Family planning program effects on contraceptive use in Morocco, 1992–1995

This study illustrates the use of panel data and a fixed-effects estimator to investigate the impact of family planning program inputs on contraceptive utilization in Morocco during the 1992–1995 period. By controlling the potential bias resulting from common unobserved determinants of program resource allocation decisions and program outcomes, the methodology helps overcome an important constraint to the use of non-experimental study designs in undertaking meaningful impact assessments. Data from a panel of women interviewed in both the 1992 and 1995 Morocco Demographic and Health Surveys were used in the study, along with program data from Service Availability Modules undertaken in conjunction with each survey round. The results indicate that changes in the family planning supply environment, in particular increased presence of nurses trained in family planning and the level of infrastructure at public clinics, played a significant role in the increased use of modern contraceptives during the study period.     

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.     

Do incentives matter? – Evaluation of a family planning program in India

Indian Family Planning programs in the past haveintroduced a number of approaches such as providingmonetary benefits, and motivational programs toimprove contraceptive use among rural illiteratewomen. Under the Ammanpettai family welfare program,the Melatur PHC administered three program typesinvolving a combination of monetary and motivationalapproaches to improve contraceptive use in threetreatment areas. The program was introduced duringJanuary 1989 and was simultaneously discontinued aftera period of two years. The present evaluation wasconducted in 1994. Data from a random sample of 933non-sterilized women at the time of social surveyusing a questionnaire approach is used in this study. The implementation of incentive programs in asocio-economically homogenous population has resultedin an increase in the likelihood of current ofcontraceptive use. The results of this study suggestthat motivational programs are more likely to improvelong term use of temporary family planning methodsthan cash incentive programs. One implication of ourfinding is that motivational programs should provide peer based family planning education and training incommunity work to contact persons who make door todoor visits to promote family planning programs.     

Population research and education in Vietnam

Population research and education in Vietnam have expanded in their functions since the early 1980s. There are currently 5 departments conducting demographic studies: the National Committee for Population and Family Planning within the Ministry of Health, the Ministry of Education, and the Institute of Pedagogical Sciences, the Ministry of Labor Fore, the Vietnam Women's Union, and the Youth Union. An overview is provided of each department and its research and educational activities as well as the General Statistics Office (GSO) and the Institute of Sociology. GSO provides statistics on population annually from a variety of sources including the decennial census. The last census was conducted in 1989 and is useful for understanding general demographic trends. Vital rate data are considered too low. The Institute of Sociology uses the sample survey and focus groups to examine social and economic conditions and their effects on norms and values about reproduction. The Institute conducted a knowledge, attitudes, and prevalence (KAP) survey in 1984. Studies have focused on the commune level and the role of government in population regulation. Findings have supported a position that the goal of a 2-child family is not attainable without social and economic change as well as family planning. Migration studies have also been undertaken with the Ministry of Labor. The National Committee for Population and Family Planning is concerned with studies on the biotechnology of contraceptive methods and abortion. A study in 1987 examined health workers attitudes toward and knowledge of a variety of contraceptive methods. In 1988 the Demographic and Health Survey was conducted and data were comparable internationally. Studies have been helpful in designing training programs and in informing decision makers. Forecast data in 1990 were useful in setting targets for the coming decade. The Ministry of Education targets the general public and students. Materials aim to create positive attitudes to family planning and to inform about general population issues. Special groups such as the Women's Union have conducted KAP studies and the Center for Women's Studies has focused on the problems of women in development.     

Family growth and family planning: Responses to a family-planning action program in a rural district of Thailand

A resurvey of a rural district in Thailand, of about 70,000 population, was conducted after a family-planning program had been in operation for eight months in order to ascertain indications of effectiveness of the program. Both the "before" and "after" surveys employed a 25 percent simple random, though non-overlapping, sample of married women 20-44 years of age whose husbands were living. The only difference in design and execution was the inclusion in the resurvey of questions about the action program. Barring one or two exceptions, the characteristics of the two population samples were so similar that differences in knowledge, attitudes, and practices could be regarded as effects of the program.The action program not only made itself widely known in the district, it also evoked a highly favorable appraisal, to such an extent that nine of every ten women thought the program should be extended over the entire kingdom. Motivation to engage in family planning increased perceptibly. A substantial proportion (23 percent) of the women who formerly disapproved of the practice changed their attitudes to approval, mainly because they had become convinced of the harmlessness and the utility of fertility control. Less than 3 percent of the former approvers had become negative.The proportion of women who claimed some kind of knowledge about contraceptive methods more than doubled during the eight months of the program's operation. More impressive, however, was the change in actual use of methods, which rose from 1 to 21 percent of the eligible women (women who were not pregnant, subfecund, or sterilized). Another 16 percent, in the resurvey, planned to begin use of contraceptives in the near future, in most instances after a current pregnancy. The frequency of acceptance of family planning practice exceeded the expected frequency among women who were approaching or had attained the "ideal" number of children (4.0 children). High-parity women 40 or more years of age seldom accepted clinical assistance.     

The right to have a second birth given up

The Government of the Wendeng County, Shandong Province has taken measures to carry out the family planning program in a down-to-earth way. For the past few years, there are 2141 couples who have given up, of their own accord, the right to have a 2nd birth, though they are entitled to have. During the practice of family planning, the Wendeng Government started with the publicity of family planning policies. More than 30,000 copies of publicity pamphlets were distributed and about 220 shows of videotapes, films and slides were played in the countryside. The county's Family Planning Committee and the Maternal and Child Health Care Station, together with other departments concerned gave 120 lectures on birth control in the rural areas and sent contraceptives to every village with guidance to households. For the past 3 years, the proportion of women at childbearing age using contraceptives has increased by 62%.     

The role of contraceptive supply and demand in Mexican fertility decline: evidence from a microdemographic study

This paper uses retrospective life history data to assess the impact of family planning services on contraceptive use in a rural Mexican township. Between 1960 and 1990 contraceptive use rose and fertility declined dramatically. Both contraceptive supply and demand factors were influential in these trends. The start of the government-sponsored family planning programme in the late 1970s was associated with a sharp rise in female sterilization and use of the IUD. However, once we controlled for the changing socio-economic and demographic characteristics of the sample, the presence of family planning services had no significant effect on the likelihood that women used modern reversible methods compared to traditional methods. Men and women expressed concerns about the safety of modern methods such as the pill and the IUD. Efforts to increase modern contraceptive use should place greater emphasis on communicating the safety of these methods and improving the quality of services.     

The Role of Contraceptive Supply and Demand in Mexican Fertility Decline: Evidence from a Microdemographic Study

This paper uses retrospective life history data to assess the impact of family planning services on contraceptive use in a rural Mexican township. Between 1960 and 1990 contraceptive use rose and fertility declined dramatically. Both contraceptive supply and demand factors were influential in these trends. The start of the government-sponsored family planning programme in the late 1970s was associated with a sharp rise in female sterilization and use of the IUD. However, once we controlled for the changing socio-economic and demographic characteristics of the sample, the presence of family planning services had no significant effect on the likelihood that women used modern reversible methods compared to traditional methods. Men and women expressed concerns about the safety of modern methods such as the pill and the IUD. Efforts to increase modern contraceptive use should place greater emphasis on communicating the safety of these methods and improving the quality of services.     

Why women who don't want to get pregnant don't use contraception

In the developing world about 120 million women have an unmet need for contraception. They want to postpone childbearing, yet they do not use contraception, often because of the unavailability of services and supplies. However, according to a recent article by John Bongaarts, the primary factors are lack of knowledge about a contraceptive method, concern about side effects, and the disapproval of the male partner in developing countries. Lack of knowledge means inability to describe the uses of a contraceptive, its side effects, and the locale of its availability. An approximate knowledge index was calculated for such women, which showed that knowledge level positively correlated with contraceptive prevalence. Countries where the index was below 50% had a contraceptive prevalence of 8% only. The determinant reasons why women were reluctant to use the pill, IUD, and sterilization had to do with health and the fear of side effects, such as nausea and increased bleeding. The contraceptive prevalence among these women was reduced by 71% for the pill, 86% for the IUD, and 52% for sterilization. In Sub-Saharan countries nearly 70% of women cited partner disapproval of contraception, although they had never discussed family planning with their partners. The central concept for reducing unmet need is access with quality, which means that services are voluntary, safe, and appropriate in delivery. Some of the recommendations to reduce the unmet need for contraception include: one-on-one same-sex discussions to increase contraceptive knowledge and acceptability; sensitive responses by programs to their client's health concerns; support by service providers to women negotiating with male partners in order to mitigate male disapproval; and sex education and family planning services to reduce unwanted and early sexual contact and pregnancy while girls develop identities apart from mothering roles.     

Family planning for new mothers in the Philippines

From November 1997 to February 1998, a survey was conducted to evaluate postpartum family planning (FP) services in the Philippines. Data were gathered from records at 86 clinics in 28 provinces and from interviews with 338 FP providers and 3452 clients who began to use FP within 6 months of delivery. Only 7% of women began using FP within 6 months of delivery, and most postpartum attention was devoted to child care issues. Among the women surveyed, most resumed sexual intercourse at 2.4 months postpartum and experienced a return of menses at 4.4 months postpartum despite breast feeding for 6.2 months. The most commonly recommended method to space births was the IUD followed by the injectable contraceptive. Very few providers recommended use of barrier methods. The results indicate that many breast-feeding women are receiving hormonal contraceptives too soon and that IUD insertion may not be occurring at the ideal time postpartum. While a significant percentage of providers recommended use of the lactational amenorrhea method (LAM) and 16% of the women relied on it, the providers lacked sufficient understanding of LAM. In addition, many women switched or discontinued methods. The study led to the recommendations that postpartum FP services be promoted as an essential part of maternal-child health care and that FP providers receive improved training about contraception and LAM.     

Regional variation in acceptance of Indonesia's family planning program

Indonesia's family planning program is regarded as a major success.Survey data from 1997 reveal that rates of contraceptive use vary dramatically amongIndonesia's 27 provinces, from a high of 67 percent of ever married women currently using contraceptives in the province of North Sulawesi, to a low of 19 percent current users in East Timor and28 percent in Aceh. This study uses both a quantitative analysis of the 1997 Indonesia Demographic and Health Survey, and a qualitative study carried out in July of 2000 to understand regionalvariation. The study identified a small number of factors that show a clear relation with levels of contraceptive use. Media exposure and education are the strongest and most consistent predictors of levels of contraceptive use, and appear to be the surest strategies for promoting family change. But the study also showed that the process of social change is subjectto culturally and historically specific local factors whose presence and importance is difficult to predict. Our study of regional variation in contraceptive use illustrates the range and complexityof obstacles faced by Indonesia's leaders in attempting to forge a single nation fromsuch a diverse and far-flung population. Although the creation of Indonesia in the space of just half a century is a monumental achievement, the project is clearly not yet complete.     

Secrecy and silence: why women hide contraceptive use

A recent Population Council survey of 1860 married women and 1056 of their husbands in urban Zambia found that many women who use contraception do so without their husbands' knowledge and that those women who hid their practice of contraception from their husbands did so because they found it very difficult to bring up the subject of family planning with them. These findings indicate that low levels of contraceptive use are not the result of a simple communication matter. Sex and sexuality are often the exclusive domain of African husbands. As such, if a wife initiates a discussion of family planning, she may threaten her husband's sense of control and create discord within the family. The culture of silence about sex and sexuality is very strong in Africa. 57% of women stated that were they to propose contraceptive use with their husbands and the husband opposed such practice, they would nonetheless use them without his knowledge. 7% of the women stated that if their husbands disapproved of contraceptive use, they would nonetheless openly use a method against his wishes. The majority of women correctly perceived their husbands' views on family planning use and fertility preferences. In focus groups, both men and women said that they did not believe that women have the right to independently act upon their reproductive preferences. A husband's inadequate financial support of his children could, however, justify clandestine contraceptive use. These findings point to the need to include easily hidden methods in the mix of contraceptives family planning programs offer. Moreover, service providers should not automatically encourage husbands' involvement. A client's right to privacy should always be respected.     

Gender differences in knowledge and attitudes toward modern and traditional methods of child spacing in Malawi

This paper examines male-female differences in knowledge and attitudes towards traditional and modern methods of child spacing in Malawi, based on the survey on traditional methods of child spacing in Malawi which was conducted in 1988. The results show that most people in Malawi are knowledgeable about both traditional and modern methods of child spacing. In general more men than women report knowledge and practice of traditional methods. For modern methods, however, females are more knowledgeable than males of all the specific methods, with the exception of condoms. The greater knowledge by women of female-based modern contraceptives appears to be a manifestation of the exclusion of males from the family planning program. The high rates of knowledge do not translate into equivalent high rates of utilization for both modern and traditional methods of contraception. The study further demonstrates that, while women are involved in making decisions to use contraception, the proportion of men initiating such decisions is greater than that of women. This finding calls for family planning planners to think seriously about revising their target population to include men.     

Barriers to contraceptive use among Pakistani couples

Despite the existence of a family planning program in Pakistan since 1965 and widespread knowledge among Pakistanis about contraception, there is a high level of unmet need for family planning. One recent survey found that while 53% of married women express the desire to avoid pregnancy, less than 20% use contraception. A recent Population Council study conducted in urban and rural areas of Punjab province investigated personal beliefs, family circumstances, social norms, and gender relations among 1310 married women and 554 of their husbands. The unmet need for contraception was highest among women over age 30 years, those with more living children, less educated women, and women living in rural areas. The study found that while most Pakistanis approve of family planning, obstacles to contraceptive use exist in most marriages. 97% of respondents who wanted another child wished for a boy. That preference for sons influences contraceptive use behavior. The fear of social disapproval of contraceptive use, perceived opposition from in-laws and husbands, and fear of health side effects and divine punishment were major reasons identified against contraceptive use. Female contraceptive users were more autonomous and likely to make domestic decisions without consulting their husbands, while husbands defer to social and cultural norms.     

Adding choice to the contraceptive mix: lessons from Indonesia

Researchers asked 1945 women of reproductive age living in East Java, Indonesia what contraceptive method they preferred during the women's 1st visit to a government family planning clinic. Soon after field workers introduced them to a method, the researchers asked the women what method the field workers suggested and what method the women planned to use. They again spoke to them 1 year later to determine contraception continuation. The field workers granted 86.3% of the women their method choice. Only 9% of these women had stopped using their chosen method while 72% of the women who were not allowed to use their chosen method stopped using the method assigned to them. Thus choice was a key factor in sustained use of contraceptives. Further if family planning workers stick to a mutual participation of both themselves and their clients, they respect clients' method choices and, by informing clients about the chosen method, they strengthen clients' decision making. In the early 1990s, another researcher had developed a system to determine contraceptive needs at various stages of the reproductive period (before 1st marriage, after 1st marriage but prior to 1st birth, after 1st birth but prior to last birth, and after last birth). She applied observed contraceptive preferences for women using contraception within each life cycle stage to the age specific contraception need, derived from data from the 1987 Contraceptive Prevalence Survey for Indonesia, to determine the ideal contraceptive mix. Her calculations demonstrated that oral contraceptive use was high, IUD use was low, particularly among older women, and too few sterilizations had occurred, particularly among older women. Thus Indonesia needed to broaden the contraceptive mix to encourage methods that better meet women's reproductive life cycle needs.     

Tonga: family planning survey

A survey was carried out in 1975 in Tonga to determine how many families are practicing family planning. Public health nurses visited every household except the Niuas and remote islands. 4253 women out of the total of 9307 married women aged 15-44 years were using a contraceptive (45.7%). The percentage of users ranged from 4.5% in Ha'afeva District to 63.6% in the district of Kolonga. 60% of the users practice effective methods such as the pill, Depo-Provera, IUD, or sterilization; 23% use the condom, and 17% rely on withdrawal, calendar ovulation, or rhythm.     

Health worker pilot project

In a survey conducted by the Kavar Village Health Worker Project in Iran, among married women, aged 15-44, residing in 16 villages served by project trained, auxillary rural health workers, 28% used oral contraceptives, while only 13% of the women who resided in 16 control villages served by untrained rural midwives used oral contraceptives. Among women in the 25-35 age bracket, the % of oral contraceptive users in the project villages was twice as great as in the control villages. Surprisingly, despite the strong Muslim tradition extant in these villages, no significant differences in usage were found between those villages served by male auxillary health workers and those served by female workers. The auxillary health workers had been trained to provide a wide variety of preventive and curative medical services, in addition to providing family planning and contraceptive distribution. At the time of the survey, these workers had been serving the 16 villages for 21 months. In the 16 control villages the nonresident midwives had received no training but had been provided with oral contraceptives for distribution.     

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.     

The international family planning movement

Over the past 3 decades, the number of women using family planning has increased 6-fold to over 400 million married women of childbearing age. The evolution of behavior and attitudes toward using birth control among third world couples reflects the goals and hard work of an international network of individuals, governments and organizations. This article follows the progression of this movement, from early opposition in developed as well as developing countries, to the present day, when birth control is practiced by a slight majority of the world's women of childbearing age. Among world regions, contraceptive use ranges from about 17% in Africa to 75% in Asia. In some African countries, however, family planning is still a foreign concept, and fewer than 5% of women use any birth control. International organizations played a crucial role in spread of family planning by providing training for developing country professionals, funding actual family planning programs and helping to evaluate programs. But the success of a country's family planning program also was dependent upon a national commitment, and often on a strong socioeconomic setting. The private sector has had a limited role except in some countries, notably in Latin America, but its involvement is likely to expand in the future. Also, as financial support from the US and international organizations wanes, national governments will cover a larger share of the cost. The worldwide increase in the practice of family planning has led to fertility declines in many third world countries, slowing rapid population growth rates. For individuals, family planning has been a liberating influence, allowing them to participate more fully in the shift from traditional to modern society.     

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.