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.     

Women--the deciding factor in family planning?

Prominent women from Korea, Nepal, India, Philippines, Thailand, and Afghanistan discuss family planning attitudes in broad terms. Educated women in urban areas make decisions regarding birth control and family size, but the tradition in most developing countries is that of the man in the authority role. Family planning is intrinsically a joint decision. Obligations to family and family lineage prohibit family planning. In the Philippines, Catholicism is the dominant religion and because of population density, encourages family planning. For economic and social reasons, rural families prefer more children. The changing role of women to include jobs and education will have a positive effect on family planning. The representative from Nepal points out that it is necessary to have family planning in order to have changing women's roles. Rather than emphasizing smaller family size, it is recommended by concensus, that family planners communicate health and nutritional benefits for each individual child.     

To grasp the family planning program early, carefully and surely according to the law of reproduction]

China's February 1982 Directive on Improving Family Planning Work stipulated that family planning should be incorporated into national economic and social planning by understanding it early, carefully, and surely according to the law of reproduction. Understanding family planning early means to implement the policy of birth control as a primary goal, to plan early for births, and to carry out birth control measures, i.e., formulating a plan is the basis of understanding early. For example, the following must be considered when mapping out a plan for 1983: the number of fertile women who wanted children but who remained childless for 3 years of marriage; those who conceived late in 1982 and will deliver in 1983; the number of newlyweds over 23 years of age who have not planned a pregnancy; those with 1 child over 4 years who due to unusual circumstances will have a 2nd child; the number of people planning marriages before March 1983. The next step is to make arrangements, which include submitting individual requests, getting permission from communes and approval from the general public, and delivering contraceptives to the homes of newlyweds and mothers. 9 months after arrangements are completed, adjustments must be made, e.g., those who were unsuccessful in their plan to conceive this year will try the next year. To understand carefully is to understand the concept, circumstances, and data of family planning and thus be able to administer it scientifically. This means primarily controlling fertile women who are newlyweds, mothers of 1 child, and mothers of multiple children. To understand surely is to conform to the organization, concept, policy, planning, and measures of family planning. This means training basic level birth control cadres in population theory and methods of family planning. In addition, it means persuading the masses to be enthusiastic, diligent, fearless, understanding, and to show initiative toward family planning.     

Thinking about several problems of the research of our family planning strategy]

On the basis of 1982 census data, it is estimated that from 1987-1997 13 million women will enter the age of marriage and child-bearing each year. The tasks of keeping the population size around 1.2 billion by the year 2000 is arduous. Great efforts have to be made to continue encouraging one child/couple, and to pursue the current plans and policies and maintain strict control over fertility. Keeping population growth in pace with economic growth, environment, ecological balance, availability of per capita resources, education programs, employment capability, health services, maternal and child care, social welfare and social security should be a component of the long term development strategy of the country. Family planning is a comprehensive program which involves long cycles and complicated factors, viewpoints of expediency in guiding policy and program formulation for short term benefits are inappropriate. The emphasis of family planning program strategy should be placed on the rural areas where the majority of population reside. Specifically, the major aspects of strategic thrusts should be the linkage between policy implementation and reception, between family planning publicity and changes of ideation on fertility; the integrated urban and rural program management relating to migration and differentiation of policy towards minority population and areas in different economic development stages. In order to achieve the above strategies, several measures are proposed. (1) strengthening family planning program and organization structure; (2) providing information on population and contraception; (3) establishing family planning program network for infiltration effects; (4) using government financing, taxation, loan, social welfare and penalty to regulate fertility motivations; (5) improving the system of target allocation and data reporting to facilitate program implementation; (6) strengthening population projection and policy research; (7) and strengthening training of family planning personnel to improve program efficiency.     

To the barrios] The new course charted by the national population program

In order to reduce the Philippine birthrate to 2% by 1980, the number of rural women practicing contraception must be trebeled. To facilitate such an effort, a large-scale reorganization and reorientation in all areas of family planning activity--delivery, training, research, information, education, and communication--is proposed, shifting the delivery of family planning services from clinics to the 36,000 barrio bases. A goal of 16,000 extension workers in family planning is set for 1976; these workers will be the ones to make the initial contacts with potential acceptors. Then full-time family planning workers will try to make potential acceptors into bonefide ones, giving advice or prescribing the method and providing follow-up. Family planning workers will be supervised by nurses and midwives in health stations, who in turn will be supervised by the physician in the rural health unit. Acceptability among community residents is the most vital characteristic of a family planning worker, with the country's 27,000 hilots (birth attendents) seen as leading candidates. Attracting and training manpower in the field is a major challenge, as is lack of personnel in the area of research. Several possible avenues for the development of research interest and manpower for the population program are explored.     

The National Conference of Propaganda Work on Family Planning held Beijing]

The National Conference on Propaganda Work in Family Planning, held in Beijing from November 1-6, 1982, was sponsored by the the Propaganda Department of the Chinese Communist Party Central Committee and the National Family Planning Committee. Among the 136 participants were representatives from various provincial, city, and autonomous region propaganda and family planning units, the General Political Department of the People's Liberation Army, general trade unions, All China Women's Federation, Communist Youth League, and propaganda reporters. The purpose of the conference was to discuss how to organize family planning propaganda in meeting China's goal of limiting the population to 1,200,000,000 by 2000, and how to arrange a Family Planning Propaganda Month for early 1983. The Chairman of the National Family Planning Committee made 3 points: family planning is a basic national policy, greater propaganda efforts must be made towards peasant family planning, and everyone must work hard to create a new situation in family planning work. The Vice Minister of the Propaganda Department remarked that family planning propaganda was foremost among the 12 national propaganda topics; these sentiments were supported totally by the representatives of the women and youth groups. The Vice Chairman of the Advisory Committee of the Central Committee said that family planning work was longterm, and that its success lay in the countryside. Finally, the Vice Chairman of the National Family Planning Committee encouraged all delegates to take the spirit of the conference back to their home. During the conference delegates also met to discuss important points in planning the Family Planning Propaganda Month.     

Publicity and education on family planning information in Keshan County

In 1984 the Keshan (Northeast China) County Government and the Family Planning Committee initiated an education campaign to disseminate family planning information to farmers. The team of propagandists consisted primarily of full-time family planning workers. Village cadres, school teachers, and rural physicians, who are properly educated and positive about family planning work, enjoy high prestige among the workers. They were invited to be team members after training and are supported by the villagers because they come from among the local people. All the childbearing women aged 15-49 in each village were classified by the propagandist into 5 groups according to their marital and childbearing status, i.e., women at the age of puberty, women of new marriage, pregnant and lying-in women, women with children to be reared, and middle-age and old women. The women were organized into groups to attend lectures on different subjects such as population policy, relationship between population growth and socioeconomic development on the 1 hand and individuals and environment on the other. Also included were physiology, the health birth and rearing of children, and health care for women and the aged. The publicity effort included broadcasting, films, video aids, and slide shows. Increased classs were during the slack seasons, and lectures were given once a week. By 1986, about 80% of the population at childbearing age in Keshan County had attended the family planning lectures.     

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.     

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.     

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.     

Pakistan's population growth: the need for action

Despite the existence of a national family planning program that dates to 1965 Pakistan has not seen a reduction in the fertility rate. One of the poorest countries in the world, Pakistan has 1 of the highest population growth rates in the world at about 3.0% annually. For over 2 decades, the average woman in Pakistan has given birth to more than 6 children. At the current fertility rate, the country's current population of 120 million will increase to over 150 million by the year 2000, and it will increase to 280 million by 2020. And even if today every woman were to begin having only 2 children, the population would still reach 160 million before leveling off. But reducing fertility in Pakistan will prove difficult. One of the leading obstacles is the low status of women. Few women in Pakistan have advanced education or professional jobs. Only 1/4 of those women without education or who are not working have any knowledge concerning contraception. Family size and composition also fuel the high rate of fertility. On the average, women desire 5 children (the fact that women average more than 5 suggests an unmet need for contraception). And due to social, cultural, and economic conditions, Pakistanis generally prefer male offsprings. Islamic opposition to family planning has also contributed to the continued high rates of fertility. Finally, administrative and management weaknesses have hindered Pakistan's family planning program. In order to overcome these obstacles, Pakistan will have to enlist the commitment of political, religious, and community leaders. The status of women will have to be improved, and the attitudes of people will need to change.     

论计划生育“三结合”模式的科学性

计划生育“三结合”由吉林省率先提出近十年,并已被国家充分肯定。十年来的实践已证实了计划生育“三结合”的正确与可行,尚缺少理论上的深入研究,经在国家计生委立项的“计划生育三结合之路研究”的软课题中找到了计划生育三结合提出的理论依据,进一步论证了计划生育三结合的科学性。     

India: New family planning program direction outlined

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

CFPA in development

The China Family Planning Association (CFPA) was established in Beijing on May 29th, 1980 as a nongovernment organization. Its purpose and tasks are defined as uniting all the people and activitists involved with family planning to assist the government family planning units in communicating the state principles, policies and tasks on family planning, motivating the people to practice family planning voluntarily, organizing academic activities in family planning in cooperation with the related units, and promoting international exchanges and cooperation. Since its establishment, the CFPA has organized a variety of activities (communication, training, consulting) for promoting communication and education so as to spread among the masses of people the scientific knowledge about contraception, and maternal and child care. The services provided by the associations of various regions in response to the needs of the local people were greatly welcomed and highly appreciated by the people.     

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

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

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.     

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.     

Health on wheels: public service of a private hospital

This article describes the history and activities of the mobile clinic field by the Lorma Medical Center in Carlatan, San Fernando, in the province of La Union. The clinic is free and offers integrated medical services to 4-5 baranguays (villages) per day, averaging 861 cases including an average of 86 family planning cases. The clinic is part of Lorma's Outreach Program which includes a daily radio program answering questions on "Better Health for You and Your Family," a seminar program for local, voluntary health assistants and an "Adopt a Family" program in which nursing students visit and care for an indigent family throughout their training. In September 1977, a mobile vasectomy clinic will begin daily rounds. The mobile clinic program has little access to remote areas because the van cannot navigate the narrow, bumpy roads. However, funding is the program's only real limitation and its possibilities for improved health and family planning services are very great.     

Gender inequalities and demographic behavior

A summary was provided of the central findings about gender inequalities in Egypt, India, Ghana, and Kenya published by the Population Council in 1994. These countries exhibited gender inequalities in different ways: the legal, economic, and educational systems; family planning and reproductive health services; and the health care system. All countries had in common a high incidence of widowhood. Widowhood was linked with high levels of insecurity, which were linked with high fertility. Children thus became insurance in old age. In Ghana, women's insecurity was threatened through high levels of marital instability and polygyny. In Egypt, insecurity was translated into economic vulnerability because of legal discrimination against women when family systems were disrupted. In India and all four countries, insecurity was reflective of limited access to education, an impediment to economic autonomy. In all four countries, women's status was inferior due to limited control over reproductive decision making about childbearing limits and contraception. In India, the cultural devaluation of girls contributed to higher fertility to satisfy the desire for sons. In India and Egypt, family planning programs were dominated by male-run organizations that were more concerned about demographic objectives than reproductive health. The universal inequality was the burden women carry for contraception. Family planning programs have ignored the local realities of reproductive behavior, family structures, and gender relations. The assumption that husbands and wives have similar fertility goals or that fathers fully share the costs of children is mistaken in countries such as Ghana. Consequently, fertility has declined less than 13% in Ghana, but fertility has declined by over 30% in Kenya. Family planning programs must be aware of gender issues.     

Integrated family planning/parasite control project: a different approach to community health problems

An obstacle to the acceptance of family planning is the fact that its advantages are not immediately apparent or tangible. A way to get around this obstacle is through the use of "entry points"--projects which yield tangible results in a relatively short time. Through these entry points, the fieldworker builds credibility and wins the confidence of the people in the community he or she is serving. Thus, when the time comes, the people will be receptive to the family planning message. This strategy of the use of entry points is common to integrated projects with a community development program becoming a sort of entry point for family planning fieldworkers. 1 such project, begun quite recently by the Family Planning Organization of the Philippines (FPOP) in 4 pilot sites, uses deworming as an entry point. It is officially known as the Integrated Family Planning/Parasite Control/Nutrition Project. It is 1 of several projects cosponsored and financed by the Japanese Organization for International Cooperation in Family Planning (JOICFP) and the Asian Parasite Control Organization (APCO) in almost a dozen other Asian and Latin American countries. The immediate objective of the project is to establish or increase the credibility of family planning fieldworkers among the people in a target area. Fieldwork connected with family planning is conducted alongside a related community health effort that can produce immediate and visible results. The ultimate goal is to encourage community participation to such an extent that there will no longer be a need for the fieldworker. Strategic planning involves thinking up the "backbone" and molding the "skeleton" of the project, i.e., its concept and basic policies. As the project goes into the design and development stage, additional people are drawn into it. Project experience in Thailand underscores the need to consult with local leaders. The earliest projects were initiated in 1976, but some are already showing successful results. The overall Philippine experience provided support to JOICFP Director Kunii's reiteration of his belief in the effectivity of parasite control as an entry point for population planners. Integration of the nutrition element in the project is regarded as essential.