Latin American hospitals improve postabortion care. Maternal health

Approximately 4 million women undergo illegal abortions each year in Latin America and the Caribbean, and hundreds of thousands of women with postabortion medical emergencies or incomplete abortions seek hospital care. Once in an emergency ward, a woman may await treatment for 24 hours, bleeding, frightened, and in pain. A woman in such a situation may also experience nurses who chastise her for becoming pregnant or committing a sin, be examined with several staff members observing, undergo unexplained treatment without anesthesia, and/or leave the service facility without knowing whether she is still fertile or how to avoid pregnancy. INOPAL, Population Council's operations research program on family planning and reproductive health in the region, is working to find the best ways, medically and financially, for hospitals to deliver high-quality, comprehensive services to postabortion patients. Most maternal deaths and injuries could be prevented by access to family planning services and information about contraceptive use. The Population Council and colleagues from hospitals, governments, and nongovernmental organizations are conducting studies in Guatemala, Peru, and Mexico on the emergency treatment of incomplete abortions with the goal of improving and standardizing postabortion services.     

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.     

Sustainability of family planning and health projects

USAID has assisted the Ghanian Ministry of Health since 1991 to boost family planning services under the Ghana Family Planning and Health Project by providing supplies and information and increasing the effectiveness of HIV/AIDS prevention and control. The sustainability of the health system is endangered by favoring capital expenditures in lieu of continuous expenditures; the lack of linkage between project activities and regular activities; the centralization of resource flow; and too ambitious targeting. Capital outlays provided by USAID featured in the construction of four public health laboratories, but their operation also requires continuous financing amounting to about 10% of the whole investment. The latter is the responsibility of the government, although the details of these recurrent costs were not detailed at the outset and providing these funds for continuous operation may impair the operation of other systems. The resource constraints could be alleviated by an effective cost-recovery system or by the general improvement of the economy. The lack of linkage between project and regular activities is serious at regional and district levels. The centralization of resource flow means that most resources are kept for headquarter level activities, thus other activities suffer and the health sector becomes excessively reliant on donor support. Too ambitious planning stems from pressure on donors and hastily implemented projects result in duplication and waste. Closer consultation with the parties involved would improve the situation. The rivalry of technical and policy groups has contributed to past deficiencies. Double funding for the same activity has also occurred further increasing the dependence on donor funding. By concentration on people and systems sustainability would be enhanced, while cost recovery would help the operation of the laboratories. The Health Education Unit (HEU) recognized the importance of IEC and obtained financing for such activities.     

The Barangay service point officers: their performance and potentials

The Strengthening BSPO (barangay service point officer) Operations project aims to strengthen the outreach structure at the BSPO level by hastening its attainment of self-sufficiency and making it more responsive to community needs and demands. It has 2 specific objectives: to provide policymakers and managers of the outreach project with a research-based assessment of current organizational procedures, practices, and factors taht hindet the effectiveness od organizations and operations at the BSPO level; and to provide Popcom's decision makers with alternative means for evolving regional and national action plans to improve BSPO operations. This discussion presents the highlights of a 3rd major project report on the "Qualitative Survey Research on BSPOs and BSPO Operations." The report covers the outcome of focus group discussions (FGDs) conducted in 3 selected regions, with resondents consisting of BSPOs, fulltime outreach workers (FTOWs), married couples of reproductive age (MCRA), and barangay captains. 6 priority issues were taken up in the FGDs conducted: selection and recruitment of BSPOs; taining; incentives and awards; perception of roles and functions; functional relationships of BSPOs and other workers; and BSPO associations. The FTOWs considered the following qualities when choosing BSPOs: influence in the community; accessibility to neighbors; approachability and friendliness; respectability in the community; belief in family planning; satisfaction with family planning use; and ability to motivate people. Before starting volunteer work, BSPOs are trained formally for 3 days. While BSPOs recognize the importance of their role in community development, they are hesitant to accept too many tasks. They perceive the replenishment of contraceptive supply to be their primary function. Record keeping, home visits, information dissemination, and motivation are considered secondary. Popcom regional offices have incentive programs meant to cover all BSPOs. There also are incentives for outstanding BSPO performances. The available incentives are not always enough. Some BSPOs experience strained working relationshiops with workers of other agencies. Coordination among the various groups is limited. Experience has shown that the performance of BSPOs in general has not come up to the program's expectations because of improper recruitment practices, inaccurate communication of roles and functions, poor trining, inadequate incentives, and lack of coordination.     

Using operations research to guide family planning program development and policy formulation in sub-Saharan Africa

The process by which a population policy and family planning program evolve in a given country is influenced by many factors that combine to make each country's experience unique. One of the most influential factors among these is the role played by external technical assistance, normally provided through donor-supported mechanisms. One donor-supported mechanism that seeks to guide the operational policy and program development process is technical assistance through operations research. Many questions are raised during the design of family planning programs that are often best answered with reference to empirical evidence collected through applied, or operations research (OR). This paper provides a review of the three main OR approaches currently being used in sub-Saharan Africa: diagnostic or needs assessment studies; experimental pilot studies; and intensive technical assistance for problem-solving and institutional development. The extent to which these OR approaches can play a role in family planning program development to improve and expand service delivery activities is discussed, and examples where these approaches have been used are given.     

Family planning programs in industrial establishments: an operations research study

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

Total maternal and child care: an approach to the population problem

This article describes the Bohol Province Maternal Child Health/Family Planning Project, a 5-year project financed by the United Nations Fund for Population Activities and the Philippines Department of Health. The objectives of the project are to improve general health services, introduce family planning services in the context of the MCH program, improve training of personnel and evaluated the results of the program. 88 barrio health centers have been established, offering a range of maternal, child health and family planning services. 34 boticas (drugstores) have been set up in local variety stores, dispensing drugs at low cost. A strong research unit collects data for program evaluation and has so far published 23 reports, which are listed at the end of this article. Community acceptance of the program has, in general, been good; midwives have been welcomed. The program has encountered problems of religious conservatism and insufficient contraceptive supplies and has learned the need for good relations with the barrio leaders and residents. The 5-year limit needs to be extended. Progress in health services has been excellent. The effect on family planning, while encouraging, cannot yet be evaluated.     

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.     

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.     

Cagayan de Oro taps own resources to cope with population problem

In 1972, the Model City Population Planning Project (MCPPP) was begun in the Philippine city of Cagayan de Oro. The MCPPP was an attempt to encourage family planning on the community level. Funding was provided by the Ford Foundation for the program in 1974, for 2 years. There were 5 main objectives of the program: to provide family planning information to parents, to test small scale projects which could be applied elsewhere in the country, to actively involve local government, to reduce the birthrate, and to facilitate, coordinate and strengthen population and family planning services of the different agencies of Cagayan de Oro. While the MCPPP's efforts to reduce the birth rate were mostly concerned with coordinating and facilitating prexisting family planning services, evaluators of the project credit it at least partially, for the cities' declining birthrate. In 1971, the birthrate was 36.5 per 1,000 and in 1975, it had dropped to 29 per 1,000. In mid 1976 the program was incorporated into the nationwide Outreach Program. Although some evaluators felt that private citizens were not sufficiently involved with it, the program has been judged successful in demonstrating a city's capacity to work toward solving it's own problems. Particularly successful were efforts at educating the population and dissemination of family planning information.     

A cost benefit analysis of the barbados family planning programme

Abstract Of the Caribbean islands, Barbados has the lowest fertility level. The crude birth rate in 1970 was only 20·5 per 1,000, which is one of the lowest found in any country of similar economic development anywhere in the world. In 1960 the crude birth rate was much higher, at about 33·6 and for almost 40 years before that had fluctuated around a value of 33. Thus, a decline of about 40% has been achieved within the comparatively short period of a decade. The reasons for this rapid decline are of particular interest to all those concerned with population growth and economic development in the less developed areas. In Barbados, the importance of population control and the role of family planning was recognised early by the government and other civic agencies, and the Barbados Family Planning Association (BFPA), an autonomous national family planning agency, was established. Since its modest beginning in 1955 the BFPA has grown to be a major social institution, comprising 14 clinics situated in various localities throughout the island. In 1970, a full-time staff of 28 were providing services to an estimated 10,000 clients, about 20% of all women of reproductive age. Funds for the BFPA have come from local government with considerable assistance from international agencies.     

New home for a dynamic programme

In Nepal the promotion of activities aimed at improving the skills and status of women was formerly the task of the national organization, Mahila Sangathan, but is now the responsibility of the newly created Subcommittee for Women's Affairs. The subcommittee operates under the guidance of the Co-ordinating Council for Social Services under the sponsorship of Her Majesty the Queen. The subcommittee cooperates through chapters located in each of the country's 75 districts. Many of these chapters are actively engaged in 1) promoting family planning via door to door campaigns and through training local women for family planning motivational work; 2) stimulating the production and marketing of crafts made by women; 3) providing legal assistance to women; and 4) conducting literacy programs for approximately 10,000 women. A new headquarters for the subcommittee is being built with UNESCO assistance. The committee hopes to establish a library in the new building since a lack of reading material is hindering progress in its literacy program.     

Reproductive health care in India: a new paradigm

India has adopted a new approach to family planning that locates these services within the reproductive health care context. This means that family planning and reproductive health services will be offered as an integrated package. To implement this approach, the government will follow a framework for reproductive health designed by Saroj Pachauri, director of the Population Council's office in New Delhi, to guide the government's new Reproductive and Child Health Project. This initiative marks a significant paradigm shift in India; away from a population-control approach, implemented through a top-down, bureaucratic, target-driven program, towards a gender-sensitive high-quality services responsive to the health needs of clients, especially the women. Considering the geographical variations in reproductive health, the framework contains two service packages: an essential and comprehensive version, each consisting of broad categories of service and matrix of interventions. To support the transition underway, the Council has launched an advocacy project to educate health care providers and policymakers about reproductive health issues and help them translate the framework into effective programs. In order to successfully implement this initiative, partnerships with the nongovernmental sector, especially at the community level are essential.     

The jeepney driver: ally in family planning

Report of a project involving jeepney drivers as distributors of family planning information in the Philippines, implemented by the United Neighbors Philippines (UNP). This organization had previously experimented with using barbers and beauticians as distributors but lack of organization on their part led to difficulties. An experiment which used Protestant pastors had to be abandoned for lack of funds. The current program involves the 200-member jeepney driver's association in Cubao, Quezon City. A box of family planning informational materials is placed in each vehicle, within research of passengers. Materials include referral sheets entitling holders to free supplies (chiefly pills) at family planning clinics along jeepney routes. Encouraging numbers of passengers turned in the sheets, and some 50-80% of drivers themselves began to practice family planning. The project has since been expanded under the auspices of an 800-member driver's association in the Sta. Mesa area. Drivers in this project will undergo a 3-day paid training period, which will include information on location and facilities of family planning services along their routes.     

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

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

Basic policies of the Philippine Population Program

This history of the Philippine Population Commission, which was created in 1969, is summarized. In 1970 President F.E. Marcos defined the government's task in this area as: 1) educating the people on the urgent need for population control; 2) disseminating knowledge on birth control techniques; and 3) providing facilities, especially in rural areas. Funding began in 1971. The 4 basic policies are noncoercion, integration, multiagency participation, and the partnership of the public and private sectors. The noncoercion policy means that all birth control techniques are offered and couples are free to use or reject whatever they wish. This has probably slowed the spread of family planning, but has also minimized opposition. Family planning has never been the domain of 1 agency but has been implemented through many agencies working together. Now it is being implemented through total community development plans, of which family planning is merely 1 component. This approach puts irrigation workers, agricultural development workers, and many others on the family planning team. private agencies have also had an important role to play in the development of the total program. For the past 5 years these have been mainly voluntary sociocivic and health associations whose interests are very close to or naturally related to family planning. Now the entry of business into the Population Program through the commercial contraceptive marketing program has enlarged the role of the private sector in the diffusion of family planning products and services. It is possible that the partnership between the public and private sectors may soon be based on segmentation of the target population with government agencies going deep into rural areas while private organizations concentrate on urban and adjacent rural areas.     

Philippines: decentralized approach shows results

In the Philippines several steps have been taken to meet the challenge of increasing population growth. Commencing with the Republic Act 6365, known as the Population Act (1971) program directives focus on achieving and maintaining population levels most conducive to the national welfare. In 1978 a Special Committee was constituted by the President to review the population program. Pursuant to the Committee's findings certain changes were adopted. The thrust is now towards longterm planning to ensure a more significant and perceptible demographic impact of development programs and policies. Increasing attention is paid to regional development and spatial distribution in the country. The 1978-82 Development Plan states more clearly the interaction between population and development. The National Economic and Development Authority, the central policy and planning agency of the government, takes charge of formulation and coordinating the broader aspects of population policy and integrating population with socioeconomic plans and policies. At present the National Economic and Development Authority (NEDA) is implementing a project known as the Population/Development Planning and Research (PDPR) project with financial support from the UN Fund for Population Activities (UNFPA). This project promotes and facilitates the integration of the population dimension in the planning process. It does this by maintaining linkages and instituting collaborative mechanisms with the different NEDA regional offices and sectoral ministries. It also trains government planners in ways of integrating population concerns into the development plan. PDPR promotes the use of population and development research for planning purposes and policy formation. The Philippine Development Plan, 1978-82, recognized that an improvement in the level of 1 sector reinforces the performance of the other sectors. Since the establishment of the National Population Program 12 years ago, population and family planning have been successfully integrated with various development sectors, notably, labor, health, and education. Through the policies of integration, multiagency participation, and partnership of the public and private sectors, the Commission on Population uses existing development programs of government and private organizations as vehicles for family planning information and services and shares the responsibility of implementing all facets of the population program with various participating agencies in the government and private sector.     

Population activities of the United States government

The editor's comment in this issue of the journal cites 5 overlapping phases in the evolution of population and family planning programs in the United States. The phases are 1) collecting census data and vital statistics, 1790-, 2) family planning assistance to developing nations, 1963, 3) family planning assistance to the U.S. "disadvantaged," 1964-, 4) overpopulation as a national concern, 1969-, and 5) the multiple action phase, 197? (phase including diverse steps to limit population growth and occurring after basic attitudes toward human reproduction have changed). The issue of the journal focuses on total population size and rates of population increase rather than on the distribution of population, and on federal action rather than on the activities of state and local governments. The editor's comment is followed by an extensive discussion of population activities of the United States government, especially since 1963. Topics discussed include demographic data, international programs, research, federally subsidized family planning services, medical care programs, educational and international programs, national growth policy, and the roles of the legislative and executive branches of government. A directory listing federal agencies with substantial and identifiable programs concerned with population and family planning is appended.     

Malaysia implements the integrated approach

Malaysia has implemented an integrated approach in providing family planning services to eligible couples. In 1964 the government of Malaysia adopted a national family planning program, and implementation began in the urban areas and extended into the rural areas. Other agencies are involved in providing family planning services and information including the Federation of Family Planning Associations, the Ministry of Health, the National Family Planning Board, and the Federal Land Development Authority. The number of women practicing contraception has increased from 20,726 in 1967 to 533,646 by 1976. and other methods, 3.9%, respectively. There has been an increase in the percentage of acceptors between ages 15-29 from 56% in 1968 to 71.3% in 1975. The 2nd Malaysian national plan will use a multidisciplinary approach to the problem.     

Integrating family planning with nutrition and parasite control

At the Inter-Governmental Coordinating Committee Workshop on an Integrated Approach towards Family Planning and Health Programs held at Kuala Lumpur from March 23 to 25, 1977, the feasibility of integrating family planning with nutrition and parasite control through the proper planning of motivational considerations, resource allocation and coordination was studied in detail. Discussion focused on the experience of participating countries in generating community participation in total health programs. Malaysia reported that in the expansion of the national program into the rural areas functional integration has been the approach. In Indonesia nutrition has been an important objective of maternal and child health services. A total integrated development approach has been the objective in the Philippines where family planning information-education-communication has been integrated with nutrition programs and a pilot project on integration of family planning and parasite control has been conducted. Thailand reported on the introduction of an integrated family planning and parasite control program, while Sri Lanka reported on an integrated approach that included family planning with maternity and child health services. A recommendation of the meeting was that experimental pilot projects be established which include nutrition and parasite control elements within the framework of family planning services.