Measuring acceptances in a family planning program: the decomposition of rates by eligibility criteria

Acceptance rates in family planning programs can be broken into components useful in analyzing programs and in evaluating success. In almost any program some couples can be defined as "ineligible" on the basis of alternative criteria. (Sterilized couples are an obvious example.) Then, the total acceptance rate can be initially separated into two components-the proportion eligible and the acceptance rate among the eligible. If some of those initially defined as ineligible become acceptors, there is a third component-the ratio of all acceptances to acceptances among the eligible only. These various components can be used to analyze the basis for varying acceptance rates between different strata of a population.     

India well prepared for meeting future goals

In India many of the past goals for reduction in birth rates have not been achieved for various reasons, and although contraceptive usage has increased it has not been sufficient to overtake the reduction in death rates. From 1971-80 about 1/2 of the population of the country was subject to a decline in growth rate, and the number of eligible couples using effective contraception was 10.6% in 1971 and 22.7% in 1981 in spite of an increase in the number of such couples. The death rate declined from 27.4 in 1941-51 to 14.8 in 1971-81 with a corresponding increase in life expectancy from 32-52 years. However the growth rate has reached a plateau during 1971-81. Since its inception the Family Welfare Program in India is estimated to have averted 49 million births including 5 million in 1981-82. Future goals are: 1) reduction in birth rate from 35 in 1981 to 21, death rate from 14 to 9 and infant mortality rate from 125 to 60 by the year 2000 along with reductions in maternal mortality and morbidity, and 2) an increase in the percentage of couples protected from 23.6 in 1982 to 60 in 2000, and 3) population size of 950 million by the year 2000 and the commencement of population stabilization leading to a population of about 1200 million by the middle of the 21st century. Future strategies for the promotion of planned parenthood include information, education, and communication programs, incentives and disincentives, involvement of nongovernmental agenices, provision of services and supplies, linkages with other sectors, and monitoring and evaluation activities. Emphasis will be put on interpersonal communication channels to promote the program as a mass movement.     

Magdamayan: drawing the family into community work

Magdamayan is an old word meaning to help one another; it has been chosen as an acronym for a program currently being undertaken by the Family Planning Organization of the Philippines (FPOP) that addresses itself to family life and community development -- a departure from previous FPOP projects. It aims to reach out to rural villages through 44 chapters covering selected communities in the 3 major island groups. Its main objectives are to reach the majority of the eligible population in each village, increasing the awareness, knowledge and understanding of family planning; to enlist 80% of eligible couples; and to maintain a 90% continuation rate. The 1st cycle of the project activities was begun in July 1975, divided into 3 phases spread over 18 months. Phase 1 involved preparations for the project in the villages, including a baseline survey. Phase 2 was the actual program phase, including a mass information drive, contraceptive promotion, identification of target groups, training of motivators, and provision of backup services. Phase 3 involved the phasing out of FPOP staff and turning the project over to community volunteers, and evaluation. Among the activities employed to facilitate integration of family planning into community life were 57 vocational skills training courses, various income generating activities (dances, sporting events, raffles) and community development projects. Preliminary evaluation of the 1st cycle indicates impressive success, but below the 80% acceptance and 90% continuation rates. Community development activities were seen as much enhanced, and basic health services and vocational skills training were successfully introduced. Constraints identified as limiting the success are discussed, and it is concluded that the program's performance this far is good enough to warrant its use as an alternate or model for similar family planning projects.     

Falling fertility in Indonesia: success in national family planning

This publication summarizes the findings of the National Indonesia Contraceptive Prevalence Survey (NICPS), which revealed a rapid decline in Indonesia's fertility rate. This article also describes how the successful Indonesia family planning program is designed and maintained. Since 1975, fertility rates have dropped from 5.5 to 3.3 children per woman. Those practicing contraception during the same period has risen from 400,000 couples to 17 million. Contraceptive education is high (e.g. 95% of all married Indonesian woman are familiar with a modern contraceptive method). The Indonesia family planning program cooperates with other government activities designed to improve people's health and welfare. It emphasizes access to contraceptive methods and promoting the idea small family. The program was structured to us extensive community involvement, and cultural beliefs were incorporated into program policy; Islamic leaders were consulted before program implementation. The program is flexible so that the differing needs of each region can be effectively met by the family planning program. The future main goal will be to contain a potential population boom when the 40% of the present population which is under 15 years of age becomes reproductively mature.     

Indonesia: paradise lost

Bali has been facing a rapid increase in population over the past 15 years. The total now is 2.3 million and density is 409/sq km. Recent family planning efforts have produced good results with 56.2% of eligible couples using a contraceptive. This success appears to be due to 1) religion (most are Hindus), 2) Balinese women are receptive to arguments of having fewer children as many work, 3) many (68%) use the IUD so the dropout rate is low, and 4) the traditional community organization system (BANJAR) is used and it has monthly meetings.     

We must complete the population control system to control the population peak and achieve our population goal]

Since 1986, China has experienced another baby boom which is expected to last till 1997. If no effective measure is implemented to check population growth, the population target of around 1.2 billion will not be achieved. The author proposed four population regulation mechanisms that need to be strengthened. First, ideological education needs to be used to change people's perceptions about family size, so that couples would willingly accept small families. Second, financial incentives and penalties need to be used to direct people to regulate their fertility. The incentive and penalty technique directly affect the interests of the family and is likely to produce rapid results. Third, legislation can be used to regulate reproductive behavior, the laws and legislation which restrict social behavior should be utilized for population control purposes. Once legislation on fertility regulation is passed, those who violate the law can be penalized. Furthermore, legislation gives family planning (FP) workers legitimacy in implementing the program and can help avoid disputes in the process of FP program implementation. Fourth, provision of contraception and abortion services is an important mechanism to ensure the realization of the objectives of population growth control. Meanwhile, the effectiveness of contraceptive methods and the acceptance of abortion depends on the research and development of contraceptive technology and on abortion techniques. These fertility regulatory mechanisms have not be adequately established, and their functions have not been fully utilized. The current FP program is hampered by simplistic ideological education, abusive use of incentives and penalties, lack of legislation, and unmet needs in contraceptive development. To achieve the population targets, these mechanisms need to be strengthened.     

Economic development and fertility decline: lessons from Asia's newly industrialized countries

The general thesis that economic development and fertility decline are interrelated is substantiated in literature that discusses the successes of the newly industrialized countries of Hong Kong, Korea, Singapore, and Taiwan. When countries are developing rapidly, family planning accelerates the rate of fertility change, particularly among the poor uneducated rural population. Relying on economic and social development is not enough. National policy in Hong Kong, Singapore, Korea, and Taiwan recognized that population growth drains resources and the family planning programs operating since the 1960s contributed to a drop from 5 children/woman to 2 by 1988, and 70% of married couples used contraception. Coupled with this, age at marriage rose, contraception became more available, and educational and employment opportunities increased. Economically, the growth rate in the 1980's was 6-10% annually, with growth in the manufacturing and service sectors and export trade. Close economic ties evolved between governments and private sectors. Social development programs had been fully funded and gains evident in education, living standards, health care and nutrition, and life expectancy. The success of family planning is attributed to encouraging contraceptive awareness and use. Fertility reduction may occur with social and economic development, but no developing countries have reduced fertility without family planning. The relative importance of family planning may change over time, and reducing the cost through government sponsored family planning programs and encouraging the acceptability of contraceptive usage.     

The time response in averted births

Abstract A calculation of the timing of births that are averted may seem a curious exercise, when not only do the births in question not occur, but the corresponding conceptions may never have existed. However, such a calculation may have considerable use. In order to assess the likely direct impact of a contraceptive programme on birth rates it is useful to estimate the number of births that would, in the absence of the programme, have occurred among the couples who accept it. Moreover, some time would necessarily elapse before a new 'steady state' in fertility could be reached, even if the programme and the potentially fertile population did not change in any way; and it is worth while to seek to find the times (for a few years after the start of a programme) when the (averted) births would have occurred in its absence, and to examine any inherent oscillations produced in birth rates by it. This question is considered below only for groups of women aged 20 at marriage (a state which is taken to be the start of regular exposure to the risk of conception), but the same methods are applicable to other ages, (possibly allowing for mortality) and appropriate combinations of age groups and cohorts in the fertile range may be used to estimate changes in fertility and reproduction rates expected from a programme, subject to given conditions, for several years after its start. The methods can also be generalised, by means of convolution, to contraceptive programmes that change with time, but these are not considered further.     

Educational efforts in the implementation of rural family planning programs in East Pakistan

The pilot family planning studies reported in this paper were conducted in a rural area adjacent to the city of Dacca in East Pakistan. It reports the preliminary findings of action-research in the implementation of educational efforts to reach rural villagers of a developing country.Preliminary analyses of the records identify two significant educational problems: (1) most of the villagers (85-90 percent of the couples) who initially accepted contraceptives do not truly adopt and become continuing users and (2) the continuing users (10-15 percent of the initial users) are generally characterized by large families. (Later data show an even lower percentage of continuing users.)The field activities in the development of various educational approaches to family planning are described. Three separate geographic areas (from 15,000 to 20,000 population) were each approached in a different way, varying in the number and educational qualifications of the workers and in the degree of involvement of village leadership. Preliminary analyses of field records indicate that these variations of approach apparently have little effect on the percentage of the population willing to accept contraceptive supplies.It is the opinion of the writers that more intensive educational efforts are necessary at the village level to develop social support for continuing use of contraception and to gain adoption of contraception by younger married couples primarily for spacing of births.The impact of introduction of the IUCD in populations where condoms and foam tablets have been available for one to two years has also been reported. Preliminary findings indicate that the IUCD encourages adoption by previous non-users and may increase the over-all percentage of contraceptive users.     

Emotional Variation and Fertility Behavior

Emotional influences on fertility behaviors are an understudied topic that may offer a clear explanation of why many couples choose to have children even when childbearing is not economically rational. With setting-specific measures of the husband-wife emotional bond appropriate for large-scale population research matched with data from a long-term panel study, we have the empirical tools to provide a test of the influence of emotional factors on contraceptive use to limit fertility. This article presents those tests. We use long-term, multilevel community and family panel data to demonstrate that the variance in levels of husband-wife emotional bond is significantly associated with their subsequent use of contraception to avert births. We discuss the wide-ranging implications of this intriguing new result.     

The dynamics of contraceptive adoption in Bohol,Philippines: 1976-1978

A researcher analyzed 1976 and 1978 data on 414 rural women who had never used a family planning method to prevent pregnancy and lived in the predominantly Catholic island province of Bohol in the Philippines to look at the influence certain aspects of the family planning program, begun in 1976, as predictors of changes in contraceptive behavior. 34.5% accepted contraception between 1976-1978. The researchers learned that couple traits (e.g., age, income, education, and religiosity) had only an indirect effect on change in contraceptive behavior. A desire to stop, limit, or space births (motivation) was a strong predictor of family planning method acceptance (p.001). Further couples who clinic providers contacted the most often or who had received more family planning services (services) were much more likely to use contraceptives (p.001). Indeed a significant relationship existed between motivation and services (p.001). Moreover couples who were truly motivated to use family planning methods did not let distance to family planning services prevent them from seeking these services (p.001). On the other hand, couples who confronted personal obstacles to family planning including social, psychological, and other subjective costs (cost index) tended not to accept family planning methods (p.001). A negative association existed between services and location of households vis a vis the intervention program (p.001) which indicated that the program did have an effect in the area of the province where it was located. In conclusion, the strongest predictors of change in contraceptive behavior included motivation, services, and cost index. Services and cost index indicated the great importance of interpersonal and/or client staff contact, especially since they were more important in influencing behavior change than distance and family planning site.     

Effect of declines in mortality on the birth rate and related measures

In December 1961, the government of the Republic of Korea adopted a programme of family planning as part of its public health services. In 1962 a pilot research project was begun, under university auspices, with the object of demonstrating and assessing what can be achieved through intensive family planning education and services. Wondang Myun near Seoul, with a rural population of 9,000 in seven villages, was chosen for the study. A baseline survey covering attitudes and practices related to family planning was made of the population under study, as well as of a similar population in the control area of Kimpo Myun. This report outlines the design, the programme of education and services, and some of the preliminary results of the study. After eighteen months of the programme, acceptance of birth control measures increased fourfold among the married women in the fertile age range. Acceptance was highest among the 25–39 age group, and among high-parity women. Economic considerations were foremost among the reasons given for adopting family planning. Among the traditional methods offered, the condom was the favoured method of choice, indicating that husbands were taking the initiative in contraceptive practice. A decline in the crude birth index was observed; whether the decline was due more to contraceptive practice or to abortion, at least an increase is reflected in the effective desire for family limitation. The high failure rate among Users should be investigated further. Continued effort is needed to provide more information and detailed instruction to users, and to develop social circumstances that support the practice of family planning. Along with an effort to achieve more effective use of traditional methods, other methods, including intra-uterine devices, deserve trial.     

Sex preference and fertility: what is the link?

It is argued that investment in programs for changing attitudes toward sex preference may not have the greatest impact on reducing fertility or increasing fertility control. Arnold's new method of analysis of determining sex preference was applied to data from a 1977 Egyptian survey of 36,000 rural households in Menoufia Governorate. Findings indicated that couples increased their use of modern contraceptives in direct proportion to an increase in the number of sons. Arnold determined that a large majority of all couples would have at least one boy early in their childbearing years. Thus sex preference would not have a large effect on fertility. Arnold's analysis among 27 countries found that without any sex preference, contraceptive usage would increase by an average of less than 3.7 percentage points. Arnold found that sex preference was strongest in Asia, particularly in South Korea and Taiwan that already have reduced fertility levels. In Africa, where fertility is high, the total elimination of sex preference would have only a 2.9 percentage point difference in contraceptive use. Sex preference had small effects on the percent of women who practice contraception, the percent who desire no more children, and the average number of additional children wanted. For example, in Bangladesh having no sex preference would show a percentage difference of 1.6 percentage points for contraceptive use, 4.7 percentage points difference for women desiring no more children, and -0.1 percentage point difference for the average number of additional children wanted. The effect of having no sex preference was strongest in India compared with Bangladesh, Indonesia, Nepal, the Philippines, Thailand, Ghana, Kenya, Costa Rica, Haiti, Paraguay, and Peru. The effect of no sex preference in India would have the respective percentage point effect of 3.7, 8.9, and -0.2. Public policy should be directed to information, education, and communication with other social goals.     

Application of life table techniques to measurement of contraceptive effectiveness

Two problems are associated with the analysis of use-effectiveness of contraception. First, couples belonging to a sample of contraceptors typically vary in their monthly chances of contraceptive failure. Second, one does not observe for many, and perhaps a majority of the couples, how long they can remain protected with the contraceptive, because either they are stopping contraception to plan a pregnancy or else observation of them is being interrrupted by lost contact, by discontinuation of contraception for other reasons, or by the end of the study. It is argued that because of these two problems-namely, sample heterogeneity and incomplete histories-the Pearl pregnancy rate, which has been traditionally used to measure contraceptive effectiveness, is inadequate.A life table method is described that permits one to combine incomplete histories with complete ones for purposes of estimating the proportions of the sample that might have remained protected for specified periods if all members had remained under observation for these periods. The versatility of the techniques is illustrated in relation toa retrospective survey. A detailed account of procedure is given. Finally, it is shown that only under specialized conditions that are rarely met in practice is it possible to estimate the results of the new technique from knowledge of Pearl pregnancy rates alone.     

Improvement of contraception during the course of marriage

Contraceptive effectiveness is conventionally measured by a pregnancy rate, which reveals little about the way in which pregnancy risks vary among couples. In this paper a technique is presented for estimating curves of pregnancy risk. The technique is applied to data from the Family Growth in Metropolitan America study for purposes of estimating how much these couples would have to Improve their initial contraception In order to realize, by contraception alone, the calibre of family limitation claimed by respondents late in their childbearing period. A very substantial improvement Is estimated as necessary.

It Is also argued that the notable increase In contraceptive effectiveness before and after second birth, observed for couples desiring only two children is attributable mainly to a more regular practice of contraception. Changes Iin method preference, decline in average fecundabillty and increased contraceptive skill are viewed as secondary factors.     

Differences in mortality by marital status in Finland from 1976 to 2000: analyses of changes in marital-status distributions, socio-demographic and household composition, and cause of death

Being currently not married is more common today than 25 years ago. Over this period relative differences in mortality by marital status have increased in several countries, mainly as a result of a sharp decline in mortality among the married. Using Finnish census data linked with death certificates, we show that these increases are not explained by the non-married population becoming more marginalized in socio-economic status or household composition. However, the increases in marital-status differences in mortality from accidental, violent, and alcohol-related causes of death in the 30-64 age group indicate that changes in the health-related behaviour of the non-married population may play a role. The public-health burden associated with not being married has also grown. At the end of the 1990s about 15 per cent of all deaths above the age of 30 would not have occurred if the non-married population had had the same age-specific mortality rates as the married population.     

Advocating "one couple with one child" being an optimal choice]

Zero population growth within the next 5 years in China would be reached only if many couples were not allowed to have their own child. On the other hand, if every couple were allowed to have 2 children China's population would reach 1500 million within the next 50 years. It seems advisable to advocate the "1 couple 1 child" idea; couples will have to keep in mind both the national interest and the communist ideology; social welfare to assure good living conditions for the old people will relieve the worries of parents with 1 child only. Most people are willing to follow this decision made by the Communist Party; many people declare their willingness to stick by this rule during their wedding ceremony; many couples send back their permit to have a second child, and many women choose abortion when pregnant with a second permitted pregnancy. By the end of 1979 the proportion of "1 couple 1 child" couples was 90% in many large cities; people realize that the practice of "1 couple 1 child" is the best assurance for the future of the country and of their children. This policy will not result in aging of the population, lack of manpower and shortage of soldiers; even if birth rate were 1% in 1985 the proportion of older people for the next 25 years will still be lower than that in European countries. The problem of aging of the population will not occur in this century, and population policies can always be adjusted when needed. Today's problem is to control population through the "1 couple 1 child" policy, even if it may result in many lonely old people, which is a lesser problem than too many people. Even if China has reduced its population growth by 10 million births each year from 1970 to 1979, the necessity to control population growth is still present, in the interest of the country and economic development.     

A new estimate of permanent sterility by age: sterility defined as the inability to conceive

The proportion of couples permanently sterile beyond a certain age is an important component of the reproductive process. Unless medical assistance is used, this age is the upper bound of the fecund period. Most estimates of sterility by age of the woman have been derived from natural fertility populations, in which the number of births and the timing of the last birth (of the complete reproductive history) were not controlled by the couples. Because data on these populations do not include pregnancies not ending in a live birth, the sterility estimates apply to the proportion of couples unable to conceive and to have a live birth. For this reason, it is useful to have an estimate of sterility based on the risk of conceiving, independently of the fate of the pregnancy. Using this new estimate, sterility increases with age much more slowly than with most previous estimates.     

Fertility decline in Scotland, England and Wales, and Ireland: comparisons from the 1911 census of fertility

Data on family size by year of marriage, age at marriage, and duration of marriage, from the 1911 Fertility Census, are compared between Scotland, England and Wales, Irish county boroughs, and the rest of Ireland. While means show significant inter-country differences, from the 1880s marked similarities are found across all the countries in the pattern of fertility decline, strongly suggesting significant fertility limitation in rural Ireland well before 1911. Noting the implications for the use of rural Ireland as a natural fertility population, the data are instead compared with the Coale-Trussell and Hinde-Woods schedules. The former provides more plausible results, which imply strong period rather than cohort effects in the fertility decline. Except in rural Ireland, little evidence is found for significant fertility limitation early in marriage among younger marrying couples, but many older marrying couples appear to have stopped childbearing at very low parities from an early date.