189 TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE. Vol. 69. No. 2. 1975.
HOSPITAL
BASED
FAMILY PLANNING IN RURAL AFRICA: SOME LESSONS THE MIDWESTERN STATE OF NIGERIA XT0
Medical
Director,
Zuma Memorial
FROM
OKOJIE Hospital,
Irma,
Midwest
State, Nigeria
JOEL MZTAGUE Regional Director,
Near East/Africa,
The Population
Council, 245 Park Avenue, New York, New York.
Introduction The Ishan Division of the Midwestern State of Nigeria covers an area of approximately 1,162 square miles (3,021 kmz) in the northern half of the Ishan-Asaba plateau, which is west of the River Niger. The plateau forms a watershed for the rivers flowing into the River Niger and those flowing into the Ethiope River. Except for river valleys the relief is gentle, 500-1,500 feet (153 to 460 m) above sealevel, and heavily wooded. The area has a moderate climate with a temperature ranging between 22 to 27°C all year around; a dry seasonvarying from 3 to 5 months from November through April and a wet seasonfrom May through October. Economic activities are typical of much of central Nigeria and relate primarily to the exploitation of rubber and timber, though petty trading is also important. The soils, once fertile, have been depleted and while small farming is still the most common occupation, it is no longer a viable form of livelihood. According to the 1963censusit appearsthat women do not contribute significantly to the total economically active population. The inhabitants of the Division are primarily Christians or Animists. They constitute the membership of some32 distinct clans ranging in size from the Uromi with 63,000 to the Orowa with 524. The most important unit of the traditional socialstructure is lineage and each clan comprisesthose descendantswho trace their ancestry from the samemale ancestor. Family organization is basedupon the extended family unit whose members lodge in the samecompound. A typical compound contains several dwelling units occupied by many related families, with the dwelling unit of the chief constituting a sizableportion of the compound. In all the clans numerouschildren of both sexesare very much desired for many reasons,not the least of which is the bride prices fetched for daughters. As in other areasof Nigeria there is a paucity of systematic data in demography. However, the total population of the Division according to the 1963 censuswas some 270,903persons (ASCADIet al., 1972). At that time most of the population wasrural and an urban total of only 12,379was recorded. The population according to the 1963 censusfigures appearsdisproportionately young with perhaps some46.5% in the O-14 agecategory. The density of the rural population washigh and in various placesexceededsome 600 per square mile (220/knP). The Institute of Population and Manpower Studies at the University of Ife hascharacterized the areaas one of “(a) exceedingly high fertility, (b) high but declining mortality, and (c) limited in and out migration. The number of children surviving to the women on the averageis on the order of 6.” The crude birthrate is probably in excessof 50 per 1,000. The health of the population wasand remainsprecarious due to inadequate sanitation; lack of private dnd government health education and other services; traditional cultural and social attitudes, norms and customson the part of the population; the varying availability of food; lack of cashemployment, etc. The most common health problems are intestinal parasites,tuberculosis, malaria and a variety of infectious diseasesand skin infections. Children are afllicted with diarrhoea, respiratory disordersand malnutrition. Repeated childbearing by Ishan women constitutes one of the major barriers to the improvement of the levels of maternal and child health in the population. Factors affecting fertility include polygamy, near universality of marriage, low mean age of marriage, low female literacy and abstinenceduring the postpartum period. The authors wish to expresstheir appreciation to a number of distinguished colleagueswho kindly commentedon earlier drafts of the manuscript. Needlessto say, entire responsibility for any errors in the final version restswith ourselvesand not with those who assistedus. Our thanks go to Dr. Robert Castadot, Medical Director, International Postpartum Programme, the Population Council; Dr. N. R. E. Fen&h, Liverpool School of Tropical Medicine, Liverpool, England; and George Acsadi (Ph.D.), consultant, World Fertility Survey, London, England.
190
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
Medical services The Zuma Memorial Hospital at Irrua, Ishan Division was founded as a private, secular medical institution in March, 1950 in a rented house with 6 rooms and 12 wooden beds. It was establishedby Xto Okojie, the son of Chief Okojie, the Onojie (king) of Ugboha, a district of the Ishan Province. At that time the Ishan Division had 1 doctor, an Englishwoman, working at a Catholic hospital in Uromi. At the present time there are 3 hospitals, 28 maternity homes and 14 dispensariesserving the total population of 270,000. Nonetheless,now as then the population receives medical care from traditional medicinemen or herbalists. Some of these individuals specializein various ailments, i.e. bone setting, gunshot wounds, snake bites, mental illness, etc. Since its creation the hospital hasgrown in size significantly though its delivery of high quality health care to the rural population is constantly in jeopardy due to lack of funds, medical personnel,the workload and its isolation. The hospital’sX-ray machine,for example,is 40 years old. There is no laboratory assistant, no medical technician, no anesthetist, and only one physician. During the 6 month dry season,water is brought in by car from a river 16 miles away. Personnelproblems continue to plague its operations. The first midwife hired left, for example, becausethe only entertainment offered in Irrua wasthe “incessant drumming in the home of the native doctor.” The hospital is still run by its founder and his wife, who has been the matron and tutor in charge of the government sponsoredmidwifery school at the hospital. Its staff consistsof 2 nurses,4 midwives and the 30 nursing aideswho are undergoing midwifery training. Of its 120 beds, 40 are maternity; 28 male and 16 female medical-surgical; 16 isolation and 19 pediatrics. About 100 women attend the weekly ante-natal clinics. An orphanageis associatedwith the hospital becauseone of the beliefs of the Ishan tribe is that if a mother dieswhile giving birth to a child, no other womanshould take careor feed the infant. Invariably such babiesdied. The hospital now takes them in. While a variety of individuals, organizations and companies have taken an interest in the hospital and have provided somesupport, both in kind and money to assist it, its existence remains precarious. Family planning In spite of the indisputable problems which have beset the development of services at this “bush hospital,” it has managedto initiate and sustain a remarkably effective rural family planning effort. When the hospital first adopted a family planning programme(February 1969)there wasno reasonto be optimistic about its chancesfor success.Indeed, during the first 12 months of the programme in 1969-70, only 96 IUDs were inserted and oral pills were prescribed in 55 cases.Of the 96 IUD acceptors65 had 7 or more children. Over the years there hasbeen a considerableimprovement and it is conceivable-indeed likelythat there is no other hospital in rural Africa with such limited resourcesthat has a comparable record in family planning services. During the period June 1970 through May 1971 the numbers of acceptors increasedto 646. During the period July 1 through December 31, 1972, a total of 622 new clients were seenat the hospital, with some400 accepting the IUD. During the first six months of 1973, a total of 671 clients were seen,with 496 accepting the IUD. We feel that this is a most satisfactory-indeed remarkable -performance in a rural African setting with such high fertility norms, high infant and maternal mortality levels, poor transportation and communication, low literacy rates, etc. The hospital’s programme is probably worth studying for this reason. Indeed there are a number of useful lessonspossibly applicable to other efforts in Nigeria as well as elsewherein Africa which have been learned by the hospital and are worth reflecting upon. For this reason and for the purposesof our analysis of the hospital’s programme we will adopt as a conceptual framework the general family planning programme functions noted by FREYMAN (1966). These he conceivesas (1) instrumental functions (provisions of services, supplies, provision of information, general social support); (2) control functions (top leadership, peripheral supervision and evaluation); (3) supporting functions (training, financial support and research). TABLE
I. Fertility
and subfertility. Number
Family Planning Subfertility
Acceptors
Acceptors
of clients
1960-70
1970-71
1971-72
151
646
839
1298
609
52
2
1
523
300
1972-73
1973 6 months
XT0
OKOJIE
AND
JOEL
191
MONTAGUE
TABLE II. Acceptors by method. Type IUD
1969-70
1970-71
1971-72
1972-73
1973 6 months
96
472
595
967
403
8
31
45
26
7 4
Depo-Provera Condom
-
-
-
-
Foam
-
-
-
-
-
PillS
55
143
199
305
199
TABLE III. Average age and parity of IUD and pill acceptors. Client
Age Parity
1973 Pill/IUD
1969-70 Pill/IUD
1970-71 Pill/IUD
1971-72 Pill/IUD
1972-73 Pill/IUD
32
31
30
28
30
8
6
4
3
5
This table shows a very interesting and factual trend. At the beginning of the programme in 1969, only the grand-multiparae who were advanced in child bearing age, known by the Ishans to face increasing risks in subsequent pregnancies, took advantage of the family planning scheme. As knowledge, attitudes and practice increased, age and parity of acceptors decreased. Even the 1973 average age and parity of 30 and 5 respectively is in order as it only shows that acceptors are now a mixed group; the very young (mainly students and those whose jobs forbid child bearing, like prison wardresses), the advanced in age but still open to risks of pregnancy and the grand multiparae. Instrumental
functions
Provision of Services and SuppZies. Family planning is completely integrated into the hospital’snormal outpatient services.The hospital staff has noted that interviewing clients in the hospital and provision of contraceptive information in general outpatient clinics has to be handled with very considerabledelicacy. Most of the clients are illiterate and are unable to express themselvesvery articulately to medical professionals.Adding to this difficulty is the fact that women are opposedto discussinganything remotely connected with sex with anyone except their husbands, particularly in public places. A major problem is that many men feel that their wives will be unfaithful if they accept contraception. In theory, at least a woman must have her husband’s written permission to accept contraception. Motivation of malesto accept family planning has not been successful. In the clinic the duties of the individuals associatedwith family planning are as follows: a nursemidwife issuesand sorts cards, takes temperatures, pulses, etc; second a nurse-midwife takes complete medical histories; a third nurse-midwife sterilizes equipment and assiststhe physician in the insertion of IUDs. A fee is chargedfor clinic visits basedon the feescharged by the Nigerian Family Planning Association. All the major types of contraceptives are offered. Those who accept contraception are charged 60 kobos (about 36 new pence) for an IUD insertion and 10 kobos (about 6 new pence) for a monthly supply of pills. In advising on contraception at the hospital stressis placed upon the IUD, as pills for resupply are not generally available commercially in rural Ishan. After the IUD insertion the patient returns for an examination as follows: second visit 1 week after insertion; third visit 2 months after insertion; fourth visit 3 months after insertion; patients are then seenon a yearly basis. The hospital’smedical director has found it essentialto establisha rigid return visit schedulebecause the number of patients who have pelvic infections or will develop pelvic infections after insertion is high. His feeling is that rigorous follow-up will detect early infections and, if he can possibly treat these patients immediately, this will keep the IUD from disrepute in the Ishan community. Although it is of debatable medical status in more developed areasof the world, at present the hospital’s medical director makesa strong casefor treating IUD patients with penicillin and streptomycin at the time of insertion. The type of
192
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
treatment and the considerable time spent on counselling and careful medical work-up invariably increases the cost of the programme. Clients who accept the pill are seen each month and receive their monthly supply of pills. They are charged 20 kobos (about 12 new pence) per visit. TABLE
III. Age of family planning acceptors by contraceptive methods and year.
Contraceptive Methods Pill Under 20 20-24
25-29 30-34 40 35-39 +
1969-70
: ::
1970-71 4 i: i;
1971-72
1972-73
J$$y;& .
48
z ;;
50 103 61
;:: 55
69
165
28
26 10
31 12
:57
55
143
199
305
320
4
24 67 71
IUD Under 20
20-24 25-29 30-34
35-39 4Q+
1: 17 iii 15 96
Depo-Provera Under 20
-
25-29 20-24
-
30-34
35-39 4Of
Total
134
142
21 126 204 228
152
210
309
119 170
47
59
79
66
472
595
967
517
-
-
1::
3
i 8
Foam/Jelly, Condom, etc.
i:77
B
20 1:
i 9
: 1
i 17 2
r -
1 7
9
31
45
26
-
-
-
-
-
159
646
839
1,298
846
While considerableemphasisis placed upon the IUD, the Lippes Loop has not been without side effects. The most troublesome manifestations are excessivemenstrual loss and vaginal discharge. For example, of the original 472 IUDS inserted in the beginning of 1972,7 were removed becauseof menorrhagia and pain; 5 were removed becausehusbandswished their wives to become pregnant; and 12 were lost through spontaneousexpulsion. Of the 12 women who lost loops through spontaneousexpulsion, 6 agreed to reinsertion. No pregnancieswere noted with the IUD in place and there was no uterine perforation. The most common side effects associatedwith the pill seemoccasionallyto be at variance with those mentioned in the literature (BINGEL and BENOIT, 1973and ANDREWS,1971).In a study madeat the hospital (OKOJIE, 1971),by order of frequency, the most common sideeffects were nausea,vomiting, lack of appetite or fear lest the client becomesick, lassitude, a general feeling of being unwell, scanty or irregular menses, discomfort in the breasts. Complaints are far more common among the younger patients, the educated patients, and what appearsto be insufficiently motivated women. Grand multiparae and working young educated women, it has been noted, rarely complain about the side effects of any sort of contraception. It has been found at the hospital that the variables associatedwith complaints are closely associatedwith need and education. All casesof dysmenorrhoea, menorrhagia and anaemiaare treated free.
XT0
TABLE IV. Number No. of Living 0
Total
Children
OKOJIE
of living
AND
children
1969-70
1970-71
-
-
JOEL
193
MONTAGUE
of contraceptive 1971-72
acceptors by year. 1972-73
1973-74
9
15
20
1
3
25
28
31
52
2
4
12
19
121
40
3
16
15
58
62
29
4
16
28
59
105
87
5
11
83
122
72
55
6
39
132
118
210
158
7
20
78
169
273
175
8
38
96
117
176
90
9
6
108
93
145
70
10
3
41
48
43
62
11
3
28
9
27
8
12
-
-
-
9
-
13
-
-
-
9
-
13+
-
-
-
-
-
159
646
839
1,298
846
Provisim of Infmmatim. The population of Ishan is largely rural, illiterate and without radios. Information about the hospital’sclinics hastherefore comeabout from face to face contacts, group meetings, etc. with potential clients. In the early days of the project, full time family planning field workers were working from the hospital in 8 districts in a radius of 25 miles of the hospital. The field workers, 8 auxiliary midwives and 2 male motivators, met once a month in Irrua to discussproblems, submit an itinerary for visits in the coming months, etc. At the end of the first year, by a processof trial and error, it was found that peripheral supervision was difficult to maintain and a system of fixed targets was then establishedfor field workers. A certain number of referrals for each motivator per month was required. Those who failed to achievetheir targets got no pay and those who failed to achieve their targets for two months in succession were terminated. Most of the field workers were ultimately terminated, new oneswere hired, and they too were terminated. In the last group of 20 part time educators who underwent family planning motivation training, only 13 (11 women, 2 men) were finally utilized. In 1971, 10 women and 3 men were utilized. The males attempted to motivate husbandsthrough their experience but this has not been successful. Family planning campaignsare now carried out 3 times a year, avoiding the harvest season,the monsoon, etc. No continuous peripheral programme is carred out but rather a seriesof periodic forays into the communities. The Ishan Division has been divided into 3 regions and field workers are selected on the basis of their ability to work in these regions. Many of the individuals who have been involved in field and motivation work are ex-teachers. It has been found that individuals with a low level of education are not appropriate as field workers. Therefore, in newspaper advertisements for the positions, it is stated that qualified applicants must have at least a primary school education. Sex is not specified. Each individual field worker in a campaign is given 100 personal forms. The field workers descend in twos and threes on a compound in the very early morning and after obtaining clearancefrom the tribal chief or leader, attempt to talk to individuals in a village, on an individual or group basisabout the merits of family planning. Supervision is provided by the 1 or 2 full-time staff membersin the outreach programme
194
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
and major problems are handled by the hospital’s medical director, as is overall supervision. When group talks are given only minimal and simple visual aids are utilized, as more complicated visual aids have been found to be too distracting. Field workers do not discuss the individual methods of contraception in detail, and emphasis is placed on stimulating thought as to the possibilities of spacing or planning the arrival of children. Individuals who show some interest provide their names and addresses. Those who want immediate appointments for family planning services receive an appointment paper from the motivator. Transportation is provided immediately to take them to the hospital. Those individuals who are not interested in coming to the clinic immediately but who are interested in discussing family planning are revisited later by a field work supervisor who talks to the person in detail. TABLE V. Reasons for IUD removal by year.
Reasons
1969-70
Pelvic inflammatory
disease
Cervicitis, etc.
1970-71
1971-72
1972-73
1973-74 up to 2012174
1
1
1
-
-
-
-
-
-
-
-
-
-
-
-
-
1
Vaginitis, etc.
Total 3 1
Perforation of uterus
-
-
-
Perforation of cervix
-
-
-
Fibromyomata
-
-
-
-
-
-
Ovarian cysts
-
-
-
-
-
-
Cystocoele and rectocoele
-
-
-
-
-
-
Insertion into pregnant uterus
-
-
-
Retracted appendage
-
-
-
Erroneous diagnosis of pregnancy
-
-
-
Accidental removal by user
-
-
-
-
Discomfort
-
-
-
-
of uterus
to husband
1
Menorrhagia Pain and cramps
-
Wanted to have another child General feeling of being unwell and changing to other methods
3
-
2 -
1 -
1 -
-
1
-
-
4
3
11
5
3
7
15
9
10
23
45
2
4
5
6
Demanded by a hostile husband
1
1
1 -
-
8
2 4
27
-
3
6
-
1
2
Excessive vaginal discharge
-
After settled menopause
-
-
-
Wants to get married
-
-
-
-
12
22
32
2
-
1
Spontaeous expulsion
Total removals
3
1
-
1
2
1
-
1
1
-
1
-
1 2
2
47
121
The evidence is that while field work is not as active as it was previously, increasing acceptance of the clinic may indicate that intensified field work on a campaign basis is effective. ACSADI, IGUN and JOHNSON
XT0
OKOJIE
AND
JOEL
195
MONTAGUE
(1972) found a direct relationship between knowledge, attitudes and practices of family planning in those areaswhere there had been campaigns.The namesand addressesof interested women were taken. Later follow-up of these women by motivators was pointed toward a firm clinic appointment. For this purpose the motivators used books of coupons numbered sequentially. Becauseof low productivity, most of the motivators were dropped and only 2 remained. A motivator incentive of 3 naira (E2) per casehas not notably improved performance. At the present time the hospital has initiated a new systemof service statistics so that the namesand addressesof all new acceptors are entered in a ledger. A clinic record system was establishedso that all information about a patient reachesa single file. Social Support. In any innovative programme a certain modicum of socialsupport must be generated for the agent of changeor he or sherisks a fiasco. Certainly, in order to undermine resistance,allay fears, and avoid infringing the territorial imperatives of local interest groups, considerableunderstanding of local customs, values, rivalries is essential.In this instance the fact that the hospital’s medical director was a tribesman himself, had once been in training to be a witch doctor and had written the definitive work on the sociology and anthropology of the Ishans did little harm and possibly considerablegood. In any event, prior to commencingwork on a broad scale,the physician in charge of the programmetook very considerable pains to obtain the compliance if not cooperation or support of the area’s31 traditional leaders, the secretariesof the 8 district councils, local pharmacists,etc. Secondly, he found that over the long term dealing with the patient’s immediate needsand wants, rather than confronting only the problem of excessivefertility, was the most effective way of developing confidence in the hospital and its ability to help. To this end, during the first 2 years of the programme infertility problems became a major and time consuming preoccupation of the family planning clinic. For example, during the first year of the programme, now in its lifth year, some523 clients were examined and treated for sub-fertility. Of these228 already had 3 or more children. Gradually the number of infertile caseshastapered off and they are now rarely seen.The reasonsare the relative ineffectivenessof methods of dealing with such problems and the growth of family planning work which haspre-empted clinic time. Women who had cometo the hospital, many for the first time, for solutions to what they felt were important problems,talked to family planning and hospital staff and no doubt rememberedtheir kindly treatment. Leadership, Peripheral
Supervision,
Evaluation
Leadership.One of the major reasonsfor the programme’s“success”is the fact that a single individual, who is sympathetic and interested in the programme, handlesall the IUD insertions and complainsabout side effects himself. In addition, all hospital staff membersknow that family planning clients are to be given preference over all other patients, except those with pressingproblems, and are to be treated with considerable deference. Indisputably, the fact that the individual is both a tribal chieftain and a physician enhancesthe programme’s credibility. Peripheral Superkim. Given the scarcity of core family planning staff, peripheral supervision of full time field workers activity has been a troublesome problem. One of the solutions, as mentioned previously, has been to avoid having a full time motivational staff in the field but rather to undertake a series of campaignswith field workers hired specifically for the purpose. This has meant that supervision from the central level need only be given periodically. The periods in between the campaignare utilized by the 2 most reliable full time field workers for follow-up visits and other related activities. Of key importance to both the supervisor and the effectivenessof the field workers has been the availability of transportation. A vehicle has been an essentialcomponent of the programme, particularly as a meansof transportation of prospective clients to the clinic. Evaluation. Two types of programme evaluation have taken place at the hospital. The first is family planning service statisticskept in the hospital. On first attendance,a card is madeout for the client, showing date, names, age, address, parity, number of children alive, nursing period and last menstrual period The doctor carries out a full medical examination of the client with particular reference to the size of the uterus, condition of the cervical OS, the presenceor absenceof any infection in the pelvis, varicosities, etc. He makesa note of the service given and, if an IUD, the size. Except in the very young girls’ Lippes Loop size D is used as a routine becauseof the rather high spontaneousexpulsion rate in the grand-para
196
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
women. On subsequent visits, the client is asked about bleeding after insertion, lower abdominal pain, vaginal discharge and retention of the IUD. In the light of the complaints and re-examination, treatments mainly for abdominal pain and waistache and in some cases, pelvic inflammatory disease, are given. The doctor keeps a ledger containing the names of the acceptors by type, the complaints and any treatments given. Now a fuller record is being kept, showing attendance daily and a summary of history, complaints and treatments given. In addition, the staff of the Population and Manpower Studies Unit at the University of Ife has undertaken 4 rounds of a survey in Ishan to determine what the impact of the clinic and field workers associated with the hospital have had on the attitudes, knowledge and practice of family plating in Ishan Division. The first survey undertaken by the University of Ife team was in December 1969 when 27 enumerators interviewed some 278 married women between the ages of 15 and 44. A second round was undertaken in December 1970 with a sample size of 5,183. A third and fourth round of the evaluation survey have subsequently been carried out and it is estimated that coding, cleaning, punching and verification of all 4 rounds of surveys will be completed in the summer of 1974 at Ife. Preliminary findings of the first two rounds of the survey are available elsewhere in considerable detail (ACSADI, IGUN, JOHNSON, 1972). Of significanceis the finding that the averagecompletedfamily size desired by women who wanted a limited family size was 7.3 children. Whatever the attitudes expressed,there is someevidence to showthat the hospital’sprogramme may have had someimpact on people’sattitudes and behaviour. For example, at the time of the first survey only 11.1y0 of the women professedto know any way to avoid becoming pregnant or having a baby, and only 2.9% had ever used contraception. By 1970 some27% professedto know about birth control and the constant usersof contraceptives rose to 185’$& Although-as pointed out elsewhere-there are problems with thesefigures, there is every reasonto believe that a significant change of attitude and contraceptive use seemedto have taken place, much of which could be attributed to the programme at the hospital. Of the 185% constant userson the secondsurvey, 7.3% said they were practising with the help of the Zuma clinic, 3.3% were practising without the help of the clinic, and 1.6% gave no response. A table published by ACSADI, IGUN and JOHNSON (1972) which does much to illustrate the impact of the clinic on knowledge, if not contraceptive use, in 1969 is as follows : Characteristic
No. of women
Percentage
Aware of Zuma clinic
1,570
30.3
Contacted by the clinic
1,185
22.8
571
11.0
1,322
2.5
382
7.3
1,431
27.6
Knowledge of Zuma transportation Attendance at Zuma clinic Practising contraception with help from clinic Knows someonewho attended clinic Training,
Financial
Support, Research
Training. Nearly all of the candidatesselectedfor field worker training have never had any form of medical training. Training is now spread over 2 weeks. Government officers of the Community Development Division, whosework consistsof stimulating village community projects, have always been of great assistancein training thesefield workers. The training consistsof taking the traineesaround the hospital to seewomen at the generaloutpatient department, antenatal clinic and infant welfare clinic and to seenurses and midwives addressingwomen. Then come 6 to 9 days’ intensive training which begin with a simple lecture in the anatomy of the female reproductive organs, and how and where pregnancy takes place. There is a lecture on possiblecausesof sterility (which has always excited more interest than what to do to avoid unwanted pregnancy), methods of prevention of pregnancy with emphasison the IUD, pills, foam, diaphragms,condomsand spermatocidaltablets. The third and fourth days are devoted to methods of addressingvarious groups of people; in the compounds, at village meetings, markets, etc., bearing in mind the custom of paying homageto the Onojie (king), the village elders, compound headsand husbands. In Ishan there are some7 ways of committing adultery with a married woman, even without actual carnal
XT0 OKOJIE AND JOEL MONTAGUE
197
knowledge. So the male workers must know these and avoid them meticulously. Various examplesof types of resistance, cultural, religious and even political, are given and trainees are taught how to anwer the questionsof those who raise them. Each trainee is given an identification card with a number, name and a passport-sizephotograph, all signedby the hospital’smedical director. The last day, if not Sunday, is for a visit to a nearby village for field practice. This routine has had to be followed before each family planning campaign, since new field workers have to be recruited to replacethose who have married and left Isham, or are themselvespregnant, or have not been up to standard during the previous campaign. Financial Support. The hospital’sfamily planning programmeis partially supported by the Population Council under a grant from AID. Lessonsto be learned on the financial sideare that institutionalizing any sort of new and innovative public health programme in a rural area requires more time, hard work, determination, and money than most “experts” are inclined to believe. Research. Some research has been undertaken in conjunction with the programme. Initially, the programme had to answer the question whether it was possiblefor simple, uneducated women in a rural area to appreciatethe need and so accept and benefit from family planning education. The Zuma Memorial Hospital programme has made it possible for one to say “Yes”. Secondly, at least 8 different types of contraceptive pills are now in use in the programme. A group of 256 women between 18 and 45 were selectedfor a trial to find out what the side effects of oral contraceptives were, which was responsiblefor most of the acceptorsdiscontinuing and what type of acceptors were most affected. The results had been published in the Nigerian Medical Journal (OKOJIE, 1971) and are stated earlier in this paper. In addition, one of the questionsto be answeredwas which of the contraceptive methods would be most suited to such rural women. We can now say that the IUD is the cheapestand easiestmethod. The next step was to find out its effects and the extent to which they affect acceptability and continuous usage.Flooding, prolonged menstruation and hydrorrhoea (in some casesmaking acceptors wear sanitary pads constantly) are the most serious side effects and have been the reason for most demands for removals. As a result of this finding, pre-insertion examinations are now more thorough and women with cervical erosion and trichomonal infection, all of which cause excessive vaginal discharge, are first treated before insertion. Despite elimination of pelvic infection, we have been unable to pinpoint causesof metrorrhagia or what type of acceptor will develop this most seriouscomplication of the IUD. REFERENCES ANDREWS, W. C. (1971). Obstetl. gynec. SUPV., 26, 477. ACSADI, G., IGUN, A. & JOHNSON, G. (1972). Surveys of Fertility, Family Planning in Nigeria, pp. 51-95. Institute of Population and Manpower Studies, Faculty of Social Sciences, University of Ife, IleIfe, Nigeria. BINGEL, A. S., BENOIT, P. S. (1973). Pharm. Sci., 62, 179. FREYMANN, M. (1966). Family Planning Population Programmes, Ed. B. Berelson, et al., pp. 321-334. Univer-
sity of Chicago Press,Chicago. OKOJIE, C. G. (197 1). Nigerian
med. J., 1, 248.
HOSPITAL
BASED
FAMILY PLANNING IN RURAL AFRICA: SOME LESSONS THE MIDWESTERN STATE OF NIGERIA XT0
Medical
Director,
Zuma Memorial
FROM
OKOJIE Hospital,
Irma,
Midwest
State, Nigeria
JOEL MZTAGUE Regional Director,
Near East/Africa,
The Population
Council, 245 Park Avenue, New York, New York.
Introduction The Ishan Division of the Midwestern State of Nigeria covers an area of approximately 1,162 square miles (3,021 kmz) in the northern half of the Ishan-Asaba plateau, which is west of the River Niger. The plateau forms a watershed for the rivers flowing into the River Niger and those flowing into the Ethiope River. Except for river valleys the relief is gentle, 500-1,500 feet (153 to 460 m) above sealevel, and heavily wooded. The area has a moderate climate with a temperature ranging between 22 to 27°C all year around; a dry seasonvarying from 3 to 5 months from November through April and a wet seasonfrom May through October. Economic activities are typical of much of central Nigeria and relate primarily to the exploitation of rubber and timber, though petty trading is also important. The soils, once fertile, have been depleted and while small farming is still the most common occupation, it is no longer a viable form of livelihood. According to the 1963censusit appearsthat women do not contribute significantly to the total economically active population. The inhabitants of the Division are primarily Christians or Animists. They constitute the membership of some32 distinct clans ranging in size from the Uromi with 63,000 to the Orowa with 524. The most important unit of the traditional socialstructure is lineage and each clan comprisesthose descendantswho trace their ancestry from the samemale ancestor. Family organization is basedupon the extended family unit whose members lodge in the samecompound. A typical compound contains several dwelling units occupied by many related families, with the dwelling unit of the chief constituting a sizableportion of the compound. In all the clans numerouschildren of both sexesare very much desired for many reasons,not the least of which is the bride prices fetched for daughters. As in other areasof Nigeria there is a paucity of systematic data in demography. However, the total population of the Division according to the 1963 censuswas some 270,903persons (ASCADIet al., 1972). At that time most of the population wasrural and an urban total of only 12,379was recorded. The population according to the 1963 censusfigures appearsdisproportionately young with perhaps some46.5% in the O-14 agecategory. The density of the rural population washigh and in various placesexceededsome 600 per square mile (220/knP). The Institute of Population and Manpower Studies at the University of Ife hascharacterized the areaas one of “(a) exceedingly high fertility, (b) high but declining mortality, and (c) limited in and out migration. The number of children surviving to the women on the averageis on the order of 6.” The crude birthrate is probably in excessof 50 per 1,000. The health of the population wasand remainsprecarious due to inadequate sanitation; lack of private dnd government health education and other services; traditional cultural and social attitudes, norms and customson the part of the population; the varying availability of food; lack of cashemployment, etc. The most common health problems are intestinal parasites,tuberculosis, malaria and a variety of infectious diseasesand skin infections. Children are afllicted with diarrhoea, respiratory disordersand malnutrition. Repeated childbearing by Ishan women constitutes one of the major barriers to the improvement of the levels of maternal and child health in the population. Factors affecting fertility include polygamy, near universality of marriage, low mean age of marriage, low female literacy and abstinenceduring the postpartum period. The authors wish to expresstheir appreciation to a number of distinguished colleagueswho kindly commentedon earlier drafts of the manuscript. Needlessto say, entire responsibility for any errors in the final version restswith ourselvesand not with those who assistedus. Our thanks go to Dr. Robert Castadot, Medical Director, International Postpartum Programme, the Population Council; Dr. N. R. E. Fen&h, Liverpool School of Tropical Medicine, Liverpool, England; and George Acsadi (Ph.D.), consultant, World Fertility Survey, London, England.
190
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
Medical services The Zuma Memorial Hospital at Irrua, Ishan Division was founded as a private, secular medical institution in March, 1950 in a rented house with 6 rooms and 12 wooden beds. It was establishedby Xto Okojie, the son of Chief Okojie, the Onojie (king) of Ugboha, a district of the Ishan Province. At that time the Ishan Division had 1 doctor, an Englishwoman, working at a Catholic hospital in Uromi. At the present time there are 3 hospitals, 28 maternity homes and 14 dispensariesserving the total population of 270,000. Nonetheless,now as then the population receives medical care from traditional medicinemen or herbalists. Some of these individuals specializein various ailments, i.e. bone setting, gunshot wounds, snake bites, mental illness, etc. Since its creation the hospital hasgrown in size significantly though its delivery of high quality health care to the rural population is constantly in jeopardy due to lack of funds, medical personnel,the workload and its isolation. The hospital’sX-ray machine,for example,is 40 years old. There is no laboratory assistant, no medical technician, no anesthetist, and only one physician. During the 6 month dry season,water is brought in by car from a river 16 miles away. Personnelproblems continue to plague its operations. The first midwife hired left, for example, becausethe only entertainment offered in Irrua wasthe “incessant drumming in the home of the native doctor.” The hospital is still run by its founder and his wife, who has been the matron and tutor in charge of the government sponsoredmidwifery school at the hospital. Its staff consistsof 2 nurses,4 midwives and the 30 nursing aideswho are undergoing midwifery training. Of its 120 beds, 40 are maternity; 28 male and 16 female medical-surgical; 16 isolation and 19 pediatrics. About 100 women attend the weekly ante-natal clinics. An orphanageis associatedwith the hospital becauseone of the beliefs of the Ishan tribe is that if a mother dieswhile giving birth to a child, no other womanshould take careor feed the infant. Invariably such babiesdied. The hospital now takes them in. While a variety of individuals, organizations and companies have taken an interest in the hospital and have provided somesupport, both in kind and money to assist it, its existence remains precarious. Family planning In spite of the indisputable problems which have beset the development of services at this “bush hospital,” it has managedto initiate and sustain a remarkably effective rural family planning effort. When the hospital first adopted a family planning programme(February 1969)there wasno reasonto be optimistic about its chancesfor success.Indeed, during the first 12 months of the programme in 1969-70, only 96 IUDs were inserted and oral pills were prescribed in 55 cases.Of the 96 IUD acceptors65 had 7 or more children. Over the years there hasbeen a considerableimprovement and it is conceivable-indeed likelythat there is no other hospital in rural Africa with such limited resourcesthat has a comparable record in family planning services. During the period June 1970 through May 1971 the numbers of acceptors increasedto 646. During the period July 1 through December 31, 1972, a total of 622 new clients were seenat the hospital, with some400 accepting the IUD. During the first six months of 1973, a total of 671 clients were seen,with 496 accepting the IUD. We feel that this is a most satisfactory-indeed remarkable -performance in a rural African setting with such high fertility norms, high infant and maternal mortality levels, poor transportation and communication, low literacy rates, etc. The hospital’s programme is probably worth studying for this reason. Indeed there are a number of useful lessonspossibly applicable to other efforts in Nigeria as well as elsewherein Africa which have been learned by the hospital and are worth reflecting upon. For this reason and for the purposesof our analysis of the hospital’s programme we will adopt as a conceptual framework the general family planning programme functions noted by FREYMAN (1966). These he conceivesas (1) instrumental functions (provisions of services, supplies, provision of information, general social support); (2) control functions (top leadership, peripheral supervision and evaluation); (3) supporting functions (training, financial support and research). TABLE
I. Fertility
and subfertility. Number
Family Planning Subfertility
Acceptors
Acceptors
of clients
1960-70
1970-71
1971-72
151
646
839
1298
609
52
2
1
523
300
1972-73
1973 6 months
XT0
OKOJIE
AND
JOEL
191
MONTAGUE
TABLE II. Acceptors by method. Type IUD
1969-70
1970-71
1971-72
1972-73
1973 6 months
96
472
595
967
403
8
31
45
26
7 4
Depo-Provera Condom
-
-
-
-
Foam
-
-
-
-
-
PillS
55
143
199
305
199
TABLE III. Average age and parity of IUD and pill acceptors. Client
Age Parity
1973 Pill/IUD
1969-70 Pill/IUD
1970-71 Pill/IUD
1971-72 Pill/IUD
1972-73 Pill/IUD
32
31
30
28
30
8
6
4
3
5
This table shows a very interesting and factual trend. At the beginning of the programme in 1969, only the grand-multiparae who were advanced in child bearing age, known by the Ishans to face increasing risks in subsequent pregnancies, took advantage of the family planning scheme. As knowledge, attitudes and practice increased, age and parity of acceptors decreased. Even the 1973 average age and parity of 30 and 5 respectively is in order as it only shows that acceptors are now a mixed group; the very young (mainly students and those whose jobs forbid child bearing, like prison wardresses), the advanced in age but still open to risks of pregnancy and the grand multiparae. Instrumental
functions
Provision of Services and SuppZies. Family planning is completely integrated into the hospital’snormal outpatient services.The hospital staff has noted that interviewing clients in the hospital and provision of contraceptive information in general outpatient clinics has to be handled with very considerabledelicacy. Most of the clients are illiterate and are unable to express themselvesvery articulately to medical professionals.Adding to this difficulty is the fact that women are opposedto discussinganything remotely connected with sex with anyone except their husbands, particularly in public places. A major problem is that many men feel that their wives will be unfaithful if they accept contraception. In theory, at least a woman must have her husband’s written permission to accept contraception. Motivation of malesto accept family planning has not been successful. In the clinic the duties of the individuals associatedwith family planning are as follows: a nursemidwife issuesand sorts cards, takes temperatures, pulses, etc; second a nurse-midwife takes complete medical histories; a third nurse-midwife sterilizes equipment and assiststhe physician in the insertion of IUDs. A fee is chargedfor clinic visits basedon the feescharged by the Nigerian Family Planning Association. All the major types of contraceptives are offered. Those who accept contraception are charged 60 kobos (about 36 new pence) for an IUD insertion and 10 kobos (about 6 new pence) for a monthly supply of pills. In advising on contraception at the hospital stressis placed upon the IUD, as pills for resupply are not generally available commercially in rural Ishan. After the IUD insertion the patient returns for an examination as follows: second visit 1 week after insertion; third visit 2 months after insertion; fourth visit 3 months after insertion; patients are then seenon a yearly basis. The hospital’smedical director has found it essentialto establisha rigid return visit schedulebecause the number of patients who have pelvic infections or will develop pelvic infections after insertion is high. His feeling is that rigorous follow-up will detect early infections and, if he can possibly treat these patients immediately, this will keep the IUD from disrepute in the Ishan community. Although it is of debatable medical status in more developed areasof the world, at present the hospital’s medical director makesa strong casefor treating IUD patients with penicillin and streptomycin at the time of insertion. The type of
192
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
treatment and the considerable time spent on counselling and careful medical work-up invariably increases the cost of the programme. Clients who accept the pill are seen each month and receive their monthly supply of pills. They are charged 20 kobos (about 12 new pence) per visit. TABLE
III. Age of family planning acceptors by contraceptive methods and year.
Contraceptive Methods Pill Under 20 20-24
25-29 30-34 40 35-39 +
1969-70
: ::
1970-71 4 i: i;
1971-72
1972-73
J$$y;& .
48
z ;;
50 103 61
;:: 55
69
165
28
26 10
31 12
:57
55
143
199
305
320
4
24 67 71
IUD Under 20
20-24 25-29 30-34
35-39 4Q+
1: 17 iii 15 96
Depo-Provera Under 20
-
25-29 20-24
-
30-34
35-39 4Of
Total
134
142
21 126 204 228
152
210
309
119 170
47
59
79
66
472
595
967
517
-
-
1::
3
i 8
Foam/Jelly, Condom, etc.
i:77
B
20 1:
i 9
: 1
i 17 2
r -
1 7
9
31
45
26
-
-
-
-
-
159
646
839
1,298
846
While considerableemphasisis placed upon the IUD, the Lippes Loop has not been without side effects. The most troublesome manifestations are excessivemenstrual loss and vaginal discharge. For example, of the original 472 IUDS inserted in the beginning of 1972,7 were removed becauseof menorrhagia and pain; 5 were removed becausehusbandswished their wives to become pregnant; and 12 were lost through spontaneousexpulsion. Of the 12 women who lost loops through spontaneousexpulsion, 6 agreed to reinsertion. No pregnancieswere noted with the IUD in place and there was no uterine perforation. The most common side effects associatedwith the pill seemoccasionallyto be at variance with those mentioned in the literature (BINGEL and BENOIT, 1973and ANDREWS,1971).In a study madeat the hospital (OKOJIE, 1971),by order of frequency, the most common sideeffects were nausea,vomiting, lack of appetite or fear lest the client becomesick, lassitude, a general feeling of being unwell, scanty or irregular menses, discomfort in the breasts. Complaints are far more common among the younger patients, the educated patients, and what appearsto be insufficiently motivated women. Grand multiparae and working young educated women, it has been noted, rarely complain about the side effects of any sort of contraception. It has been found at the hospital that the variables associatedwith complaints are closely associatedwith need and education. All casesof dysmenorrhoea, menorrhagia and anaemiaare treated free.
XT0
TABLE IV. Number No. of Living 0
Total
Children
OKOJIE
of living
AND
children
1969-70
1970-71
-
-
JOEL
193
MONTAGUE
of contraceptive 1971-72
acceptors by year. 1972-73
1973-74
9
15
20
1
3
25
28
31
52
2
4
12
19
121
40
3
16
15
58
62
29
4
16
28
59
105
87
5
11
83
122
72
55
6
39
132
118
210
158
7
20
78
169
273
175
8
38
96
117
176
90
9
6
108
93
145
70
10
3
41
48
43
62
11
3
28
9
27
8
12
-
-
-
9
-
13
-
-
-
9
-
13+
-
-
-
-
-
159
646
839
1,298
846
Provisim of Infmmatim. The population of Ishan is largely rural, illiterate and without radios. Information about the hospital’sclinics hastherefore comeabout from face to face contacts, group meetings, etc. with potential clients. In the early days of the project, full time family planning field workers were working from the hospital in 8 districts in a radius of 25 miles of the hospital. The field workers, 8 auxiliary midwives and 2 male motivators, met once a month in Irrua to discussproblems, submit an itinerary for visits in the coming months, etc. At the end of the first year, by a processof trial and error, it was found that peripheral supervision was difficult to maintain and a system of fixed targets was then establishedfor field workers. A certain number of referrals for each motivator per month was required. Those who failed to achievetheir targets got no pay and those who failed to achieve their targets for two months in succession were terminated. Most of the field workers were ultimately terminated, new oneswere hired, and they too were terminated. In the last group of 20 part time educators who underwent family planning motivation training, only 13 (11 women, 2 men) were finally utilized. In 1971, 10 women and 3 men were utilized. The males attempted to motivate husbandsthrough their experience but this has not been successful. Family planning campaignsare now carried out 3 times a year, avoiding the harvest season,the monsoon, etc. No continuous peripheral programme is carred out but rather a seriesof periodic forays into the communities. The Ishan Division has been divided into 3 regions and field workers are selected on the basis of their ability to work in these regions. Many of the individuals who have been involved in field and motivation work are ex-teachers. It has been found that individuals with a low level of education are not appropriate as field workers. Therefore, in newspaper advertisements for the positions, it is stated that qualified applicants must have at least a primary school education. Sex is not specified. Each individual field worker in a campaign is given 100 personal forms. The field workers descend in twos and threes on a compound in the very early morning and after obtaining clearancefrom the tribal chief or leader, attempt to talk to individuals in a village, on an individual or group basisabout the merits of family planning. Supervision is provided by the 1 or 2 full-time staff membersin the outreach programme
194
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
and major problems are handled by the hospital’s medical director, as is overall supervision. When group talks are given only minimal and simple visual aids are utilized, as more complicated visual aids have been found to be too distracting. Field workers do not discuss the individual methods of contraception in detail, and emphasis is placed on stimulating thought as to the possibilities of spacing or planning the arrival of children. Individuals who show some interest provide their names and addresses. Those who want immediate appointments for family planning services receive an appointment paper from the motivator. Transportation is provided immediately to take them to the hospital. Those individuals who are not interested in coming to the clinic immediately but who are interested in discussing family planning are revisited later by a field work supervisor who talks to the person in detail. TABLE V. Reasons for IUD removal by year.
Reasons
1969-70
Pelvic inflammatory
disease
Cervicitis, etc.
1970-71
1971-72
1972-73
1973-74 up to 2012174
1
1
1
-
-
-
-
-
-
-
-
-
-
-
-
-
1
Vaginitis, etc.
Total 3 1
Perforation of uterus
-
-
-
Perforation of cervix
-
-
-
Fibromyomata
-
-
-
-
-
-
Ovarian cysts
-
-
-
-
-
-
Cystocoele and rectocoele
-
-
-
-
-
-
Insertion into pregnant uterus
-
-
-
Retracted appendage
-
-
-
Erroneous diagnosis of pregnancy
-
-
-
Accidental removal by user
-
-
-
-
Discomfort
-
-
-
-
of uterus
to husband
1
Menorrhagia Pain and cramps
-
Wanted to have another child General feeling of being unwell and changing to other methods
3
-
2 -
1 -
1 -
-
1
-
-
4
3
11
5
3
7
15
9
10
23
45
2
4
5
6
Demanded by a hostile husband
1
1
1 -
-
8
2 4
27
-
3
6
-
1
2
Excessive vaginal discharge
-
After settled menopause
-
-
-
Wants to get married
-
-
-
-
12
22
32
2
-
1
Spontaeous expulsion
Total removals
3
1
-
1
2
1
-
1
1
-
1
-
1 2
2
47
121
The evidence is that while field work is not as active as it was previously, increasing acceptance of the clinic may indicate that intensified field work on a campaign basis is effective. ACSADI, IGUN and JOHNSON
XT0
OKOJIE
AND
JOEL
195
MONTAGUE
(1972) found a direct relationship between knowledge, attitudes and practices of family planning in those areaswhere there had been campaigns.The namesand addressesof interested women were taken. Later follow-up of these women by motivators was pointed toward a firm clinic appointment. For this purpose the motivators used books of coupons numbered sequentially. Becauseof low productivity, most of the motivators were dropped and only 2 remained. A motivator incentive of 3 naira (E2) per casehas not notably improved performance. At the present time the hospital has initiated a new systemof service statistics so that the namesand addressesof all new acceptors are entered in a ledger. A clinic record system was establishedso that all information about a patient reachesa single file. Social Support. In any innovative programme a certain modicum of socialsupport must be generated for the agent of changeor he or sherisks a fiasco. Certainly, in order to undermine resistance,allay fears, and avoid infringing the territorial imperatives of local interest groups, considerableunderstanding of local customs, values, rivalries is essential.In this instance the fact that the hospital’s medical director was a tribesman himself, had once been in training to be a witch doctor and had written the definitive work on the sociology and anthropology of the Ishans did little harm and possibly considerablegood. In any event, prior to commencingwork on a broad scale,the physician in charge of the programmetook very considerable pains to obtain the compliance if not cooperation or support of the area’s31 traditional leaders, the secretariesof the 8 district councils, local pharmacists,etc. Secondly, he found that over the long term dealing with the patient’s immediate needsand wants, rather than confronting only the problem of excessivefertility, was the most effective way of developing confidence in the hospital and its ability to help. To this end, during the first 2 years of the programme infertility problems became a major and time consuming preoccupation of the family planning clinic. For example, during the first year of the programme, now in its lifth year, some523 clients were examined and treated for sub-fertility. Of these228 already had 3 or more children. Gradually the number of infertile caseshastapered off and they are now rarely seen.The reasonsare the relative ineffectivenessof methods of dealing with such problems and the growth of family planning work which haspre-empted clinic time. Women who had cometo the hospital, many for the first time, for solutions to what they felt were important problems,talked to family planning and hospital staff and no doubt rememberedtheir kindly treatment. Leadership, Peripheral
Supervision,
Evaluation
Leadership.One of the major reasonsfor the programme’s“success”is the fact that a single individual, who is sympathetic and interested in the programme, handlesall the IUD insertions and complainsabout side effects himself. In addition, all hospital staff membersknow that family planning clients are to be given preference over all other patients, except those with pressingproblems, and are to be treated with considerable deference. Indisputably, the fact that the individual is both a tribal chieftain and a physician enhancesthe programme’s credibility. Peripheral Superkim. Given the scarcity of core family planning staff, peripheral supervision of full time field workers activity has been a troublesome problem. One of the solutions, as mentioned previously, has been to avoid having a full time motivational staff in the field but rather to undertake a series of campaignswith field workers hired specifically for the purpose. This has meant that supervision from the central level need only be given periodically. The periods in between the campaignare utilized by the 2 most reliable full time field workers for follow-up visits and other related activities. Of key importance to both the supervisor and the effectivenessof the field workers has been the availability of transportation. A vehicle has been an essentialcomponent of the programme, particularly as a meansof transportation of prospective clients to the clinic. Evaluation. Two types of programme evaluation have taken place at the hospital. The first is family planning service statisticskept in the hospital. On first attendance,a card is madeout for the client, showing date, names, age, address, parity, number of children alive, nursing period and last menstrual period The doctor carries out a full medical examination of the client with particular reference to the size of the uterus, condition of the cervical OS, the presenceor absenceof any infection in the pelvis, varicosities, etc. He makesa note of the service given and, if an IUD, the size. Except in the very young girls’ Lippes Loop size D is used as a routine becauseof the rather high spontaneousexpulsion rate in the grand-para
196
HOSPITAL
BASED
FAMILY
PLANNING
IN
RURAL
AFRICA
women. On subsequent visits, the client is asked about bleeding after insertion, lower abdominal pain, vaginal discharge and retention of the IUD. In the light of the complaints and re-examination, treatments mainly for abdominal pain and waistache and in some cases, pelvic inflammatory disease, are given. The doctor keeps a ledger containing the names of the acceptors by type, the complaints and any treatments given. Now a fuller record is being kept, showing attendance daily and a summary of history, complaints and treatments given. In addition, the staff of the Population and Manpower Studies Unit at the University of Ife has undertaken 4 rounds of a survey in Ishan to determine what the impact of the clinic and field workers associated with the hospital have had on the attitudes, knowledge and practice of family plating in Ishan Division. The first survey undertaken by the University of Ife team was in December 1969 when 27 enumerators interviewed some 278 married women between the ages of 15 and 44. A second round was undertaken in December 1970 with a sample size of 5,183. A third and fourth round of the evaluation survey have subsequently been carried out and it is estimated that coding, cleaning, punching and verification of all 4 rounds of surveys will be completed in the summer of 1974 at Ife. Preliminary findings of the first two rounds of the survey are available elsewhere in considerable detail (ACSADI, IGUN, JOHNSON, 1972). Of significanceis the finding that the averagecompletedfamily size desired by women who wanted a limited family size was 7.3 children. Whatever the attitudes expressed,there is someevidence to showthat the hospital’sprogramme may have had someimpact on people’sattitudes and behaviour. For example, at the time of the first survey only 11.1y0 of the women professedto know any way to avoid becoming pregnant or having a baby, and only 2.9% had ever used contraception. By 1970 some27% professedto know about birth control and the constant usersof contraceptives rose to 185’$& Although-as pointed out elsewhere-there are problems with thesefigures, there is every reasonto believe that a significant change of attitude and contraceptive use seemedto have taken place, much of which could be attributed to the programme at the hospital. Of the 185% constant userson the secondsurvey, 7.3% said they were practising with the help of the Zuma clinic, 3.3% were practising without the help of the clinic, and 1.6% gave no response. A table published by ACSADI, IGUN and JOHNSON (1972) which does much to illustrate the impact of the clinic on knowledge, if not contraceptive use, in 1969 is as follows : Characteristic
No. of women
Percentage
Aware of Zuma clinic
1,570
30.3
Contacted by the clinic
1,185
22.8
571
11.0
1,322
2.5
382
7.3
1,431
27.6
Knowledge of Zuma transportation Attendance at Zuma clinic Practising contraception with help from clinic Knows someonewho attended clinic Training,
Financial
Support, Research
Training. Nearly all of the candidatesselectedfor field worker training have never had any form of medical training. Training is now spread over 2 weeks. Government officers of the Community Development Division, whosework consistsof stimulating village community projects, have always been of great assistancein training thesefield workers. The training consistsof taking the traineesaround the hospital to seewomen at the generaloutpatient department, antenatal clinic and infant welfare clinic and to seenurses and midwives addressingwomen. Then come 6 to 9 days’ intensive training which begin with a simple lecture in the anatomy of the female reproductive organs, and how and where pregnancy takes place. There is a lecture on possiblecausesof sterility (which has always excited more interest than what to do to avoid unwanted pregnancy), methods of prevention of pregnancy with emphasison the IUD, pills, foam, diaphragms,condomsand spermatocidaltablets. The third and fourth days are devoted to methods of addressingvarious groups of people; in the compounds, at village meetings, markets, etc., bearing in mind the custom of paying homageto the Onojie (king), the village elders, compound headsand husbands. In Ishan there are some7 ways of committing adultery with a married woman, even without actual carnal
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knowledge. So the male workers must know these and avoid them meticulously. Various examplesof types of resistance, cultural, religious and even political, are given and trainees are taught how to anwer the questionsof those who raise them. Each trainee is given an identification card with a number, name and a passport-sizephotograph, all signedby the hospital’smedical director. The last day, if not Sunday, is for a visit to a nearby village for field practice. This routine has had to be followed before each family planning campaign, since new field workers have to be recruited to replacethose who have married and left Isham, or are themselvespregnant, or have not been up to standard during the previous campaign. Financial Support. The hospital’sfamily planning programmeis partially supported by the Population Council under a grant from AID. Lessonsto be learned on the financial sideare that institutionalizing any sort of new and innovative public health programme in a rural area requires more time, hard work, determination, and money than most “experts” are inclined to believe. Research. Some research has been undertaken in conjunction with the programme. Initially, the programme had to answer the question whether it was possiblefor simple, uneducated women in a rural area to appreciatethe need and so accept and benefit from family planning education. The Zuma Memorial Hospital programme has made it possible for one to say “Yes”. Secondly, at least 8 different types of contraceptive pills are now in use in the programme. A group of 256 women between 18 and 45 were selectedfor a trial to find out what the side effects of oral contraceptives were, which was responsiblefor most of the acceptorsdiscontinuing and what type of acceptors were most affected. The results had been published in the Nigerian Medical Journal (OKOJIE, 1971) and are stated earlier in this paper. In addition, one of the questionsto be answeredwas which of the contraceptive methods would be most suited to such rural women. We can now say that the IUD is the cheapestand easiestmethod. The next step was to find out its effects and the extent to which they affect acceptability and continuous usage.Flooding, prolonged menstruation and hydrorrhoea (in some casesmaking acceptors wear sanitary pads constantly) are the most serious side effects and have been the reason for most demands for removals. As a result of this finding, pre-insertion examinations are now more thorough and women with cervical erosion and trichomonal infection, all of which cause excessive vaginal discharge, are first treated before insertion. Despite elimination of pelvic infection, we have been unable to pinpoint causesof metrorrhagia or what type of acceptor will develop this most seriouscomplication of the IUD. REFERENCES ANDREWS, W. C. (1971). Obstetl. gynec. SUPV., 26, 477. ACSADI, G., IGUN, A. & JOHNSON, G. (1972). Surveys of Fertility, Family Planning in Nigeria, pp. 51-95. Institute of Population and Manpower Studies, Faculty of Social Sciences, University of Ife, IleIfe, Nigeria. BINGEL, A. S., BENOIT, P. S. (1973). Pharm. Sci., 62, 179. FREYMANN, M. (1966). Family Planning Population Programmes, Ed. B. Berelson, et al., pp. 321-334. Univer-
sity of Chicago Press,Chicago. OKOJIE, C. G. (197 1). Nigerian
med. J., 1, 248.
