The Philippines Department of Labor, in conjunction with the U.N. Fund for Population Activities, is sponsoring a pilot family planning program. The industrial program, supervised by the Labor Management Coordinating Council, aims at integrating family planning services into the health services or clinics of 1000 corporations with at least 200 employees within the 2-year period ending June 1977. Family planning seminars are conducted at 3 levels within the corporations and include training sessions for medical personnel. Companies have found that provision of family planning services is more economical in the long run than provision of family welfare services for employees and families.     

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.     

Traditional health workers finally earn recognition

In the Philippines the growing need for medical manpower and services can no longer ignore the traditional birth attendant, the hilot, who always played a big role in obstetrical practices, particularly in areas where paramedical workers are not available. In 1974 a survey identified more than 31,000 hilots, who assisted about 40% of all births in the islands. It must be remembered that in the Philippines 70% of the population lives in rural areas, that 65% of physicians live in urban areas, and that almost all hospitals are in metropolitan Manila. Until the early 50s the government's attitude was to discourage hilot practices, but limited resources and the small magnitude of existing health programs prompted the government to grant hilots official permission to continue their work. In 1955 the Philippines Dep. of Health and the WHO initiated a training program for 9000 selected hilots, to enable them to handle maternal and health situations in rural areas in the absence of physicians or nurses. From 1955 to 1972 only about 9200 hilots attended training programs, but from 1975 to 1977 about 10,500 hilots were trained to respond to local community health demands. Maternal and perinatal morbidity and mortality has sharply decreased from 1954 to 1972; with nearly half of the births attended by hilots it is valid to assume that the program of teaching and supervising them has contributed to such a decline.     

Understanding calendar rhythm

Rhythm has been among the family planning methods endorsed since the start of the National Population Program in the Philippines, but it has not been given as much emphasis as the other methods such as oral contraception (OC), the IUD, and sterilization. For several years, no systematic effort was made to promote the effective use of rhythm. The 1978 Community Outreach Survey (COS) tried to determine the extent to which contraceptive methods were being used in the Outreach Project areas. The project covered 2,000 barangay service points (BSPs) with 1.76 million married couples of reproductive age (MCRA), representing 32% of the estimated total MCRA in the Philippines. The COS findings revealed that, of the total sexually active married women aged 15-49, 48% were using contraceptive methods. Of these, only 11.4% were using modern methods, 20% were using other program methods (rhythm, condom, and combination of rhythm and condom); and 16.7% were using nonprogram methods (withdrawal, abstinence, and others). When used in combination with other methods, rhythm had a monthly continuation rate of 96%; when used alone, 94%. The COS data showed that the rhythm method is practiced by a large number of Filipino couples. With the renewed interest in rhythm, it became imperative for the program to help rhythm acceptors use the method more effectively and thus reduce user failure. There continues to be need for data on the "product image" of rhythm. These include the emotions that come into play in the acceptance or rejection of rhythm, the perceived side effects as well as advantages of the method, the ways women communicate their "safe" and "unsafe" days to their husbands, the manner in which couples prevent sexual contact during "unsafe" days, and the attitude of couples toward abstinence. Among important study findings were the following: couples choose rhythm because it does not disturb the sexual act, has no side effects, and poses no religious objections; 1 of the problems of rhythm users is that they get varied explanations and instructions from service delivery personnel on the correct way to practice rhythm; and many rural women do not have a clear understanding of the menstrual cycle. Requirements of successful rhythm practice include cooperation, regular cycle, and the couple's age.     

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.     

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.     

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.     

Contraceptive use in China

A national sampling survey carried out in China in 1988 showed that 90.71% of the population were using some form of contraception: male sterilization (10.99%); female sterilization (38.24%); and IUDs (41.48%). Compared with 1982, the figures gathered in 1988 showed an increase in male sterilization and female sterilization and a decrease in condoms, oral or injected contraceptives, IUDs and spermicides. A great difference was found between the contraceptive methods used by women in rural areas as compared to women in urban areas. In urban areas IUDs accounted for 58%, female sterilization for 15%, male sterilization for 1% and condoms for 13%. In the country, female sterilization accounted for 42%, IUDs for 39%, male sterilization 15%, condoms 1% and oral contraceptives for 4%. There was also a strong difference between women of certain ages; the use of IUDs was highest among women between the ages of 15-29 years, while female sterilization was more prevalent for women over the age of 30. There was also a considerable difference between the birth control taken by women with children and those without; the majority of women (31%) without children used condoms; the majority of children (78%) with 1 child used IUDs; the majority of women (65%) with 2 children were sterilized. The sample study shows that 91% of the women using contraception used long-acting contraception.     

Upgrading IEC strategy: the happy family coupon campaign

The Information, Education and Communication Division of the Family Planning Organization of the Philippines launched a Happy Family Coupon Campaign, a project to test the feasibility and the potential of a scheme whereby materials were distributed in response to individuals' expressed needs and interest. The project aims were: 1) to reach specific target groups, represented by readers of commercially printed materials; 2) to explore the potential of the mail system as a medium for the distribution of family planning materials; 3) to test the effectiveness of commercial publications as a vehicle for creating demand for family planning information; and 4) to secure feedback regarding preferences for the various family planning materials. The campaign had 2 major components: 1) advertising as a means of informing readers about the availability of certain family planning information materils, and 2) mail service as a channel for delivering requested materials to the respondents. 12 types of informational materials were distributed, each written in English, Filipino, and the Ilocano, Cebuano, and Ilongo dialects. These pamphlets and leaflets are described. The campaign drew a total of 24,226 respondents from August 1974 to December 1975. 58.7% of the respondents had 1-4 children, 26.4% had 5 or more children, and the remaining 14.9% gave no information concerning the number of children. It appears that the project has already achieved a measure of success as indicated by: 1) specific target groups were reached, 2) the potential of the mail system as a channel for the distribution of family planning was not confined to the buyers of the publications, 3) the potential of commercial publications as vehicles for creating demand for family planning information was tested, and 4) feedback regarding preferences of various groups for different family planning materials was obtained.