Rebecca Turner

Gambian religious leaders teach about Islam and family planning.

In rural Gambia a project was initiated with the aim to involve religious leaders willing to teach about the connections between Islam health and family planning. It is noted that the religious leaders in this area are relied upon and trusted by the villagers; hence they are effective in reaching the majority of the people. In September 1990 and in August 1991 meetings were held in each of the 26 project villages. The proceedings included a discussion of Islam and family planning benefits of the program and availability of specific methods. It also included the involvement of a nationally known religious leader as support for the project. Overall it is indicated that knowledge of almost all specific methods of family planning was higher after the meetings for both men and women. In addition use of any method increased from 11% for both men and women before the meetings to 24% for men and 30% for women after the meetings. Convincing religious leaders to participate was the main source of difficulty for the project coordinators. Moreover the issue of selective distribution of family planning was identified.

In Haiti, "Mystery Clients" Evaluate Quality of Care

Mystery clients posing as family planning patients evaluated the services of private family planning clinics in Port-au-Prince Haiti. This strategy was initiated in 1990 funded by the United States Agency for International Development and administered by the International Planned Parenthood Federation (IPPF). The mystery clients were 3 women and 1 man who had been trained in physiology contraceptive side effects and contraindications. The clinic directors had been notified about the mystery clients who made 5-6 visits/month. Clinics were visited by clients about 4 times in a 6-month period and reports to the clinics will include the observations of at least 3 mystery clients. If the clinic suggested that they choose a method the client accepted one (except for Depo-Provera which is implanted on the spot) or made an appointment to receive Norplant or sterilization. The coordinator recorded the informants comments on a debriefing questionnaire that contained 40 quality-of-care indicators. IPPF presented a review of the mystery clients findings from May 1990 to April 1991 to 14 involved clinics. The clients made 23 visits to 4 hospitals 27 visits to 5 clinics and 22 visits to 5 health posts offering family planning services. The informants rated the services as not acceptable on 7% of the clinic visits and 13% of the health post visits. A rating of not very acceptable was given on 33% of the clinics visits 32% of health post visits and 57% of hospital visits. They gave a rating of acceptable on 41% of visits to clinics and health posts and on 44% of visits to hospitals. A very acceptable rating was only given on 18% of the visits to clinics and on 14% of the visits to health posts. The mystery client strategy has expanded: they now visit 8 institutions that operate about 30 clinics and informants assess the messages of counselors about AIDS. In 1990-91 minisurveys a contraceptive prevalence rate of 16% was found in the mystery clients area.

Ghanaian Midwives Have New Family Planning Role

This field briefing reports on research conducted in Ghana on midwives who were trained in family planning (FP) and their activity in promotion FP methods. The research and training between Fall 1987-April 1990 was conducted by the Ghana Registered Midwives Association (GRMA) in conjunction with Columbia Universitys Center for Population and Health and the American College of Nurse Midwives and funded by USAID. Ghanaian midwives are mostly in the private sector and maintain their own maternity homes for delivery and services. 218 participated in FP training. The ages ranged from 25-70 years in the 1st group of 134; the average age was 48. 50% had been practicing midwives for >20 years and 66% were qualified nurses of which 2 were qualified FP nurses. 63% practiced in urban areas and 37% in rural neighborhoods. Most clients were from small rural villages or poor crowded urban neighborhoods. In 1987 the mean delivery number was 102. Prenatal and postnatal care was also offered along with other services. 11% offered FP services before training began. >75% thought FP should be accessible to sexually active young people and midwives should encourage women to stop having children after 6 births. 42% thought FP should be given only to women with a husbands approval. 15% thought women should not use FP to stop childbearing. After training new FP clients received questionnaires. Of the 4462 collected and analyzed 91% were women and 80% were 1st time users of FP methods. The average client was married with 4 children with a farming or trading occupation. Reasons for use of FP were to stop childbearing (25%) sexually transmitted disease protection (8%) financial reasons (4%) and other (4%). FP was promoted through word of mouth of midwives or assistants (51%) spouse or friends (33%) signboard (8%) media (4%) and other (5%). Methods used were the pill (55%) injectables (16%) foaming tablets (12%) condoms (7%) IUDs (5%) and a mix of condoms and tablets (5%). Monthly statistics were collected in 1988-89 for new acceptors which numbered 12411 with 75% reporting figures. 18884 deliveries were made and 6957 returned for FP visits. Client visits stabilized at 600/month by March 1989 or each midwife had 9 deliveries 6 new acceptors and 3 returning FP visits/month. Distribution figures are given. A group of 227 FP acceptors were still using at 3 and 9 months: 90% an 70% respectively. Discontinuation was due to side effects (24%) partners absence (22%) desire for pregnancy (17%) method failure (8%) unrelated health problems (3%) and other (26%). Another follow-up should 11% were using contraceptives after delivery. The differences in midwives were that those younger had twice the FP clients as older ones but deliveries were the same at 8-9/month.

Female fieldworkers bring family planning to Ahmedabad slums.

The Gujarat State Crime Prevention Trust (GSCPT) decided to provide family planning education and services to two slums in Ahmedabad India. They used female field workers to reach the largely illiterate female population and to recruit young low-parity couples who would use temporary methods. To assess the initial 3 years of the project a baseline survey was conducted in August 1987 among a random sample of 400 residents and follow-up surveys of 450 residents conducted in March 1991. Overall it is noted that the project had provided 36281 couple-years of protection (CYP) for an average of 349 CYP per worker in each quarter. Throughout the project the pill was the most popular choice among new clients (56%) followed by female sterilization (19%) the IUD (13%) the condom (12%) and male sterilization (0.2%). For the community residents sterilization was the most popular method (46%) followed by the pill (34%) the IUD (11%) and the condom (8%). Such a success has been attributed to innovative information education and communication strategies as well as the recruitment of an exemplary staff.

Picture Booklet Improves Knowledge About IUDs in Egypt

Despite the popularity of the IUD as a contraceptive method in Egypt discontinuation levels have been high. Reasons for discontinuation include misperceptions about the IUD and how it works. In view of this the Ministry of Health together with Family Health International tested an informational booklet to be used along with IUD counseling. This 15-page booklet with large pictures contains important facts about the IUD. A sample of 160 IUD acceptors divided into experimental and control groups were chosen. Knowledge about the IUD was measured prior to receiving the method and 5 months after insertion. Both groups were counseled before the insertion while the booklet was given to the women in the experimental group to take home. Overall the proportion of women classified as having good knowledge of the IUD increased from 16% to 86% in the group that received the booklet. No women in the rural experimental group had good knowledge in the preintervention but 100% of them did after the intervention. This improvement in knowledge was however varied depending on the question. Although it is shown that the booklet improves knowledge the study could not prove that it improves continuation rates.

Operations researchers share findings problems and goals.

Collaboration between family planning and research organizations is vital to operations research but it must run smoothly to benefit all parties involved; this was the conclusion at a conference in Washington D.C. in November 1992 organized by the Population Council. Situation analysis in Kenya Tanzania Zimbabwe and Nigeria found that about 20% of service delivery points serve 75% of family planning clients. A Honduran study found that 59% of women said at a prenatal visit that they were interested in receiving family planning postpartum and that prevalence was 7% higher at 6 months among women who were offered a method postpartum. Studies sponsored by Marylands University Research Corporation in Asia between 1985 and 1991 focused on the sustainability of public and private family planning projects in view of reduced donor support. 30-50% of eligible couples can be charged for service but halting free contraceptive distribution may reduce the prevalence rate. Effective strategies included selling nonsubsidized commercial methods through community-based distribution; allowing field workers to set contraceptive prices within an official range; pooling resources in a community; and getting factory owners to pay for family planning services for workers. Topics for future collaborative efforts are information education and communication projects to promote Norplant and injectable contraceptives. Other timely topics discussed were male contraception and male involvement elucidation of womens views and polygamous relationships. Integration of family planning services with health services for AIDS and sexually transmitted diseases was discussed (e.g. providing counseling to HIV-positive women and the issue of disposable vs. nondisposable syringes). Other problems mentioned were the need to create more formal systems of reporting data to donors and whether operations research is providing a service to other collaborating agencies.

Bringing family planning to isolated Ecuadorians.

This article discusses the establishment and impact of a 3-year project designed to bring family planning services to the indigenous inhabitants of Ecuador the Quichua who usually live in poor and isolated communities. Marked by a high marital fertility rate and low contraceptive prevalence the Quichua make up about a 1/4 of Ecuadors population. In 1987 with a grant from USAID the Centro Medico de Orientacion y Planificacion Familiar (CEMOPLAF) initiated a project to provide family planning services to 85 communities with a combined population of about 70000. The project involved a combination of clinic services and community-based distribution. Additionally the project tested the feasibility of integrating family planning with oral rehydration therapy (ORT) and the effectiveness of informational activities such as home visits radio spots and marketplace promotion. The article describes how CEMOPLAF had to overcome many obstacles in simply getting the project off the around: geographic barriers cultural barriers and difficulties in securing approval from the communities. And once the project began CEMOPLAF encountered problems in recruiting promoters and volunteers and allaying fears of side effects from contraceptive use. Nonetheless over 27 months community-based distributors recruited 1475 new clients and distributed contraceptives equivalent to 588 couple-years of protection (CPYs). 1262 new users went to or were referred clinics. Among married women aged 15-49 acceptance rate increased from 10% to 16%. As it matured the project lowered its per user cost by nearly 1/2 and its per CPY cost by more than 2/3. CEMOPLAF found that radio spots and the integrated family planning and ORT program did not succeed in increasing the recruit of clients but that home visits by promoters and marketplace promotion were indeed effective. CEMOPLAF has received additional funding to expand the project.