PREVENTIVE

MEDICINE

6, 74-91 (1977)

FORUM:

POPULATION

Family Planning Options GORDON

PLANNING

Service

Delivery

and Trends

W. PERKIN'

The Ford Foundation,

Rio de Janeiro,

Brazil

Although family planning programs differ in their objectives, some being concerned primarily with improving the health of mothers and children and others aimed at reducing fertility, their common goal is to make available safe and effective methods for the regulation of human fertility. A variety of service delivery systems has evolved. Services may be provided through specialized family planning clinics or through hospitals and maternal health‘centers as part of the offtcial health system. The private sector is frequently involved through private physicians or by using commercial distribution of contraceptives at subsidized prices. More recently, the trend has been towards local distribution programs involving the community and establishing family planning as a normal part of daily village life. Based on an assessment of the various approaches to service delivery, a seven-point strategy is suggested. It is concluded that an ambitious, well-managed, multimethod, multichanneled family planning program can have a significant impact on health and fertility.

INTRODUCTION

Family planning programs differ in their objectives. Some are concerned primarily with improvement in the health of mothers and children; others are oriented more towards reducing fertility. Regardless of their major objective, a common task is to make available safe and effective methods for the regulation of human fertility. In addition to the attributes of a specific method, who provides the method and where an acceptor has to go to get it are critical factors that influence the acceptability and use of any contraceptive. In recent years, increasing attention has been directed at reducing the number of barriers between a potential acceptor and a specific contraceptive method. This process is illustrated in Fig. 1 (28). The potential impact of administrative and policy modifications on acceptances and continued use is readily apparent. A variety of approaches to service delivery has evolved over time. However, political convenience rather than program efficiency has frequently determined the system through which services would be offered. Political and religious considerations influence the way in which methods are offered as well as the range of methods available. Certain characteristics of the various contraceptives have also limited access to them. Sterilization and abortion remain surgical procedures in spite of recent advances in technology. Successful use of an intrauterine device requires its correct insertion by an experienced person. In spite of the limitations associated with the methods of fertility regulation and the imperfections in the 1 Address for reprints: D.F.

Gordon W. Perkin, M.D., Fundacion

Ford, Alejandro

Dumas 42, Mexico

5,

74 CoPYrik!ht 0 1977 by Academic Press, Inc. All rights of reproduction in any form reserved.

ISSN 0091-7435

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PLANNING

CONTINUING USER-S AT ONE YEAR I

I-T-MEDICAL CHECK-UP REQUIRED AT REGULAR INTERVALS

\

-r-TCLINIC HOURS AND LOCATlON -r-r MUST RETURN TO CLlNlC FOR SUPPLIES

I

-r-7 NEGATIVE RUMORS

NEGATIVE RUMORS

-r‘rFORGETS PlLLS

-l--tFORGETS PlLLS

-lSIDE EFFECTS -r-I-

I

-f-

-f

--r SIDE EFFECTS 4---b

I

’ ’

PILL PACKAGE AND SCHEDULE -fI

7PRICE OF PILLS

-rYMEDICAL (PELVIC) EXAM REWlRED -T--r CLINIC VlSlT REWIRED

PS DAY PILLS AVAILABLE TO ALL “EALTHI WOMEN DIRECTLY FROM VILLAGE AGENT AT SUBSIOIZEO PRICE (NO CLINIC VISIT OR EXAM) SUPPLIES WLIVEREO REGULARLY S.1 AGENT

I-7PlLL AVAILABLE ONLY TO MARRlED WOMEN POTENTIAL ACCEPTORS

FIG. 1. Factors influencing acceptance and continued use of oral contraceptives [adapted from figure by G. W. Perkin (28)].

systems used to deliver them to clients, progress has been made. According to Freedman and Berelson (7), “under current conditions of political will, social readiness, administrative capacity, professional interest, fertility control technology, and available resources,” family planning programs can recruit up to IO-15% of the eligible population per year. Several of the more successful national programs have moved in less than 10 years from a small percentage of practitioners of family planning to a prevalence of 20-25% practice within the program. FERTILITY

REGULATION

METHODS

Prior to an examination of the options and trends in service delivery, the categories and characteristics of fertility control methods available to programs should be reviewed. Mauldin discusses five categories which exclude abstinence, rhythm, and coitus interruptus (12). The five categories include conventional contraceptives (principally condoms), hormonal methods (primarily the oral contraceptive), a variety of intrauterine devices (IUDs), sterilization, and abortion. In assessing national family planning programs in 1975, Mauldin notes that “although there has been a rapid growth in the number of countries adopting population policies and offering family planning services, the range of methods offered is greatly restricted” (12). Only 2 of 33 countries provided a method from each of the five categories-China and South Korea. Four additional countries included methods from four of the five categories. In general, fertility decline has been

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more significant in countries providing a broad choice of methods than in countries with a limited choice. Also, the inclusion of a new method seems to add another layer of users to the existing group, presumably by attracting new clientele. At least this has been the case in Taiwan, South Korea, and India (7). Inclusion of a fertility regulating method on a list of approved methods does not mean general availability. A recent report on contraceptive availability in Bangladesh estimated that, of the approved program methods, female sterilization was not available to more than 10% of the population, vasectomy to perhaps lO-20%, the IUD to 2040% of married women of reproductive age, and condoms, foam, and oral contraceptives to an estimated 50% of the eligible population (27). Chen and Mossain, commenting on the situation in Bangladesh, observe that modern technology all too often fails to reach the poor rural population (2). Services are unable to extend beyond the confines of urban centers where facilities and doctors are concentrated. India recently legalized abortion but is not prepared to make it programmatically available throughout the country. Thus, not only does the range of approved methods tend to be restricted in many programs, but also access to approved methods remains limited. Even when modern methods of fertility regulation are made available, little attention has been given to adapting them to the environment in which they are being used. For example, although oral contraceptives have been used in programs for a number of years, there has been little product-related research attempting to improve the performance of this method in developing countries. Packaging could be modified and made locally attractive. Dosage schedules and instructions could be simplified to enhance acceptability and continued use (17). A new technology, appropriate to the needs of developing countries, is under development. The mini-laparotomy kit and the variety of vacuum abortion equipment which can be operated without electricity are examples of this new technology. Current clinical studies of a paper pill and a collared copper IUD with potential for long-term protection could also be cited as examples of this encouraging trend. In their recent review of the record of family planning programs, Freedman and Berelson conclude that the “efficacy of the technology of fertility control, for program purposes, depends not only on the acceptability of the method, particularly as a generator of program activity, but upon continuity; improvements in these respects could make a non trivial difference” (7). In summary, four method-related approaches that could improve current programs include: (a) increasing the range of approved methods; (b) increasing access to approved methods; (c) adapting contraceptives to the local environment; and (d) developing new methods appropriate to local needs and circumstances. CHARACTERISTICS

OF ACCEPTORS

Program performance could also be improved by “matching” acceptors and methods. Almost every organized family planning program has found that acceptors, especially during the early years of the program, tend to be older and to have more children than the average married women of reproductive age. A new program which directed priority attention to recruiting these older, higher-parity women could actually contribute to program performance in several ways.

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Women over 30 years of age with three or more children, particularly those who have recently delivered, are most receptive to family planning. Acceptances among this “easy to recruit” group would contribute to program efficiency in terms of cost per new acceptor. On the basis of commonly reported continuation rates, acceptance of an IUD or sterilization by this group would avert at least as many and perhaps more births than a program reaching an equal number of acceptors among the population as a whole (19). Also, this same older, higher-parity group contributes disproportionately to maternal and infant mortality. A greater reduction in the number of pregnancies experienced by these women, as compared with the population as a whole, should lead to a reduction in both infant and maternal mortality rates. Since a significant proportion of these older, higherparity women will not want additional children, methods offering long-term (IUD) or permanent (sterilization) protection will be most appropriate. Recent reports suggest that the risks associated with the use of oral contraceptives increase significantly after age 40. Thus, at least for this older group, the selection of the most appropriate methods appears straightforward. Teitelbaum discusses four distinct reproductive stages in the life cycle: premarital, delay (postmarital, pre-first birth), spacing (before completion of fertility), and completion of fertility (33). He points out that the particular forms in which the stages are expressed will vary depending on the social customs and familyformation patterns in different nations, and indeed some stages may be inapplicable in some circumstances. The most appropriate contraceptive may vary during these stages in the individual’s life cycle. For example, methods available outside the formal medical system may be preferred during the premarital phase, especially in societies where sexual activity during this period is not socially accepted. During the delay and spacing phases, failure is less important; however, frequency of intercourse suggests a noncoital method such as the oral contraceptive. Following the birth of the last wanted child, pregnancies must be prevented over a time span of 15 to 20 years. Methods offering longer-term protection (e.g., an IUD for several years followed by sterilization) are most appropriate. A simple scheme that illustrates the concept of matching acceptor and method characteristics is given in Table 1. Other acceptor characteristics, such as place of residence, rural or urban; access to services or supplies; and socioeconomic status, education, and degree of modernization, will also influence the acceptability of specific methods and should be reflected in method priorities. DELIVERING

FAMILY PLANNING SERVICES

Systems to deliver family planning services can be classified in a number of ways. Over time, new approaches have gained favor and eventually overtaken earlier systems. Thus, the free-standing family planning clinic of the early 1960’s gave way to the integrated health approach of the late 1960’s and early 1970’s. Maternity-centered and postpartum approaches also enjoyed popularity in the early 1970’s. More recently, new terms, community-based distribution, household availability, continuous motivation, contraceptive innundation, and social marketing, have entered the vocabulary of family planning. Another way of looking at the organization and delivery of family planning

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TABLE 1 Stage in Life Cycle

Method of Choice

Premarital Delay Spacing Completion

Conventional contraceptives with back-up abortion Oral contraceptives Oral contraceptives IUD with back-up abortion Sterilization (male or female)

services is from a “health” vs a “demographic” point of view. Unfortunately, this dichotomy has not always resulted in constructive debate (18). The primary objective of maternal and child health (MCH) programs is to improve maternal and child health, not to reduce the birth rate. As family planning can contribute to this objective, it is accepted and integrated into the MCH structure. The objective of many national family planning programs, however, is to reduce birth rates. Integrating family planning into MCH is accepted as a logical way of reaching a substantial number of fertile women, some of whom do not wish to have additional children. The improvement in maternal and child health that would result from widespread contraceptive practice is viewed by the population planner as a fortuitous and desirable secondary benefit of family planning. Thus, the MCH and population establishments share a common ground, even though their primary objectives differ. For the purpose of presentation and discussion in this paper, the delivery of family planning services will be classified as follows: Family Planning Clinics: free-standing, mobile; Governmental Health System: postpartum (hospitalbased), maternity-centered, and high-risk approaches; Private Sector: private physicians, subsidized commercial distribution; and Local Distribution: fieldworker approach, community-based distribution, household distribution. FAMILY PLANNING

CLINICS

Family planning clinics were originally established to meet the need for medical services that were not available elsewhere. As recently as 1964, William Vogt, National Director of the Planned Parenthood Federation of America, wrote: “The continuing refusal by most federal, state, and municipal public health officials to provide child spacing, as well as the inadequacy of private care, are clear enough evidence that Planned Parenthood Organizations still have an indispensable part to play” (38). Free-Standing

Clinics

The “free-standing” family planning clinic was not created as the most efficient way to deliver services but rather as a response to the failure of the health system to offer these services. As voluntary family planning associations spread from the industrialized to developing countries, the Western clinic model was also transferred. In many countries, the voluntary association preceded official government support and action. The free-standing family planning clinic served as a highly visible focal point through which the energies of committed individuals could be channeled. Specially trained, “single-purpose” staffs provided family planning

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services which often included infertility consultation and cancer detection but excluded other health services such as immunizations and well-baby care. The clinic system expanded, particularly in those countries where government acceptance of family planning was slow to come. Occasionally, clinics were offered space in hospitals or health centers, but, more frequently, a house or building was rented and modified for the purpose. When official government services eventually were initiated, a crisis often occurred. The private clinic system was threatened and in some cases taken over by government authorities. Some clinics remain as “model clinics” or “training and demonstration” centers, but, in most countries, the free-standing, single-purpose family planning clinic system has declined in importance as family planning became a part of offtcial health services. Reynolds carried out one of the few studies comparing single-purpose family planning clinics with integrated services (24). He concluded from a sample of United States clinics that specialty clinics saw significantly more women, saw a greater proportion of high-risk women, and served these women at lower cost than did multipurpose clinics, regardless of the physical setting. Fisek has enumerated the disadvantages of the unipurpose clinic (4). These include the necessity for unipurpose clinics to serve a larger population area than multipurpose clinics and the lack of anonymity in attending a clinic that provides only family planning service. The unipurpose clinic does appear to have a continuing role in the provision of abortion services. This specialized service is now available in a number of countries as a nonhospital procedure, particularly during the first trimester of pregnancy. In 1973,45% of legal abortions in the United States took place in nonhospita1 clinics (34). Women will travel considerable distances for curative, as distinct from preventive, procedures. In the United States, during the first quarter of 1974, 118 providers of abortion services (40 hospitals and 78 nonhospital clinics), with an average of about 80 procedures per week per provider, accounted for 57% of all legal abortions in the United States (39). Mobile Clinics Mobile family planning clinics enjoyed a brief period of popularity during the early and mid-1960’s. It became obvious that “fixed” single-purpose clinics would not reach rural families. Also, many small cities, towns, and provincial centers did not have a sufficiently large population to warrant a permanent clinic facility. During this period, it was relatively easy to raise funds for specific service projects in developing countries, and the image of a handsome van taking services to remote areas was attractive to a number of small donor groups. As in other health fields where mobile units had been tried, it soon became apparent that such services were both difficult to operate and inefficient. The large van required to provide a self-contained clinic was often unable to reach the areas most in need. The unit could not operate during the rainy season in many countries. Maintenance and operating costs were high in terms of numbers of clients served. In one Asian country, for example, the mobile van donated by a well-meaning charitable organization was finally placed on cement blocks in a permanent location where it was referred to as the “fixed mobile” clinic. The Thais developed a more realistic approach. A mobile team, with the required personnel and equipment, was sent to

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the rural areas using conventional transport. A temporary clinic was set up in a village building. The visit was well publicized, and frequently several hundred IUD insertions were carried out during a single day. Follow-up care was the responsibility of the local medical officers who received training during the clinic sessions. The concept of “flexible transport,” taking the staff and needed equipment into the rural areas, emerged as a reasonable alternative to mobile units. GOVERNMENTAL

HEALTH SYSTEM

Once governments began to accept family planning as an appropriate activity, it was only natural that they would look to their Ministries of Health to provide the services. Early family planning programs were heavily dependent on the intrauterine device, and this was viewed as a “medical” method. The legitimation of family planning, as well as the available technology, thus helped move it into the health system. Fisek concisely expresses the view of the health professional: “Multipurpose health units, using multipurpose health workers as the primary change agents, serving populations of an appropriate size, and connected with hospitals, form the most efficient and effective system for fertility limitation” (4). A carefully planned study comparing various ways of providing family planning within health services was carried out in Narangwal, India. The results lend support to the multipurpose approach. When family planning services were made available along with women’s services or with services for women and children, acceptances and continued use were greater than when family planning was provided alone (23). The combination of women’s services and family planning was the most successful in terms of acceptances and continuation rates. There was little argument that family planning services “belonged” in the health system. A more important question was: How could the services best be offered, given the inadequate infrastructure and financing of most developing country public health programs? Postpartum

Approach

For decades, there have been efforts to bring family planning to the attention of recently delivered women. It was generally recognized that the immediate postpartum period represented a most receptive time to provide information and service. In 1966, the Population Council began its International Postpartum Family Planning Program. As Berelson points out, “many innovations, closely examined, turn out to be not new ideas, but new applications of familiar ideas. The novelty resides in the scale or scope of implementation rather than in the concept per se” (41). The Population Council-sponsored postpartum program began as a collaborative effort involving 25 hospitals and spread to 112hospitals by 1971. The postpartum model provides contraceptive information to all delivery and abortion clients. Medical and paramedical personnel, social workers, and family planning educators contact women in prenatal and postpartum wards and clinics. Some hospitals provide IUD insertions before the women leave the hospital; others encourage the women to return 6 weeks later for a postpartum examination and contraceptive services. A major advantage of the postpartum approach is the ability to reach highly

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fecund, noncontraceptors before a further pregnancy begins (5). Data from a worldwide follow-up survey showed that about 70% of the women in the International Postpartum Program were still using the initial method of contraception 12 months after acceptance (5). The success of this large-scale, international program helped to establish family planning as a legitimate and routine part of hospital maternity services. Maternity-Centered

Approach

The popularity and success of the International Postpartum Program stimulated further thinking about the feasibility of large-scale systematic programs for integrated maternal/child health and family planning. The advantages of a mate&ybased family planning program are summarized by Taylor and Berelson: “Such a program deals with a population of proven fertility that is clearly identifiable at a time of high motivation, hence accessible to information and education.” (32) The design and operation of an integrated maternal and child health system that includes family planning have proved, however, to be considerably more difficult than adding family planning to an existing maternity service. Several large-scale demonstration projects are under way. A major problem is the paucity of facilities and personnel related to maternal and child health services, especially in the rural areas of the developing countries. In many developing countries, 20% or less of the deliveries in rural areas are professionally supervised (32). The successful linking of family planning and maternal and child health services thus requires the existence or development of an adequate MCH infrastructure. This task calls for a long-term political and financial commitment on the part of governments that is rare in the field of health. Some observers feel that the organization and delivery of effective family planning services to large numbers of the population are sufficiently difficult in themselves without trying to develop the entire public health infrastructure at the same time. A realistic position is to encourage the integration of family planning into maternal and child health programs where the infrastructure already exists or can be easily developed. At the same time, other approaches to the delivery of services, particularly for rural areas, should be encouraged and, when they appear promising, supported. High-Risk

Approach

A modification of the MCH approach has recently gained momentum in Latin America, especially in Brazil and Columbia, where family planning is accepted for health rather than demographic reasons. The prevention of high-risk pregnancies is justified on medical grounds using evidence from a number of studies documenting the relationships between age, parity, birth interval, medical history, socioeconomic status, and maternal and infant morbidity and mortality (16). A simple screening system, which estimates the relative risk associated with a subsequent pregnancy to differently situated, nonpregnant women, has been reported previously (16). A slightly modified screening system recently evaluated in Brazil is shown in Table 2 (20). In a retrospective study of 74 Brazilian women who had delivered in 1971, it was shown that 48% of subsequent pregnancies in the highrisk group ended in reproductive failure (abortion, stillbirth, perinatal, or infant

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TABLE 2 PREVENTING HIGH-RISK PREGNANCY RISK SCREENING SYSTEM (20)

Maximum Possible Score

(1) Age

Less than 17, more than 34 (score 2) 17-19, 30-34 (score 1)

(2) Birth order

5 or more births (score 2) 3 or 4 births (score 1)

(3) History

Previous infant death, congenital defect, premature birth Obstetric complication, abortion History of diabetes, cardiovascular or renal disease, or other medical condition increasing risk of pregnancy to mother and fetus

(4) Interval

(5) Socioeconomic

(score 1 for each to a maximum of 3)

Less than 24 months since termination of last pregnancy (score 1) (a) Family income (two minimum salaries or less) (b) Mothers’ education: 2 years of formal education or less

Possible Total Score

3

1

2 10

Interpretation Score of 5 points or more

Highest risk group Contraceptive counseling should be considered mandatory Highest priority for follow-up

Score of 3 or 4 points

High priority Contraceptive counseling highly desirable Should receive periodic reevaluation of risk status

Score of less than 3

Contraceptive advice and services should be available on request

mortality) compared with 20% reproductive failure in the medium- and low-risk groups (21). The “high-risk” approach is attractive for several reasons. Women most in need of family planning from a medical point of view are identified. A high proportion of this high-risk group does not want further children. In the Brazil study, 100% of the high-risk group stated that they did not wish additional children. The scoring system thus identifies both needy and motivated women. Scarce health resources (personnel and facilities) can be directed to this special group which generally represents 3040% of the childbearing population. A program focusing on birth prevention among high-risk women can have a significant impact on infant and maternal mortality and morbidity. PRIVATE SECTOR

In most industrialized countries and in a number of developing countries, the

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private sector provides contraceptive services to more couples than are reached through public programs. As recently as 1970, it was estimated that 80% of the nearly 50 million users of foam, condom, diaphragm, IUD, and oral contraceptives worldwide received services and supplies through the private rather than the public sector (31). In many developing countries, contraception, including sterilization and abortion, is readily available to those who can afford to pay for it. A recent market study in Brazil reported that during 1974 about 39 million cycles of oral contraceptives were distributed through commercial channels (25). Thus, more than 3 million Brazilian women were using oral contraceptives (about 20% of the eligible population) purchased from pharmacies. Even in Taiwan and South Korea with large-scale national programs, the commercial sector accounts for 40 and 25% of contraceptive practice, respectively (22). Based on this evidence, it has been suggested that the private sector might be a highly efficient, perhaps the most efficient, means of extending contraceptive practice (22). Advantages include: (a) well-established systems of distribution and information dissemination; (b) uses existing network of private physicians and local retailers; (c) no burden on government administration; and (d) operation in countries where public programs do not exist. Several national family planning programs have enlisted the support and participation of the private sector in an attempt to extend contraceptive practice, but, undoubtedly, more could be done. Smith identifies three major problems which seriously restrict the contribution of the private sector (30). The first is the prescription requirement for oral contraceptives. The second is the high assessment of duties and taxes on imported contraceptives. The third is the prohibition against advertising directed to the consumer. Elimination of any or all of these barriers would almost certainly have a significant impact on the prevalence of contraceptive practice in developing countries. Private Physicians Private physicians have been used to provide services in a number of family planning programs including India, Pakistan, South Korea, Taiwan, Turkey, and Egypt. Generally, the physician is reimbursed on a “piece-work” basis for the procedure performed. IUD insertions, vasectomies, and tubal ligations are the most frequently reimbursed services. Private physicians also account for an unknown but significant number of tubal ligations, especially in Latin countries where this increasingly popular, but unrecorded, procedure is carried out at the same time as an elective cesarean section. Private physicians have both helped and hindered family planning activities. In a number of Latin American countries, much of the leadership for public programs has come from the medical community. At the same time, physicians have tended to regard the prescription of contraceptives as a medical procedure. The extension of services to couples living in rural areas has been slowed as a result of this attitude. Countries wishing to use auxiliary health workers to prescribe oral contraceptives and to insert IUDs have often encountered skepticism, or open hostility, from organized medicine. Subsidized Commercial Distribution Several national family planning programs have used commercial channels to

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distribute contraceptive supplies. The supplies are subsidized, i.e., sold at cost or below, as in the case of India’s “Nirodh” marketing program, where condoms were sold below the actual cost of production. The largest and most experienced Indian consumer goods organizations were enlisted to conduct and manage the distribution. An extensive advertising and point-of-purchase campaign accompanied the distribution program. Test-market areas reported up to a 300% increase in sales after 9 months (8). In Turkey, a subsidized distribution program for vaginal tablets and condoms led to a significant rise in the prevalence of contraceptive practice in the study area (from 12.4 to 18.4% of married women of reproductive age) (35). An important characteristic of the more successful programs is the work done to adapt the contraceptive product (name and package) to the local environment. In Sri Lanka, the successful condom marketing scheme selected and pretested an appropriate local name for the product. Some 4-5% of all eligible couples were estimated to be using the “Preethi” condoms after 2 years of program operation (1%. It is recognized that distribution relying entirely on local shopkeepers is not a panacea. An IPPF (International Planned Parenthood Federation) review states: “While it may become possible to cover the cost of administration, advertising, promotion and packaging, it is unlikely that the cost of purchasing contraceptives can also be met from revenue” (15). Results of the various subsidized commercial distribution programs permit the following generalizations: (a) Distribution of contraceptives at subsidized prices through commercial channels can significantly extend contraceptive practice in a population; (b) where such efforts are accompanied by an education/information effort, the impact will be greater; (c) retailers tend to respond to, rather than create, demand for contraceptives; (d) once convenient access is assured, excessively large numbers of outlets (in the same area) may not increase sales and may generate retailer apathy or opposition to the program; (e) such efforts complement rather than compete with programs in the health sector since each activity tends to attract a somewhat different group of acceptors; and (f) commercial distribution channels offer one means of assuring the availability of supplies in rural areas. LOCAL DISTRIBUTION

In spite of early emphasis on a clinic- or physician-based approach to family planning, it soon became apparent that other systems would need to be developed for the majority of the rural population. The major task is to bring contraceptives into the daily lives of rural people and to make them conveniently available. Efforts to extend family planning to the villages began in the early days of national family planning programs through the use of full- or part-time field staffs. Field- Worker Approach

Early efforts used field workers to inform and recruit clients who were referred to the family planning clinic for service. Subsequently, some programs began to experiment with the distribution of conventional contraceptives by field staffs and, more recently, pill distribution has been added in a few programs. Typically,

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family planning field workers have at least 6 years of schooling and have received a short (2- to 5-week) training course prior to field assignment. They may work part time or full time, are usually salaried, and may receive bonus or incentive payments (27). The full-time, single-purpose family planning field worker had been a key element in the successful programs in Taiwan and South Korea. Freedman et al. report that in Taiwan, at least, acceptance rates and a decline in fertility by district are correlated with the number of field workers operating in the district (6). In Korea, 70% of IUD acceptors in a national survey indicated that they had been motivated by a family planning worker (11). The Sialkot project in Northern Pakistan studied the use of teams of full-time, literate, male and female field workers who called on and offered contraceptive services to all eligible couples in a given geographic area. After 22 months of operation, contraceptive practice in the project area had increased from 3 to 20% (13). Other studies have shown that field-worker performance is enhanced if the worker is literate, married, from the geographic area in which she/he is working, using contraception, supervised, assigned realistic targets, and paid a reasonable wage (27). The field worker represents an important link in the movement of family planning services from the clinic into the community. Much of the experience gained with field staffs in early clinic-based programs has proved useful in designing the more recent community-based experiments. Community-Based Distribution The distribution of contraceptives through the community rather than exclusively through health channels has recently gained popularity. In part, this has resulted from changing attitudes towards the prescription requirement for oral contraceptives. Experience has shown that serious side effects associated with oral contraceptives are rare and usually cannot be predicted in advance; that effective supervision can be largely delegated to nonphysicians; and that the known benefits of avoiding unwanted pregnancy far outweigh the risks (9). In April 1973, the Central Medical Committee of the International Planned Parenthood Federation approved a resolution that “responsible, simple methods of non-medical distribution of oral contraceptives can and should be devised” (37). At least eight countries, including Antigua, Bangladesh, Chile, Fiji, Jamaica, Pakistan, the Philippines, and South Korea, have recently eliminated the prescription requirements for oral contraceptives (3). In many other countries, oral contraceptives may be purchased from pharmacies without the “required” prescription. Further impetus was given to the community-based approach by reports from the People’s Republic of China describing the distribution of contraceptives by barefoot doctors working at the commune level. Community-based distribution programs are viewed as complementing rather than replacing clinic- or health-based programs. In most demonstration projects, a link between the two systems has been established to provide a referral mechanism for the few women who do experience medical problems. Also, the community-based programs are limited in the methods they can distribute. Con-

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doms, oral contraceptives, and, occasionally, vaginal foam are included. Clients for whom these methods are inappropriate must be referred to other facilities. A major assumption behind the community-based approach is that products and services that are readily available are more likely to be used than those which are inconvenient to obtain (9). A friendly, familiar, local distributor can provide reassurance and serve as a constant reminder to use the method. A major goal of the community approach is to establish family planning as a routine and normal part of daily village life. Formerly, the acceptor was viewed as a patient who attended a health clinic, an unusual rather than a routine activity for most women. Several key elements are regarded as essential for the success of a communitybased program. First is the selection of the local distributor. Often, an influential community member is selected. the wife of the village leader, president of the mothers’ club, or a school teacher. Second, the distributor must receive orientation and training; short courses at intervals may be the preferred approach. A dependable supply system and supervision are also essential components. A referral system for complications should also be set up. Results from a number of community-based projects indicate encouraging results. In the State of Rio Grande do Norte in Northeastern Brazil, &lo% of the fertile-aged women are estimated to be regular users of oral contraceptives after 2 years of program operation (9). Distributors include local midwives, school teachers, and mothers’ clubs, all volunteers. Appointment as a local distributor carries with it considerable status and prestige. In the Brazil experiment, salaries or commissions have not been needed to maintain distributor interest. Keeney reports a similar success story from Java where, over a period of 6 years, 65% of eligible couples in one village had adopted and were using contraceptives (10). As Keeny says, “the real secret of success is that the people of the villages have made the program their own” (10). Household Distribution Door-to-door delivery of contraceptive supplies may be viewed as an extension of the community-based concept. Supplies are distributed to each household that will accept them in the hope that they will be used. Subsequently, supplies are distributed to the homes at regular intervals; thus, the acceptor does not need to leave her home to receive an effective contraceptive method. A recent report from a household distribution project in a group of rural villages in Southern Bangladesh indicates the potential impact of such programs (29). Three cycles of oral contraceptives were distributed with suitable instructions to every reproductive-aged woman who would accept them. About 70% of all such women agreed to take the pills from the local midwife and field assistant. A follow-up survey conducted 13 weeks later showed that 23% of the overall group of reproductive-aged women had actually taken the pill, and 16% were continuing their use. This is a high discontinuation rate but an encouraging report from a country where not more than l-2% of all married, reproductive-aged couples used some program-delivered fertility control method during 1974. Similar projects in other countries are relatively new. They do, however, illustrate the trend to remove barriers and reduce the “distance” between the poten-

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tial acceptor and the method. Important medical and administrative questions must still be resolved in connection with these programs. Their longer-term contribution to health and to reduced fertility must also be assessed. OTHERAPPROACHES

A variety of other approaches to the delivery of family planning services could be discussed. For the most part, these represent variations of the basic delivery systems already presented. Family planning services offered through social security systems (as in Mexico) represent an important extension of the “official” health system. Factory programs are a type of community program, in which the employees can participate in recruitment and distribution. The mothers’ clubs in Korea and in other countries are typical of yet another community resource that can be used effectively to provide family planning. The religious community in some countries may also represent an appropriate institutional focal point for a “community” program. One important trend not yet discussed in this paper is the increasing use of auxiliary health personnel to provide contraceptive services. Numerous studies have shown that auxiliary health personnel can be trained to perform various procedures usually done by physicians (1,14,26,36,40). These procedures include pelvic examinations, pap smears, IUD insertion, breast examination, screening for contraindications to oral contraceptives, and follow-up medical visits. Several studies comparing IUD retention rates and complications following medical or paramedical insertion have been conducted. In reports from Nigeria, Barbados, South Korea, and the United States, the paramedic performance compared favorably with that of the physician. The use of auxiliary health personnel can extend contraceptive availability and have a major impact on acceptances. In Thailand, the use of midwives to provide oral contraceptives was associated with a 400% increase in acceptances in the study area over a 6-month period (26). Midwives were taught to use a simple checklist to identify women with possible contraindications. OBSERVATIONS

AND CONCLUSIONS

A number of different approaches to the delivery of family planning services has been reviewed. It should be clear from the presentation that no single approach is likely to be completely successful. The trend is towards systems that eliminate both real and potential barriers between the prospective user and the method. In this sense, the community-based approach is most attractive. At the same time, it is recognized that the community approach is limited in the choice of methods that can be offered. If the objective of a family planning program is to increase the prevalence of contraceptive practice to a level that will influence both health indices (maternal and infant morbidity and mortality) and fertility, the following seven-point strategy for the organization and delivery of services would seem to be appropriate: (i) Make available the widest variety of methods. (ii) Increase the range of delivery systems through which the methods are made available. (iii) Attempt to match method and delivery system with the needs of differently situated individuals. (iv) Attempt to reduce “distance ” and eliminate “barriers” between potential

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users and methods. (v) Involve communities, institutions, and local leaders in the program. (vi) Allocate resources on the basis of program performance. (vii) Whenever possible, adapt the methods to the environment. The consequences of such a strategy may be illustrated by considering a hypothetical family planning program that offered methods from each of the five categories (Fig. 2) and used a variety of delivery systems to make them available (Fig. 3). The model reflects a number of assumptions: (i) Termination of pregnancy is legal and available through the health system, free-standing clinics, and private physicians. Since contraceptives are widely available, abortion is used primarily as a secondary or “back-up” method for failed contraception. Prevalence of abortion practice is, therefore, lower than in most countries where contraceptives are less widely available and abortion remains illegal. (ii) A relatively well-developed health system exists within the country. (iii) Private physicians are associated with the family planning program and reimbursed on a fee-for-service basis. (iv) Oral contraceptives may be distributed by village agents. A prior medical examination is not required. (v) Sterilization (both male and female) is available on request. (vi) The commercial distribution system is actively involved in distributing contraceptives at subsidized prices. (vii) The model does not include contraceptive practice outside the official program.

L ORAL CONTRACEPTIVE

CONDOM

IUD

STERILIZATION

ABORTION

METHOD DELIVERY

SYSTEM

1.

CLINIC

m

HEALTH

SYSTEM

PRIVATE

PHYSICIANS

m

SUBSIDIZED

COMMERCIAL

m

COMMUNITY

BASED

FIG. 2. Prevalence of contraceptive equals 30% prevalence.

practice

DISTRIBUTION

DISTRIBUTION

by method (5-10 years of program activity).

Total

FORUM:

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SYSTEM

PHYSICIANS

PLANNING

COMMERCIAL DISTRIBUTION

89

BASED DISTRIBUTION

DELIVERY SYSTEM METHOD 0

CONDOM ORAL

m

CONTRACEPTIVE

IUD STERlLlZATlO,, ABORTION

FIG. 3. Prevalence of contraceptive practice by delivery system (5-10 years of programactivity). Total equals 30% prevalence.

The figures illustrate that some delivery systems are inappropriate or less appropriate for certain methods. For example, it may be difficult to make intrauterine contraception available through a community-based distribution program. Also, the health system has an important role to play, since it can offer each of the methods and is especially important in providing IUDs and voluntary sterilization. In a specific-country situation, there would undoubtedly be significant differences in these figures. Some delivery systems would be more successful than others. Also, method acceptability and use will vary by country and over time. The figures do illustrate, however, that an ambitious, well-managed, multimethod, multichanelled program could have a significant impact on fertility. An objective of having 30% of the eligible population practising family planning within the program within five to ten years is realistic.3 The contraceptive methods and the channels to deliver them exist. The political will and the administrative capacity have yet to be mobilized fully. REFERENCES 1. Berggren, G. G., Vaillant, H. W., and Gamier, N. Lippes loop insertion by midwives in healthy and chronically ill women in rural Haiti. Amer. J. Pub. Health 64, 719-722 (1974). 2. Chen, L. C., and Mosain, M. The transfer of population technology. A paper presented at the 2nd Annual Conference of the Bangladesh Economic Association, 15-18 March 1976, Dacca (Mimeo). * A common “rule of thumb” equates contraceptive practice by 30% of the eligible population with a crude birth rate of 30/1000 population (28).

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3. Dean, C. E., and Piotrow, P. T. Eighteen months of legal change. Pop. Rep. Ser. E, NO. 1, 12 pp. George Washington University Medical Center, Population Information Program, Washington, D.C., July 1974. 4. Fisek, N. H. An integrated health/family planning program in Etimesgut District, Turkey. Stud. Family Plann. 5, 210-220 (1974). 5. Forrest, J. E. Postpartum services in family planning: Findings to date. Rep. on Pop. Family Plann. No. 8, 13 pp. (July 1971). 6. Freedman, R., Chow, L. P., Hermalin, A., and Takeshita, J. Y. The family planning program for ah of Taiwan, in “Family Planning in Taiwan” (R. Freedman and J. Takeshita, Eds.), pp. 313350. Princeton University, Princeton, N.J. 1969. 7. Freedman, R., and Berelson, B. The record of family planning programs. Stud. Family P/arm. 7, l-40 (1976). 8. Gupta, D. R. Achieving a social objective through modem advertising and marketing. Article for the Seventh Asian Advertising Congress, New Delhi, 18-20 November 1970. 9. Huber, S. C., Piotrow, P. T., Potts, M., Isaacs, S. L., and Ravenholt, R. T. Contraceptive distribution-Taking supplies to villages and households. Pop. Rep. Ser. J., No. 5. George Washington University Medical Center, Population Information Program, Washington, D.C. July 1975. 10. Keeny, S. M. Keeny’s Newslett. No. 73, p. 6, October-December 1975 (Mimeo). 11. Kim, T. R. “National Intrauterine Contraception Report.” National Family Planning Center, Seoul, 1970. 12. Mauldin, W. P. Assessment of national family planning programs in developing countries. Stud. Family Plann. 6, 30-36 (1975).

13. Osborn, R. W. The Sialkot experience. Stud. Family Piann 5, 123-129 (1974). 14. Ostergard, D. R., and Broen, E. M. The insertion of intrauterine devices by physicians and paramedical personnel. Obster. Gynecol. 41, 257-258 (1973). 15. People 2, No. 4, p. 15 (1975). Publication by IPPF. 16. Perkin, G. W. Assessment of reproductive risk in nonpregnant women. Amer. J. Obstet. Gynecol. 101, 709-717 (1%8). 17. Perkin, G. W., Duncan, G. W., Mahoney, R. T., and Smith, R. H. Developing contraceptives for developing countries-Unmet needs. Royal Society Meeting: Contraceptives of the Future. London, February 18, 1976, in press. 18. Perkin, G. W. Family planning within and beyond MCH. IPPF Med. Bull. 5, (February 1971). 19. Perkin, G. W. Pregnancy prevention in “high-risk” women: A strategy for new national family planning programs. Stud. Family Plann., No. 44, 19-24 (1969). 20. Perkin, G. W. Preventing high-risk pregnancies-A screening system for use in Brazil. Brazil, March 1974 (Mimeo). 21. Pinotti, J. A. Contribuicao ao Estudo de urn Score para Medida de Risco Reprodutivo na Fase Puerperal. 1976 (Mimeo, in press). 22. “The Private Sector.” The Population Council, May 1971 (Mimeo). 23. Reinke, W. A., Sarma, R. S. S., Parker, R. L., and Taylor, C. E. Programme experience in family planning as integrated with selected health activities: A report on the Narangwal Project. Paper presented at WHO Scientific Group Meeting, Geneva, 1973. 24. Reynolds, J. Delivering family planning services: Autonomous vs. integrated clinics. Family Plann. Perspect.

2, 15-22 (1970).

25. Richers, R., and Almeida, E. A. B. de. 0 Planejamento Familiar e o Mercado de Antioconcepcionais no Brasil. Revista de Administracao de’Empresas, Getulio Vargas Foundation, July/ August, 1975. 26. Rosenfield, A. G. Family planning: An expanded role for paramedical personnel. Amer. J. Obstet. Gynecol. 110, 1030-1039 (1971). 27. ROSS, J. A., Germain, A., Forrest, J. E., and Van Ginneken, J. Findings from family planning research. Pop. Family PIann., No. 12, p. 24 (October 1972). 28. Saunders, L. Maintaining practice level: Continued encouragement and support, in “Population Control Implications, Trends and Prospects,” p, 410. Proceedings ofthe Pakistan International Family Planning Conference at Dacca, January 28 to February 4, 1%9.

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29. Schearer, B. S. Fertility control technology in Bangladesh. February 1976 (Mimeo). 30. Smith, R. H. Involving the commercial sector in family planning programs, in “Fertility Control Methods-Strategies for Introduction” (G. W. Duncan, E. J. Hilton, P. Kraeger, and A. A. Lunsdaine, Eds.), pp. 83-88. Academic Press, New York and London, 1973. 31. Sollins, A. D., and Belsky, R. L. Commercial production and distribution of contraceptives. Rep. Pop. Family Plann., No. 4, 23 pp. (June 1970). 32. Taylor, H. C., Jr., and Berelson, B. Comprehensive family planning based on maternal/child health services: A feasibility study for a world program. Stud. Family Plann. 2, 21-54 (1971). 33. Teitelbaum, M. S. The human requirements of an adequate contraceptive technology. The Ford Foundation, July 21, 1975 (Mimeo.) 34. Tietze, C., and Murstein, M. C. Induced abortion: 1975factbook. Rep. Pop. Family Plann., No. 14 (2nd Ed.), 76 pp. (December 197.5). 35. Toros, A., and Treadway, R. Resume of the impact of an action program in family planning: An evaluation. Family Planning Evaluation Series, Memorandum No. 10. Population Council, New York, 1971. 36. Vaillant, H. W., Cummins, G. T. M., Richart, R. M. and Barron, B. A. Insertion of Lippes loop by nurse-midwives and doctors. hit. Med. J. 3, 671-673 (1968). 37. Victor-Bostrom Fund, Rep. No. 17, p. 31, Fall 1973. 38. Vogt, W. Planned parenthood-The curve of progress, in “Manual of Contraceptive Practice” (M. S. Calderone, Ed.), pp. 44-46. Williams and Wilkins, Baltimore, 1964. 39. Weinstock, E., Tietze, C., Jaffe, F. S., and Dryfoos, J. G. Legal abortions in the United States since the 1973 Supreme Court decisions. Family P/arm. Perspect. 7, 23-31 (1975). 40. Wright, N. Sri Lanka: The impact of allowing paramedical prescription and resupply of oral contraceptives. Stud. Family Plann. 6, 102-105 (1975). 41. Zatuchni, G. I. (Ed.) “Post-Partum Family Planning-A Report on The International Program,” Preface by Bernard Berelson, President, The Population Council, New York, p. V. McGrawHill, New York, 1970.