Cost analysis serves many purposes.

PIP: This article discusses the utility of performing cost analysis of family planning (FP) personnel resources by relying on a system analysis framework in developing countries. A study of a national provider that distributes 16% of all FP services in Mexico found that more efficient use of staff would increase the number of clients served. Nurses and doctors worked slightly more than 6 hours/day, and 38% of a nurse's time and 47% of a physician's time was spent in meetings, administrative duties, unoccupied work time, and personal time. The Mexican government proposed increasing the work day to 8 hours and increasing to 66% the portion of the work day spent on direct client activity. With this change, services would increase from 1.5 million couple-years of protection (CYP) to 1.8 million CYP in 2010, without additional staff, and CYP cost would decline. CYP costs could potentially be reduced by increasing the number of contraceptive units provided per visit and switching from a 1-month- to a 3-month-duration injectable contraceptive. A Bangladesh study found that CYP costs could be reduced by eliminating absenteeism and increasing work time/day by 1 hour. Cost studies can address specific human resource issues. A study in Thailand found that Norplant was more expensive per CYP than injectables and the IUD, and Norplant acceptors were willing to switch to other effective modern methods. The Thai government decided to target Norplant to a few target groups. Staff time use evaluations can be conducted by requiring staff to record their time or by having clients maintain records of staff time on their health cards. The time-motion study, which involves direct observations of how staff spend their time, is costly but avoids estimation error. A CEMOPLAF study in Ecuador found that 1 visit detected almost as many health problems as 4 visits. Some studies examine cost savings related to other services.^ieng

Focusing on customer service.

PIP: This booklet is devoted to a consideration of how good customer service in family planning programs can generate demand for products and services, bring customers back, and reduce costs. Customer service is defined as increasing client satisfaction through continuous concern for client preferences, staff accountability to clients, and respect for the rights of clients. Issues discussed include the introduction of a customer service approach and gaining staff commitment. The experience of PROSALUD in Bolivia in recruiting appropriate staff, supervising staff, soliciting client feedback, and marketing services is offered as an example of a successful customer service approach. The key customer service functions are described as 1) establishing a welcoming atmosphere, 2) streamlining client flow, 3) personalizing client services, and 4) organizing and providing clear information to clients. The role of the manager in developing procedures is explored, and the COPE (Client-Oriented Provider-Efficient) process is presented as a good way to begin to make improvements. Techniques in staff training in customer service include brainstorming, role playing, using case studies (examples of which are provided), and engaging in practice sessions. Training also leads to the development of effective customer service attitudes, and the differences between these and organizational/staff-focused attitudes are illustrated in a chart. The use of communication skills (asking open-ended questions, helping clients express their concerns, engaging in active listening, and handling difficult situations) is considered. Good recovery skills are important when things go wrong. Gathering and using client feedback is the next topic considered. This involves identifying, recording, and discussing customer service issues as well as taking action on these issues and evaluating the results. The booklet ends by providing a sample of customer service indicators, considering the maintenance of a customer service focus, and reporting comments from the reviewers of the booklet.^ieng

[Approaching the area of reproductive rights through a focus on conflicts]. / Una aproximacion al entorno de los derechos reproductivos por medio de un enfoque de conflictos.

PIP: This work identifies human rights conflicts that may result from the confrontation of the reproductive patterns of a population with family planning policies. It seeks to identify the parties involved in specific conflicts in order to document them and propose resources for their management. The fertility decline that began in Mexico in the 1970s and the significance of family planning policy as a means of facilitating the preexisting desire of couples to control fertility are examined. Possible sources of conflict are then explored in the relations between the population and health care providers. Class differences between service providers and clients, possible failure of providers to provide full information on reproductive and contraceptive options to their clients, imposition of one-sided decision making and power relations, and gender discrimination should all be examined from this perspective. Failure to allow a sufficient delay between birth of the last child and sterilization is a concrete example in which questions may be asked concerning safeguarding of the reproductive rights of individuals. The relationship of service providers to population and health policy is a potential source of conflict if, as has occurred in Mexico, the goals for fertility reduction are not met and the decision is made to redouble institutional efforts rather than modify the goal. A first step in confronting possible conflicts is to demonstrate systematically that inequalities exist in access to rights. Conflicts should be documented and interpreted in terms of underlying power relations. The concepts of reproduction, human rights, and family planning should be analyzed for their exact semiotic significance to indicate possible sources of conflict at the level of conceptualization. An awareness of reproductive rights and a willingness to defend them should be promoted in the population.^ieng

Quality is client oriented.

PIP: Successful growth greatly depends upon the quality of care received at each stage of one's development. As such, all family planning activities should be centered around the clients' perspective. Clients, however, are highly diverse and individual in terms of value systems, degrees of knowledge and awareness, sexes, sexualities, biomedical characteristics, lifestyles, psychosocial and economic conditions, community settings, and other factors. These influences and characteristics are also dynamic, changing over time. Each individual, regardless of his or her own particular characteristics and circumstances, still must make reproductive and sex behavioral decisions. Care providers need to be aware of such diversity and accept clients as unique individuals with individual needs, feelings, and ideas. The author considers quality of care in family planning services from the perspective of the humans involved and the opportunities for growth which each can find in the process of receiving or providing services. Understanding the needs of clients, the value of face-to-face communication, improving the attitudes and skills of providers, and the crucial role of managers are discussed.^ieng

Improving quality at many levels. Profamilia's experience in Colombia.

PIP: Profamilia, the Colombian family planning association and the country's largest family planning provider, began diversifying its services in 1982 to offer prenatal care services as well as general medical consultations. The organization has since attempted to integrate quality assurance at all levels of operation. Specifically, Profamilia is aiming to provide care which is of sustainably high quality to satisfy present clients and attract new ones without overtaxing available organization resources, thereby prompting the eventual financial collapse of the programs and the failure to increase coverage especially among the middle and lower classes of the country. Drawing from the credo of modern corporate enterprise, "the client is always right," Profamilia listens and responds to clients' needs with the goal of making their satisfaction the ultimate objective. Moreover, organization staff receive regular training to motivate their receptiveness to client needs, while the pursuit of quality exists as a major goal at the managerial level. Profamilia regards quality maintenance and improvement as indispensable in program sustainability.^ieng

Contraception. Family planning: by whom and for whom?

PIP: Many people consider family planning to be the cure for population growth and its consequences (poverty, child mortality, morbidity, depletion of natural resources, and environmental degradation). International organizations support family planning programs and population-political strategies control their operations. Other key players in family planning are the pharmaceutical industry, the churches, and governments. Women tend not be involved in developing population and family planning policies, however, but instead implement the policies. Population planners are generally not interested in family planning methods which give women control over their own bodies, e.g., female-controlled barrier methods. In fact, they distrust them because the planners consider women to be unreliable. Besides, the low effectiveness of these methods means women need to rely on abortion, which is a problem in many developing countries, e.g., Latin America. Further, family planning programs must meet predetermined goals, so their service is lacking, e.g., limited supply of contraceptives and not enough time to provide information to clients. Family planning revolves around women. For example, they encourage them to talk their partners into approving the women's use of contraception, but this is almost always difficult for women in developing countries. Provision of family planning cannot be successful without society accepting and treating women as full citizens. In addition, society needs to realize that women have a sexuality separate from men. Political will is needed for these changes in attitude. The international women's movement does not agree on the degree which women can control contraceptives themselves. Women's groups are working to improve the position and independence of women and contraception is just 1 factor which can help them achieve this goal. The Women's Sexuality and Health Feminist Collective in Sao Paulo, Brazil, is an example of a coalition of women's health groups.^ieng

A comparison of the performance of male and female CBD distributors in Peru.

This report presents the results of an operations research project to increase male involvement in family planning in Peru. Two community-based distribution (CBD) programs, PROFAMILIA of Lima and CENPROF of Trujillo, Peru, recruited male contraceptive distributors and compared their performance to that of female distributors recruited at the same time. Both programs found it harder to recruit men than women as distributors. Program supervisors, who were women, were less comfortable with men than with other women, even though there were no differences in distributor compliance with program norms. Male distributors were more likely to serve male clients and sell male methods (condoms), while female distributors were more likely to serve female clients and sell female methods (pills). Men sold as much or more total couple-years of protection than did women, and they recruited as many or more new acceptors. Gender was found to exert an impact on method mix independent of other distributor characteristics, such as age, education, marital status, and number of living children. The study suggests that family planning programs can influence method mix and client characteristics by recruiting men as CBD distributors.

PIP: The findings of an operations research (OR) project designed to compare the effectiveness of male vs. female contraceptive distributors in Peru are reported. The OR project was conducted by 2 private, nonprofit family planning agencies that have community-based distribution (CBD) programs: PROFAMILIA in Lima and CENPROF in Trujillo. The OR project sought to test 3 hypotheses: 1) male distributors would sell more condoms and female distributors would sell more oral contraceptives; 2) male distributors would serve more male clients and female distributors would serve more female clients; and 3) male distributors would sell less contraceptive protection than female distributors. Between 1987 and January 1988, the 2 agencies recruited new male and female distributors to serve in the project. Both agencies had a more difficult time recruiting male than female distributors. PROFAMILIA recruited 38 men and 171 women, while CENPROF recruited 52 men and 94 women. All but one of the supervisors in both agencies were female. The supervisors generally regarded the male distributors with skepticism, but the study found no significant difference in the reporting compliance of male and female distributors. The project confirmed hypotheses 1 and 2. In both agencies men sold twice as many condoms as did women, and women sold more oral contraceptives; and male distributors were more likely to serve men, while female distributors were more likely to serve women. The 3rd hypothesis, however, was unsupported. Men sold as much or more contraceptive protection than did women and recruited as many or more new acceptors. It is concluded that men can be effective CBD distributors, and that CBD programs can influence method and client mix by recruiting more men as distributors.

[Quality of care in family planning clinical services in Latin America]. / Calidad de atencion en los servicios clinicos de planificacion familiar en America Latina.

PIP: Quality of care in family planning is a difficult concept to measure because of the multitude of factors contributing to it and the subjective nature of many of them. Because family planning programs were developed largely in response to rapid demographic growth, their evaluation has concentrated on fulfillment of quantified goals such as numbers of new users, coverage, or prevalence. Such measures give no indication of the relative satisfaction or dissatisfaction of users. Family planning programs seeking high volume tend to have many new acceptors with low continuation rates, and a choice of methods limited to those considered highly effective and easy to distribute. In most Latin American programs, only oral contraceptives and surgical sterilization have high prevalence rates. In recent years, however, community pressure for greater attention to users needs and disappointment with results of programs oriented to obtaining high rates of new users have prompted greater attention top satisfaction of family planning clients and to quality of services. A recent review identified 6 crucial elements in determining the quality of family planning care: 1) free and informed selection of methods 2) information provided to clients 3) technical competence of service providers 4) interpersonal relations between clients and workers 5) mechanisms to promote continuation of use and 6) adequate provision of additional services. This work surveys the quality of family planning services in Latin America, using these 6 factors as a point of departure. The current situation, the ideal and minimal acceptable levels, and the most promising strategies for achieving improvements are assessed for each factor. Free selection of contraceptive method is restricted in most Latin American family planning programs because access is limited to a few methods, because inadequate information is provided to users, because high prices of some methods limit accessibility, or because some methods are considered inappropriate for particular clients or populations. The information provided to clients may be incomplete or biased, the personnel providing it may be inadequately trained, information provided by different types of workers may be incoherent of conflicting, or information provision may be neglected once the method has been chosen. Great regional differences have been found in the technical competence of family planning workers. Physicians working in family planning are usually technically competent for the most common techniques but often lack adequate training in other methods. Interpersonal relations often show a lack of concern for the needs of the client, a lack of warmth, and lack of respect for elementary modesty and privacy. Operational studies can be of great use in comparing results of different strategies to improve the quality of care on contraceptive acceptance and continuation rates.^ieng

Youth programmes in Mexico.

PIP: Research indicates that in-school adolescents in Mexico have their first sexual contact at the average age of 15.5 years. In 50% of cases, such contact is with a boyfriend or girlfriend, 28.1% with a fiance, and 18.3% with a prostitute. First sexual intercourse occurs with a spouse in only 1.3% of cases. Since only one in six young people in Mexico use a form of contraception, many unwanted pregnancies outside of marriage result. 450,000 births in 1989 were to mothers below 20 years old, with 15% of births annually being among teenage mothers. An estimated three million abortions occur annually in Mexico, and abortions are the fifth major cause of death at the national level. Teen pregnancy is decisively linked with poor living conditions and life expectancy, a relatively lower level of education, and rural residence. As for psychological and anthropological variables, most teens who become pregnant belong to large, unstable families with poor family communication, and are characterized as submissive, highly dependent, and of low self-esteem. Targeting students, workers, and other youths, the MEXFAM Youth Program selects and trains program coordinators over age 21 and volunteer promoters of both sexes aged 16-20 in urban/marginal communities. Promoters offer information to their peers and other youths in their local communities, distribute barrier contraceptives, and channel medical, psychological, and legal services to young people in need. Program procedure is described.^ieng

Incorporating AIDS prevention activities into a family planning organization in Colombia.

Three AIDS prevention activities were incorporated into the services offered by PROFAMILIA in two operations research projects. The activities included: (1) informative talks given both to the general public and to members of target groups by PROFAMILIA's community marketing (CM) program field workers (or instructors); (2) the establishment of condom distribution posts in meeting places of target groups; and (3) mass-media information campaigns on AIDS prevention. Community-based distributors were able to successfully provide information on AIDS to their regular audiences as well as to deliver information and condoms to special target groups without negatively affecting family planning information/education/communication activities and contraceptive sales. A radio campaign that promoted condom use for AIDS prevention did not affect public perceptions about the condom and did not jeopardize PROFAMILIA's image.

PIP: PROFAMILIA, a private family planning agency in Colombia, conducted an operations research (OR) project designed to explore the use of 3 AIDS prevention activities. The 3 activities includes the use family planning workers to deliver informative talks on AIDS, the establishment of condom distribution posts in places frequented by high-risk groups (homosexuals, prostitutes, soldiers, and prison inmates), and the use of mass-media educational campaigns. A total of 59 in June of 1987, the number of reported AIDS cases in Colombia increased to 474 by 1988. Recognizing the lack of activity on AIDS prevention, PROFAMILIA decided to explore education strategies. Some of the questions and concerns included: 1) How much need is there for AIDS and STD information among typical PROFAMILIA clients (mostly women of reproductive age and adolescents)? 2) How much effort would AIDS-related activities demand from field workers? 3) Would these activities disrupt contraceptive sales? 4) Would field workers be accepted by the target groups, and would they be able to convey the message and establish condom distribution posts? And 5) would a mass media campaign be effective? The study revealed that a great demand for AIDS information exists among PROFAMILIA's typical clients, as well as the fact that these services do not disrupt field workers' other activities, including condom sales. Although field workers were able to deliver the information to the target groups, they had difficulty attracting many members of high-risk groups to the informative talks. Furthermore, the sales of condoms at distribution posts were low. But the mass media campaigns were found to be highly effective in disseminating AIDS information.

How should vasectomy be promoted in Guatemala?

PIP: In the article "Evaluation of a Communications Program to Increase Adoption of Vasectomy in Guatemala" by J.T. Bertrand et al (Stud Fam Plann 1987 Nov/Dec), the authors conclude that the use of a male promoter alone was 4 times more cost-effective in increasing the number of vasectomies than the use of radio alone because the costs of the radio program were 4 times higher. This conclusion is questionable for several reasons. 1) The district where the promoter was used alone was twice as large as the radio-only district. 2) In one of the promoter-only districts the same promoter worked throughout the program, but in the other, 3 different promoters had to be recruited and trained, due to high personnel turnover. 3) The initial costs of a radio program may be higher, but 1 program can be broadcast in all districts with little or no extra cost, whereas the costs of a promoter would have to be multiplied by the number of districts. 4) Although the promoter and the radio program produced approximately equal numbers of vasectomies, the radio messages reached over 70% of the people surveyed. Thus, on a national basis, radio broadcasts would be far more cost-effective than the use of salaried promoters in each district.^ieng

Family planning needs and behavior of Mexican American women: a study of health care professionals and their clientele.

"A random sample of Mexican American women and a sample of family planning health care professionals, both from two major southwestern cities in the United States, were compared in terms of their reports of birth control methods used, problems in obtaining family planning services, and values involved in making fertility-related decisions, within the Mexican American population.... While there were points of agreement between the two samples, discrepancies were found in reports of problems in obtaining family planning services, fertility-related values, and in the acceptability of female sterilization as a birth control method. It was concluded that family planning professionals in these service areas tend to stereotype Mexican American women, and may not yet realize that the family planning attitudes and behavior of these women are probably changing in significant ways." (SUMMARY IN SPA)

Parental attitudes toward adolescent sexuality: transcultural perspectives.

The problem of teenage pregnancy continues to impact private and public resources, affecting all socioeconomic and cultural groups. A key factor for nurse practitioners to consider when planning sex education programs is the differing parental attitudes toward teenage sexuality. These attitudes are especially important to keep in mind when dealing with parents from minority cultural groups, as these groups are often highly influential in determining the nature of adolescent sexual behavior and attitudes toward reproduction. A study of Cuban and Haitian child-rearing practices clearly demonstrates two divergent parental views of adolescent sexuality. Nurse practitioners must recognize these differing views, and individualize their approach, in order to develop culturally sensitive sex education programs for adolescents and their parents. Suggestions are provided for development of such programs for Cuban and Haitian parents and children.

PIP: Teenage pregnancy continues to impact private and public resources in America. 1 key factor for nurse practitioners teaching sex education is to keep in mind the differing attitudes various cultural groups have toward teenage sex. A study of Cuban and Haitian child-rearing practices demonstrates such cultural differences. 30 Cuban and 30 Haitian mothers composed the voluntary sample obtained through the Dade County Health Department and local churches. The sample consisted of women born and raised in Cuba or Haiti who had resided in the US for 4 years or less and had children ranging in age from infancy through adolescence. Subjects were interviewed in their homes using a 110-item questionnaire adapted from the FIELD GUIDE FOR A STUDY OF SOCIALIZATION. The Cuban female learned about menstruation at a median age of 10 years. For 85% of the sample, this information was obtained from their mothers or in school classes. Most children learned about sex from sex education classes at school or through parent-child discussions. Intercourse was explained as being a normal process of human reproduction. Haitian females, on the other hand, were introduced to the topic of menstruation at the onset of the menses (at about age 13). Only 26% of the Haitian mothers stated that parents or schools provided such information. When parents gave such information, it centered around being careful around boys to avoid pregnancy. 50% of Haitian mothers did not know when children learned about intercourse since it was never discussed with children. Parents who did discuss sex with their children focused on the negative consequences of unplanned pregnancy. Nurse practitioners must consider the fact that Cuban parents expect the school system to take the initiative in providing health education instruction for their children. The nurse practitioner's most effective role may be to assist in developing school-based sex education programs and working with parent-teacher associations to encourage parent participation in school programs. Haitian clients require a different approach. Nurse practitioners may find it difficult to engage Haitian parents in discussions about sex education and reproduction since these topics are not necessarily considered to be health-related and are not discussed with strangers. One alternative would be for health care providers to join forces with social service agencies who often have Haitian personnel serving residential enclaves of Haitians. The challenge to nurse practitioners is to demonstrate respect for cultural traditions while planning interventions which are mutually acceptable and satisfying.

Barriers to modern contraceptive use in rural Peru.

This paper examines Quechua-speaking Indians' choice of contraceptive methods and discusses barriers to the use of modern contraceptives. A study conducted in a Peruvian highland community shows that contraceptive choice is strongly related to a couple's life experiences, their contact with urban centers, their economic status, and their emphasis on cultural values. Among contraceptive users, husbands are concerned with family size and encourage their wives to seek information about the use of modern contraceptives. A discrepancy in attitudes exists between spouses: the men's positive attitude toward modern contraception contrasts with the women's traditional desire for a large family. In this study population, modern contraception is a novelty that has reached only a few families. The majority of the couples practice natural and traditional family planning methods, which are not reliable. Villagers do not use modern contraceptives as a result of cultural barriers created by family planning services that do not take into account the lifestyle of these people, insufficient knowledge of human physiology, comments from dissatisfied users, and women's reliance on their reproductive role for self-esteem.

PIP: This paper, based on fieldwork done in 1984 in a Peruvian highland community with a population of about 3,500, examines Quechua-speaking Indians' choice of contraceptive methods and discusses barriers to the use of modern contraceptives. The village is poor, with many of the villagers involved in migrant labor, but there have been modernization influences: most villagers are bilingual, men average 8 years of schooling and wives 6. Government family planning programs (FP) were initiated at the local health post in 1982. This study, sampling 54 couples, 2/3 in consensual unions shows 1st pregnancy is usually at 18, and about 5 live births take place by age 31. Only 12 couples reported not using any form of contraception, 27 unreliable natural or traditional methods, and 15 modern methods. Non-contracepting women tended to breastfeed longer and have less schooling, and tended not to be working full-time. Contraceptive choice is strongly related to a couple's life experiences, their contact with urban centers, their economic status, and their emphasis on cultural values. Among contraceptive users, some husbands are concerned with family size (for economic, child welfare, and health reasons) and encourage their wives to seek information about the use of modern contraceptives. A discrepancy in attitudes exists between spouses: men's positive attitude toward modern contraception contrasts with women's traditional desire for a large family. Villagers do not use modern contraceptives because of barriers created by FP services that do not take into account the lifestyle of these people (e.g. language, work hours, respect for privacy), disturbing and poorly explained side-effects, especially of pills and injected depo-provera, insufficient knowledge of human physiology, contraception failures due to inappropriate use (often because of poor explanations by health post staff), comments from dissatisfied users, and women's reliance on their reproductive role for self-esteem.

[CBD: much more than community based distribution of contraceptives]. / DCA: mucho mas que distribucion comunitaria de anticonceptivos.

PIP: Profamilia in the Dominican Republic began a program called "Popular Promoters" in 1973 in which rural women were referred to family planning clinics, and in 1976 the community-based distribution program was formally begun. Between October 1974-October 1975, Profamilia had gained experience in the distribution of contraceptives in rural areas of the country. At the start, the community program continued promotion of family planning primarily in rural areas while offering contraceptive directly to those seeking them. By 1977, 105 communities and 12 provinces had been added to the program and 6500 women were being served. 14,500 of the 15,200 couples served in 1980 used pills. There were 23,000 users in 1984, 12,000 of whom were new acceptors. Over 34% of Profamilia's 66,000 clients are in the community-based distribution program. The program also maintains a strong educational component which each year offers over 400 talks in its 170 rural and urban communities on themes related to family planning, including health, education, nutrition, and use of available resources. Among early problems of the program were opposition from physicians, difficulty of recruiting volunteers who met the personality and other requirements, myths and incorrect beliefs of the community regarding family planning, the belief among men that contraception would encourage infidelity among women, and official pronatalist policies. The promoters work directly with the 170 distributors and also parrticipate in other community development activities such as the establishment of community organizations. Large families are seen as just 1 of the problems of the communities, most of which are impoverished, lack employment opportunities, and suffer other disadvantages of underdevelopment. Distributors are chosen by communities for leadership and other personality traits. Acceptance of family planning encourages efforts to assume control of other aspects of life.^ieng

[Acceptability of medroxyprogesterone acetate among medical and paramedical personnel in family planning]. / Aceptabilidad del acetato de medroxiprogesterona entre personal médico y paramédico en planificación familiar.

PIP: Depot medroxyprogesterone acetate (DMPA) generally injected in doses of 150 mg every 3 months, is offered in the official family planning program of Mexico. The study purpose was to assess the impact of attitudes toward DMPA of medical and paramedical family planning workers on the frequency of prescription and acceptance of DMPA in the national family planning program. A 21-item multiple choice mail questionnaire was returned by 644 persons including 279 physicians, 257 nurses, and 104 social workers from Mexico City and 24 of the 31 states, a response rate of 55.6%. 338 of the respondents worked in health centers, 274 had worked in family planning for less than 1 year, and 427 were female. 365 had previous experience with DMPA. 458 knew the correct quarterly dose. Only 66 persons (10.8%) frequently prescribed DMPA, while 373 (61.1%) occasionally prescribed it and 169 (27.7%) never did so. 582 persons knew of at least 2 other injectable contraceptives. Among side effects, 423 persons mentioned frequent amenorrhea, 267 frequent bleeding, and 329 a reduction of future fertility. 203 mentioned that it did not affect lactation. 361 noted that it has high contraceptive efficacy. 439 considered administration of DMPA simple and 235 thought it was a good contraceptive. Asked what type of injectable contraceptive they preferred, 148 selected a combined monthly injection, 125 selected a progestogen every 84 days, and 115 selected DMPA. 416 considered their information on DMPA to have come from scientific sources. Medical journals were cited by 156, training courses by 271, and commercial promotions by pharmaceutical companies by 236. 612 persons (97.0%) felt that more training on DMPA use should be provided for family planning personnel, and 594 (94.7%) felt that users should receive more information. Discrepancies in the knowledge of DMPA among family planning workers indicate the need for improved training of new family planning workers and for continuing education of experienced workers.^ieng

The extension of health service coverage with traditional birth attendants: a decade of progress.

PIP: Traditional birth attendants (TBAs) are now being recognized as valuable members of the health care team and some countries are adopting innovative approaches to their utilization. 71% now, as opposed to 36% of the countries where TBAs attend births, offer formal recognition through certification and licensure to these TBAs. Many are now being trained and the training programs show diversity in content, duration, and manner of operation. Basically, the incentive for TBAs has remained the same since 1972--the UNICEF midwifery kit. Some countries have stipends while others distribute uniforms. The basic problems with the TBAs are deficiencies in supervision and in evaluation. Some countries, however, are attempting to incorporate TBAs into the mainstream in these ways: incorporation of TBAs into national "health for all" strategies (in Bangladesh, they are attending more births; in the Maldives TBAs will help accomplish equitable distribution of basic health services by the year 2000); TBA training programs (2 programs in Malawi and Afghanistan are described whereby innovative training projects carried out on a local level led to the development of national TBA training programs); expansion of role of TBA to include family planning (they have been used successfully and have proven capable of adding important new services to the traditional functions; Malaysia's successful experience is described); and the use of TBAs to staff rural maternity centers. Brazil and Senegal are the sites for 2 unusual pilot programs which provide primary obstetric care to women with little access to formal health care. In Senegal, the rural maternity centers are now cooperatively run by TBAs and provide a good example of community participation in health services. It is a low-cost program with simplified health care, and use of local personnel. In Brazil, trained TBAs work in conjunction with a university-based hospital at satellite obstetric units. The emphasis is on traditional and nonaggressive techniques. While collaboration with TBAs in countries with high morbidity and mortality is resulting in progress, much still needs to be done to make full use of this resource. Better training for these TBAs is the most feasible alternative.^ieng

A prospective multicentre trial of the ovulation method of natural family planning. I. The teaching phase.

The percentage of 869 women in five countries capable of being taught to recognize the periovulatory cervical mucus symptom of the fertile period was determined in a prospective multicentre trial of the ovulation method of natural family planning. The women were ovulating, of proven fertility, represented a spectrum of cultures and socioeconomic levels, and ranged from illiteracy to having postgraduate education. In the first of three standard teaching cycles, 93% recorded on interpretable ovulatory mucus pattern. Eighty-eight per cent of subjects successfully completed the teaching phase; 7% discontinued for reasons other than pregnancy, including 1.3% who failed to learn the method. Forty-five subjects (5%) became pregnant during the average 3.1-cycle teaching phase. The average number of days of abstinence required by the rules of the method was 17 in the third teaching cycle (58.2% of the average cycle length). To what extent the findings of this study can be extended to other couples remains to be demonstrated.

PIP: A prospective multicenter study was conducted in 5 cities (Auckland, Bangalore, Dublin, Manilla, and San Miguel) to assess the teaching phase of a program on the ovulation method (OM) of natural family planning. 869 ovulating women of proven fertility representing a wide range of cultural, educational, and socioeconomic characteristics (83% Catholic) were taught to recognize the cervical mucus symptom of the fertile period and were then tested on the effectiveness of their learning. 52% of the subjects did not wish to have any more children. 93% were able to understand the method after 1 cycle and 97% after 3 cycles. In the 3rd cycle, the mean number of days of abstinence required was 17. 75.1% of the subjects entered the 2nd phase of the trial after the 1st 3 training cycles and an additional 8.3% after an extended period of up to 3 more cycles. 45 (5.2%) became pregnant during teaching and 99 (11.4%) withdrew from the study. 2, possibly 3, subjects became pregnant while following OM rules. 32 pregnancies occurred when couples had intercourse during the fertile period and 11 more resulted from inaccurate application of the instructions. Subjects who required teaching beyond the 1st 3 teaching cycles reported both pregnancy and discontinuation rates more than 4 times higher than women who did not require additional teaching.

Birth planning in Cuba: a basic human right.

PIP: This paper reports on the development of birth planning in Cuba and strategies that are relevant to nurses in the communities of Cuba. Cuba reduced its crude birth rate by 40% from 1964-75 without formal family planning programs and resources. By 1975, Cuba had achieved the lowest birth rate in Latin America (21/1000) except Barbados (19/1000). By 1978, Cuba's crude birth rate declined to a low of 15.3/1000. The demographic transition in Cuba has been a process of equalization by: 1) community participation to ensure basic human rights for everyone, 2) increasing the status of women while providing child care centers, 3) providing equal availability of health care services including contraceptive services, sterilization, and abortion, and 4) focusing on individual birth choice, not on limiting population growth. Emphasis in Cuba for reducing fertility has been put on literacy, education, and infant mortality. The illiteracy rate in 1961 decreased from 20% to 4%. Infant mortality decreased from 38.8/1000 live births in 1970 to 22.3/1000 in 1978. 1/3 of Cuban women were participating fully in the labor force in 1978. Polyclinics have been established as preventive care medical centers throughout Cuba and health care is free. Family planning options are integrated into routine primary health care at polyclinics and assure equal access to the total Cuban population. Abortion is freely available and increased to 61/1000 in 1976. The implications for nursing are that: 1) the traditional work of nurses places them in a key position to help extend basic human rights beyond current levels, 2) nurses can initiate discussions of birth planning with women and men in a variety of settings, and 3) nurses can increase case-finding related to birth planning needs both in health care classes or within established groups in the community.^ieng

Setting standards for monitoring the performance of primary care personnel--outreach workers.

PIP: Personnel performance evaluation should be an integral part of the monitoring of a service program's efforts, particularly in those programs utilizing outreach workers, for the effectiveness of the program will initially depend on the success of such a service element. Variables need to be selected and criteria need to be established in order to operationalize the measurements to be used and to be able to evaluate performance. The contribution of outreach personnel performance to the effectiveness of a personal health service program is based on conditions stated in the following assumptions: 1) if the working capacity of the outreach workers is maintained at a satisfactory level, the service program will have the capacity to contact and follow-up a sufficient number of consumers, therefore increasing the probabilities that the service program will succeed in achieving its objective of a high degree of "population coverage;" if the outreach worker is sufficiently "convincing," the services offered will be accepted by the consumer; and 3) if the outreach worker complies with the standards, techniques, and procedures set forth by the program, the quality of services is ensured. Based on these assumptions, it seems reasonable to consider working capacity, and compliance with standards, techniques, and procedures as variables in evaluating and monitoring outreach personnel performance, provided that these variables can be operationalized for measurement. The opportunity to apply these concepts was provided during the recent efforts to evaluate a primary care program in Cali, Colombia. PRIMOPS (Spanish acronym for Research Program in Health Delivery Models) is a primary care Maternal and Child Health/Family Planning Program designed to contribute to the reduction of mortality, morbidity, and fertility of the "target" area. The mainstay of the PRIMOPS design are the 13 health promotoras recruited and selected from the community and trained according to the tasks they will perform. Using the information gathered through the record system and the supervision report, an effort to measure the performance of PRIMOPS promotoras was conducted. It was found that the variables of working capacity, convincing capacity, and compliance with standards, techniques, and procedures can be adapted to programs with features similar to those of the PRIMOPS program. Consequently, they should be taken into consideration as managerial tools in the efforts to assess and monitor personnel performance.^ieng